sandy06
Networker
PREOPERATIVE DIAGNOSIS:
Right upper lobe lung carcinoma.
POSTOPERATIVE DIAGNOSIS:
Unresectable right upper lobe lung carcinoma (T4 lesion).
OPERATION PERFORMED:
1. Right robotic video-assisted thoracoscopy.
2. Robotic lysis of adhesions.
3. Robotic mediastinal lymph node dissection.
4. Intercostal nerve blocks and placement of an On-Q pain management
system.
SURGEON:
Dr. R
FIRST ASSISTANT:
DESCRIPTION OF THE OPERATIVE PROCEDURE:
Patient was brought to the operating room after having appropriate
monitoring lines placed by anesthesia. Patient received preoperative
antibiotics. The patient underwent general endotracheal anesthesia
without complication. The patient was positioned on the O.R. table in
the supine position and then subsequently had a Carlens double-lumen
endotracheal tube placed. The position of the tube was verified under
fiberoptic bronchoscopy. Thereafter, the patient was positioned in the
right posterolateral thoracotomy position. The patient was prepped and
draped in the usual sterile fashion. Subsequently, an appropriate
surgical time-out was taken. Subsequently, a 1.5 cm skin incision was
made in the 11th intercostal space in the posterior axillary line.
Dissection was carried down through the subcutaneous tissue. The right
lung was deflated. The pleural space was entered under direct vision
utilizing electrocautery. Subsequently, a 15 mm trocar port was
introduced into the pleural space and was hooked to low-flow carbon
dioxide insufflation. A 10 mm x 30 degree Stryker camera was then
brought onto the field. It was advanced into the chest. Upon entering
the chest, the findings were that of extensive adhesions noted in the
right upper lobe in the posterior medial aspect. Under direct vision
with the Stryker camera, three 12 mm trocar ports were placed along
the 6th intercostal space, one in the anterior, mid, and posterior
axillary lines. The 12 mm trocar ports were introduced. Subsequently,
the da Vinci-S robotic system was brought onto the field and it was
docked to the ports. The robotic arms were then armed utilizing a
three-dimensional high-definition 30 degree down camera. Robotic arms
#1 and #2 were armed utilizing the curved monopolar shears and the
Cartier forceps. Thereafter, the remaining portion of dissection was
carried out at the robotic console with on field surgical assistance
via the 11th interspace incision. The adhesions were taken down. There
was noted to be adherence of the right upper lobe to the medial aspect
of the mediastinum. Decision was made to start from below. A
mediastinal lymph node dissection was carried out. The posterior
mediastinal pleura reflexion was taken down. All lymph nodes were
removed and were sent off to pathology with appropriate lymph node
station labeling. Upon reaching the level of the tumor, just at the
level of the azygos, the tumor was noted to be directly invading the
mediastinum. Attempts were made to approach the tumor from an
anteromedial aspect as well as from the superior posterior access. The
mass was noted to be intimately adherent and invading the medial
mediastinal structures making further dissection of the mass
dangerous. This was felt to be consistent with an unresectable T4
lesion. Decision was made to stop at this time and to treat the
patient with definitive chemo and radiation. The patient was then
undocked from the robot. The Stryker camera was then reinstituted into
the chest. A #32 chest tube was placed. Prior to undocking, the
patient had intercostal nerve blocks performed utilizing 0.25%
Marcaine on a 19-gauge Wang needle. A #32 chest tube was placed
through the camera incision. It was placed in the posterolateral
aspect of the pleural space. An On-Q pain management system was
brought onto the field. The On-Q catheters were introduced utilizing
the percutaneous delivery system and were placed in the posterior
paraspinal space, one superiorly and one inferiorly. Thereafter,
ventilation was resumed. The port incisions were then closed utilizing
interrupted 0 Vicryl suture on the muscle, fascia, and subdermal
layers. The skin was closed utilizing 4-0 Monocryl. The chest tube was
secured utilizing 0 Ethibond suture and was hooked to Pleur-Evac
drainage. Sterile dressings were applied. Patient tolerated the
procedure well and remained stable throughout the case. No
complications were encountered. Blood loss was minimal. The patient
was positioned back in the supine position at the completion the
procedure. Portable chest x-ray was obtained, which revealed the chest
tube to be in good position. The patient was extubated in the
operating room. The patient was transferred to recovery room in stable
but critical condition.
Need some insight on this Opt Report please; I'm looking at CPT CODE 32124 and 32652
but I'm not sure
Thanks for any help...........
Right upper lobe lung carcinoma.
POSTOPERATIVE DIAGNOSIS:
Unresectable right upper lobe lung carcinoma (T4 lesion).
OPERATION PERFORMED:
1. Right robotic video-assisted thoracoscopy.
2. Robotic lysis of adhesions.
3. Robotic mediastinal lymph node dissection.
4. Intercostal nerve blocks and placement of an On-Q pain management
system.
SURGEON:
Dr. R
FIRST ASSISTANT:
DESCRIPTION OF THE OPERATIVE PROCEDURE:
Patient was brought to the operating room after having appropriate
monitoring lines placed by anesthesia. Patient received preoperative
antibiotics. The patient underwent general endotracheal anesthesia
without complication. The patient was positioned on the O.R. table in
the supine position and then subsequently had a Carlens double-lumen
endotracheal tube placed. The position of the tube was verified under
fiberoptic bronchoscopy. Thereafter, the patient was positioned in the
right posterolateral thoracotomy position. The patient was prepped and
draped in the usual sterile fashion. Subsequently, an appropriate
surgical time-out was taken. Subsequently, a 1.5 cm skin incision was
made in the 11th intercostal space in the posterior axillary line.
Dissection was carried down through the subcutaneous tissue. The right
lung was deflated. The pleural space was entered under direct vision
utilizing electrocautery. Subsequently, a 15 mm trocar port was
introduced into the pleural space and was hooked to low-flow carbon
dioxide insufflation. A 10 mm x 30 degree Stryker camera was then
brought onto the field. It was advanced into the chest. Upon entering
the chest, the findings were that of extensive adhesions noted in the
right upper lobe in the posterior medial aspect. Under direct vision
with the Stryker camera, three 12 mm trocar ports were placed along
the 6th intercostal space, one in the anterior, mid, and posterior
axillary lines. The 12 mm trocar ports were introduced. Subsequently,
the da Vinci-S robotic system was brought onto the field and it was
docked to the ports. The robotic arms were then armed utilizing a
three-dimensional high-definition 30 degree down camera. Robotic arms
#1 and #2 were armed utilizing the curved monopolar shears and the
Cartier forceps. Thereafter, the remaining portion of dissection was
carried out at the robotic console with on field surgical assistance
via the 11th interspace incision. The adhesions were taken down. There
was noted to be adherence of the right upper lobe to the medial aspect
of the mediastinum. Decision was made to start from below. A
mediastinal lymph node dissection was carried out. The posterior
mediastinal pleura reflexion was taken down. All lymph nodes were
removed and were sent off to pathology with appropriate lymph node
station labeling. Upon reaching the level of the tumor, just at the
level of the azygos, the tumor was noted to be directly invading the
mediastinum. Attempts were made to approach the tumor from an
anteromedial aspect as well as from the superior posterior access. The
mass was noted to be intimately adherent and invading the medial
mediastinal structures making further dissection of the mass
dangerous. This was felt to be consistent with an unresectable T4
lesion. Decision was made to stop at this time and to treat the
patient with definitive chemo and radiation. The patient was then
undocked from the robot. The Stryker camera was then reinstituted into
the chest. A #32 chest tube was placed. Prior to undocking, the
patient had intercostal nerve blocks performed utilizing 0.25%
Marcaine on a 19-gauge Wang needle. A #32 chest tube was placed
through the camera incision. It was placed in the posterolateral
aspect of the pleural space. An On-Q pain management system was
brought onto the field. The On-Q catheters were introduced utilizing
the percutaneous delivery system and were placed in the posterior
paraspinal space, one superiorly and one inferiorly. Thereafter,
ventilation was resumed. The port incisions were then closed utilizing
interrupted 0 Vicryl suture on the muscle, fascia, and subdermal
layers. The skin was closed utilizing 4-0 Monocryl. The chest tube was
secured utilizing 0 Ethibond suture and was hooked to Pleur-Evac
drainage. Sterile dressings were applied. Patient tolerated the
procedure well and remained stable throughout the case. No
complications were encountered. Blood loss was minimal. The patient
was positioned back in the supine position at the completion the
procedure. Portable chest x-ray was obtained, which revealed the chest
tube to be in good position. The patient was extubated in the
operating room. The patient was transferred to recovery room in stable
but critical condition.
Need some insight on this Opt Report please; I'm looking at CPT CODE 32124 and 32652
but I'm not sure
Thanks for any help...........