bmanus
Guru
I would appreciate any help with this exam. I am leaning towards 32482 but should the doctor get something else since all that extra time and work was done during the thoracoscopic part of the op.
Thanks
Beth
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and after patient identification and procedural verification, she
underwent general orotracheal anesthesia and the flexible bronchoscope
was introduced showing that she had normal bronchial anatomy and
bronchus and respiratory mucosa of the distal trachea, main carina, left
main stem bronchus, left upper lobe lingula, left lower lobe, right
mainstem bronchus and right upper lobe. She had occlusion of her right
lower lobe bronchus with an exophytic nonvascular, not easily bleeding
tumor that was immediately at the origin with the right middle lobe
being clear. As mentioned previously, the patient had a large extra
bronchial component, mandating bilobectomy. The patient then was
invasively monitored and endobronchially intubated. She was placed into
a left lateral decubitus position with appropriate peripheral nerve
protection, extended on the operating table and prepped and draped.
Bupivacaine with epinephrine was used for intercostal nerve blocks and
the skin, subcutaneous tissues, muscular layers of the chest wall and
the parietal pleura were infused with bupivacaine with epinephrine, the
2 utility port sites and 1 camera port site. The camera port site was
in the anterior axillary line at approximately the 10th intercostal
space.
The camera port was ultimately extended to allow placement of
instruments and 2 additional 30 mm ports were made, one in the anterior
axillary line at approximately the 5th intercostal space and the second
in the auscultatory triangle. On entering the chest, the patient had
minimal anthracotic staining of her visceral pleura, however, she had
dense adhesions from her recurrent post-obstructive pneumonias
obliterating the majority of the oblique fissure where it is adjacent to
the right middle lobe and the broadly adhered of the right lower lobe to
the diaphragm. These adhesions were taken down with electrocautery with
lysis of the inferior pulmonary ligament up to the inferior pulmonary
vein. This was time consuming. The inferior pulmonary vein, however,
was identified and circumferentially dissected bluntly and with
electrocautery, taking a generous incision of the mediastinal pleura
anterior to the vagus nerve up to the bottom of the azygos arch.
Several level 7 lymph nodes were removed in order to facilitate the
bronchial anatomic display. The inferior pulmonary vein was encircled.
Because of postobstructive pneumonia and the heavy lymphatic tissue
surrounding the tracheobronchial tree, the dissection was difficult
throughout the case, thus accounting for the long operative time.
The inferior pulmonary vein was ultimately encircled and divided with a
single firing of a vascular Endo-GIA. The right middle lobe vein was
handled in a like manner and the right upper lobe vein had been
identified and preserved. Next what followed was a time consuming
dissection to identify the right middle lobe and right lower lobe
bronchi with the surrounding casing lymphatic tissue causing dissection
to be difficult with large serpiginous bronchial arteries requiring
electrocautery and Hemoclips for hemostasis. Ultimately, the
dissection, in order to define the bronchial margins was performed both
from a back and forth exposure of retracting the lung cranially or
anteriorly and repositioning all lung clamps in order to facilitate
this. Ultimately, the right main pulmonary artery and the bronchus
intermedius were dissected from one another after this long tedious
dissection; however, I was never able to fully cross and
circumferentially isolate by dissection the bronchus intermedius. The
horizontal fissure was completed with serial firings of an Endo-GIA
thick load which was carried out down to the bronchus. This took the
pulmonary arteries in continuity. With this, I was still not able to
encircle the bronchus intermedius free from the main pulmonary artery
and we were in danger of failure to progress, the reason for conversion
to open thoracotomy in this morbidly obese woman (BMI 42).
Therefore, the remaining horizontal and oblique fissures were completed
with serial firings of a thick load Endo-GIA, which took the pulmonary
arteries and bronchus intermedius in continuity after trial clamping
prior to each firing, showed excellent ventilation of the right upper
lobe. The bilobed specimen was then placed into a fabric bag, which was
removed through the anterior utility thoracotomy and by frozen section
had a negative bronchus intermedius margin. The chest was irrigated
with a liter of warm water and aspirated to clear the chest of blood.
Several level 11R lymph nodes around the bronchus intermedius have been
sent for permanent sectioning. Several level 7 were sent also for
permanent evaluation. The superior mediastinum was then dissected and
with the patient's morbid obesity, the superior mediastinum was
fat-filled. Fat and hopefully inclusive of 2R and 4R lymph nodes were
removed from their appropriate anatomic positions. The chest was
drained with a 28-French chest tube with multiple additional holes cut
to 14 cm placed apically and posteriorly. The anterior utility port had
been extended in order to deliver the bilobar surgical specimen through
the chest and this was closed with #2 intracostal heavy braided
absorbable sutures placed with a rib punch inferiorly in a
figure-of-eight fashion. The wounds were then closed in layers with
running braided absorbable suture and a subcuticular skin stitch. The
utility port at the camera had been partially closed in the same manner.
The wounds were dressed with collodion occlusive dressings and the
chest tube was dressed with antibiotic ointment
Thanks
Beth
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and after patient identification and procedural verification, she
underwent general orotracheal anesthesia and the flexible bronchoscope
was introduced showing that she had normal bronchial anatomy and
bronchus and respiratory mucosa of the distal trachea, main carina, left
main stem bronchus, left upper lobe lingula, left lower lobe, right
mainstem bronchus and right upper lobe. She had occlusion of her right
lower lobe bronchus with an exophytic nonvascular, not easily bleeding
tumor that was immediately at the origin with the right middle lobe
being clear. As mentioned previously, the patient had a large extra
bronchial component, mandating bilobectomy. The patient then was
invasively monitored and endobronchially intubated. She was placed into
a left lateral decubitus position with appropriate peripheral nerve
protection, extended on the operating table and prepped and draped.
Bupivacaine with epinephrine was used for intercostal nerve blocks and
the skin, subcutaneous tissues, muscular layers of the chest wall and
the parietal pleura were infused with bupivacaine with epinephrine, the
2 utility port sites and 1 camera port site. The camera port site was
in the anterior axillary line at approximately the 10th intercostal
space.
The camera port was ultimately extended to allow placement of
instruments and 2 additional 30 mm ports were made, one in the anterior
axillary line at approximately the 5th intercostal space and the second
in the auscultatory triangle. On entering the chest, the patient had
minimal anthracotic staining of her visceral pleura, however, she had
dense adhesions from her recurrent post-obstructive pneumonias
obliterating the majority of the oblique fissure where it is adjacent to
the right middle lobe and the broadly adhered of the right lower lobe to
the diaphragm. These adhesions were taken down with electrocautery with
lysis of the inferior pulmonary ligament up to the inferior pulmonary
vein. This was time consuming. The inferior pulmonary vein, however,
was identified and circumferentially dissected bluntly and with
electrocautery, taking a generous incision of the mediastinal pleura
anterior to the vagus nerve up to the bottom of the azygos arch.
Several level 7 lymph nodes were removed in order to facilitate the
bronchial anatomic display. The inferior pulmonary vein was encircled.
Because of postobstructive pneumonia and the heavy lymphatic tissue
surrounding the tracheobronchial tree, the dissection was difficult
throughout the case, thus accounting for the long operative time.
The inferior pulmonary vein was ultimately encircled and divided with a
single firing of a vascular Endo-GIA. The right middle lobe vein was
handled in a like manner and the right upper lobe vein had been
identified and preserved. Next what followed was a time consuming
dissection to identify the right middle lobe and right lower lobe
bronchi with the surrounding casing lymphatic tissue causing dissection
to be difficult with large serpiginous bronchial arteries requiring
electrocautery and Hemoclips for hemostasis. Ultimately, the
dissection, in order to define the bronchial margins was performed both
from a back and forth exposure of retracting the lung cranially or
anteriorly and repositioning all lung clamps in order to facilitate
this. Ultimately, the right main pulmonary artery and the bronchus
intermedius were dissected from one another after this long tedious
dissection; however, I was never able to fully cross and
circumferentially isolate by dissection the bronchus intermedius. The
horizontal fissure was completed with serial firings of an Endo-GIA
thick load which was carried out down to the bronchus. This took the
pulmonary arteries in continuity. With this, I was still not able to
encircle the bronchus intermedius free from the main pulmonary artery
and we were in danger of failure to progress, the reason for conversion
to open thoracotomy in this morbidly obese woman (BMI 42).
Therefore, the remaining horizontal and oblique fissures were completed
with serial firings of a thick load Endo-GIA, which took the pulmonary
arteries and bronchus intermedius in continuity after trial clamping
prior to each firing, showed excellent ventilation of the right upper
lobe. The bilobed specimen was then placed into a fabric bag, which was
removed through the anterior utility thoracotomy and by frozen section
had a negative bronchus intermedius margin. The chest was irrigated
with a liter of warm water and aspirated to clear the chest of blood.
Several level 11R lymph nodes around the bronchus intermedius have been
sent for permanent sectioning. Several level 7 were sent also for
permanent evaluation. The superior mediastinum was then dissected and
with the patient's morbid obesity, the superior mediastinum was
fat-filled. Fat and hopefully inclusive of 2R and 4R lymph nodes were
removed from their appropriate anatomic positions. The chest was
drained with a 28-French chest tube with multiple additional holes cut
to 14 cm placed apically and posteriorly. The anterior utility port had
been extended in order to deliver the bilobar surgical specimen through
the chest and this was closed with #2 intracostal heavy braided
absorbable sutures placed with a rib punch inferiorly in a
figure-of-eight fashion. The wounds were then closed in layers with
running braided absorbable suture and a subcuticular skin stitch. The
utility port at the camera had been partially closed in the same manner.
The wounds were dressed with collodion occlusive dressings and the
chest tube was dressed with antibiotic ointment