Would you bill for the vein repairs or would these be included with the main procedures?
We then turned our attention to mobilizing the right lobe of the liver. We took down the right triangular ligament with the cautery. The right lobe of the liver was adherent to the retroperitoneum and adrenal gland, and we carefully dissected through this area. There was a large aberrant right adrenal vein draining up to the liver and then to the vena cava. In the course of mobilizing the liver and taking down the adhesions this resulted in an injury to the right adrenal vein. We controlled the bleeding with finger pressure. We then controlled the right adrenal vein bleeding with DeBakey forceps and performed a direct repair of the right adrenal vein with a 4-0 Prolene suture, and this achieved nice hemostasis. We continued mobilizing the right lobe of the liver. Some small veins draining to the vena cava were clipped with hemoclips and divided. We were then able to identify the larger segment 7 lesion as an area of scarring on the capsule of the liver. We ultrasounded the liver and this corresponded to a lesion measuring about 1 cm in diameter in the same location as was seen on the preoperative MRIs. We used the ultrasound to mark out a circumferential border of margin of 1 cm with the cautery. We then tightened our Pringle clamp and began the right hepatic transection of the segment 7 lesion. We used the TissueLink cautery and a tonsil clamp. Larger vessels were clipped with hemoclips. The lesion was sitting right on the right hepatic vein. In order to get a good margin around the lesion, we had to dissect it right off the right hepatic vein. During the course of this dissection, this resulted in some bleeding from the right hepatic vein. A direct repair of the right hepatic vein was performed with a 4-0 Prolene suture. We continued the parenchymal dissection until we completely removed the segment 7 liver mass. The deep aspect of the specimen corresponded with the surface of the right hepatic vein.
Feeling confused today!
We then turned our attention to mobilizing the right lobe of the liver. We took down the right triangular ligament with the cautery. The right lobe of the liver was adherent to the retroperitoneum and adrenal gland, and we carefully dissected through this area. There was a large aberrant right adrenal vein draining up to the liver and then to the vena cava. In the course of mobilizing the liver and taking down the adhesions this resulted in an injury to the right adrenal vein. We controlled the bleeding with finger pressure. We then controlled the right adrenal vein bleeding with DeBakey forceps and performed a direct repair of the right adrenal vein with a 4-0 Prolene suture, and this achieved nice hemostasis. We continued mobilizing the right lobe of the liver. Some small veins draining to the vena cava were clipped with hemoclips and divided. We were then able to identify the larger segment 7 lesion as an area of scarring on the capsule of the liver. We ultrasounded the liver and this corresponded to a lesion measuring about 1 cm in diameter in the same location as was seen on the preoperative MRIs. We used the ultrasound to mark out a circumferential border of margin of 1 cm with the cautery. We then tightened our Pringle clamp and began the right hepatic transection of the segment 7 lesion. We used the TissueLink cautery and a tonsil clamp. Larger vessels were clipped with hemoclips. The lesion was sitting right on the right hepatic vein. In order to get a good margin around the lesion, we had to dissect it right off the right hepatic vein. During the course of this dissection, this resulted in some bleeding from the right hepatic vein. A direct repair of the right hepatic vein was performed with a 4-0 Prolene suture. We continued the parenchymal dissection until we completely removed the segment 7 liver mass. The deep aspect of the specimen corresponded with the surface of the right hepatic vein.
Feeling confused today!
