toria11
Guru
Hi! Am I only able to bill for the laparoscopic nephrectomy in this case? Thank you.
POSTOPERATIVE DIAGNOSIS:
Left ureteral foreign body and injury.
PROCEDURE PERFORMED:
1. Left ureteral exploration with removal of foreign body.
2. Hand-assisted laparoscopic nephrectomy.
INDICATIONS:
The patient is a 73-year-old diabetic gentleman, who presented with worsening renal insufficiency, and was found to have a large stone in the proximal ureter causing significant hydroureteronephrosis and left renal atrophy. The stone had been present for a long time and I suspected was contributing to his renal insufficiency, so I recommended getting it removed. He was not having a lot of symptoms from the stone. Risks, benefits, alternatives reviewed and he underwent left ureteroscopy, laser lithotripsy with dusting of the stone, but when attempts were made to remove the ureteroscope at the end of the case, there was a scope malfunction and the tip of the scope became dislodged and remained in the left distal ureter. I could not get anything beyond the tip of the scope and the wire which had been in place fell out during the manipulations. He ended up getting a percutaneous nephrostomy tube placed and workup with nephrostogram showed reduced function of the left kidney. We discussed options of the various types of ureteral repair and reimplant versus nephrectomy due to the poor function in the kidney. Because we were trying to preserve his kidney function, the patient and his wife wish to pursue repair with nephrectomy only as a final option if deemed completely necessary and agreed to proceed.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed on the table in a supine position. After smooth induction of general anesthesia, he was placed in a modified left flank position with the kidney rest up and the table tilted to the right. A Foley catheter was placed and his genitalia and complete abdomen were prepped and draped in a standard sterile fashion. An incision was made 2 fingerbreadths above the iliac crest and carried down through the subcutaneous tissues with electrocautery. The anterior rectus fascia was opened in the direction of the fibers and the internal obliques were then opened in the direction of their fibers and maintained an extraperitoneal retroperitoneal approach and dissected down to the ureter and identified a brownish discolored scarred segment of ureter that was intact and connected to a more normal appearing dilated ureter proximally. I passed a wire up the kidney without any difficulty through a small incision in the proximal ureter, but the distal wire would only go a few cm, and therefore, it appeared that although the ureter was intact. The inside of the ureter had been denuded during the removal of the scope, with dissection distally, I was able to identify the tip of the scope close to the bladder. I removed the foreign body. At this point, several attempts were made to free up the bladder and draining the ureter down close enough to either do a psoas hitch or a Boari flap, but although we could mobilize the bladder readily and get it to come up into the level of above the bifurcation of the vessels. The ureter only looked viable at approximately just below the UPJ region. I tried to free up the kidney to enable to pull the ureter down to gain more length, but this was unsuccessful and it was felt a very long Boari flap would be required and the proximal ureter did not look very healthy, and therefore, the difficult decision was made to simply remove the kidney and help prevent the patient needing several more procedures and operations and potential risks and complications from a long Boari flap with a questionably viable ureter and in a limited functioning kidney. The perineum was entered and a 12 and 5 mm ports were placed in the left abdominal wall. Hand port was then placed through the existing incision and pneumoperitoneum was created. White line of Toldt was opened. The kidney was dissected out circumferentially. There was a lot of perinephric fat around the kidney. The hilum was dissected down and stapled with the Ethicon stapling device. Once the kidney was completely freed, it was removed through the hand port incision. Inspection revealed good hemostasis and no injury to any of the surrounding tissues. The fascia with a 12 mm port was then closed with a #1 Tycron stitch. The fascial layers of the HandPort were then closed with 2 layers of #1 PDS stitch. The skin edges were then approximated with 3-0 Vicryl and the skin edges were then closed with a 4-0 subcuticular Vicryl stitch. Marcaine was injected into all the incisions. Benzoin, Steri-Strips followed by Band-Aids were placed over the port sites and benzoin, Steri-Strips followed by island dressing were placed over the hand port incision. The patient was then awakened from anesthesia, extubated, brought to recovery room in stable condition and tolerated procedure well. NR 20211206
POSTOPERATIVE DIAGNOSIS:
Left ureteral foreign body and injury.
PROCEDURE PERFORMED:
1. Left ureteral exploration with removal of foreign body.
2. Hand-assisted laparoscopic nephrectomy.
INDICATIONS:
The patient is a 73-year-old diabetic gentleman, who presented with worsening renal insufficiency, and was found to have a large stone in the proximal ureter causing significant hydroureteronephrosis and left renal atrophy. The stone had been present for a long time and I suspected was contributing to his renal insufficiency, so I recommended getting it removed. He was not having a lot of symptoms from the stone. Risks, benefits, alternatives reviewed and he underwent left ureteroscopy, laser lithotripsy with dusting of the stone, but when attempts were made to remove the ureteroscope at the end of the case, there was a scope malfunction and the tip of the scope became dislodged and remained in the left distal ureter. I could not get anything beyond the tip of the scope and the wire which had been in place fell out during the manipulations. He ended up getting a percutaneous nephrostomy tube placed and workup with nephrostogram showed reduced function of the left kidney. We discussed options of the various types of ureteral repair and reimplant versus nephrectomy due to the poor function in the kidney. Because we were trying to preserve his kidney function, the patient and his wife wish to pursue repair with nephrectomy only as a final option if deemed completely necessary and agreed to proceed.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed on the table in a supine position. After smooth induction of general anesthesia, he was placed in a modified left flank position with the kidney rest up and the table tilted to the right. A Foley catheter was placed and his genitalia and complete abdomen were prepped and draped in a standard sterile fashion. An incision was made 2 fingerbreadths above the iliac crest and carried down through the subcutaneous tissues with electrocautery. The anterior rectus fascia was opened in the direction of the fibers and the internal obliques were then opened in the direction of their fibers and maintained an extraperitoneal retroperitoneal approach and dissected down to the ureter and identified a brownish discolored scarred segment of ureter that was intact and connected to a more normal appearing dilated ureter proximally. I passed a wire up the kidney without any difficulty through a small incision in the proximal ureter, but the distal wire would only go a few cm, and therefore, it appeared that although the ureter was intact. The inside of the ureter had been denuded during the removal of the scope, with dissection distally, I was able to identify the tip of the scope close to the bladder. I removed the foreign body. At this point, several attempts were made to free up the bladder and draining the ureter down close enough to either do a psoas hitch or a Boari flap, but although we could mobilize the bladder readily and get it to come up into the level of above the bifurcation of the vessels. The ureter only looked viable at approximately just below the UPJ region. I tried to free up the kidney to enable to pull the ureter down to gain more length, but this was unsuccessful and it was felt a very long Boari flap would be required and the proximal ureter did not look very healthy, and therefore, the difficult decision was made to simply remove the kidney and help prevent the patient needing several more procedures and operations and potential risks and complications from a long Boari flap with a questionably viable ureter and in a limited functioning kidney. The perineum was entered and a 12 and 5 mm ports were placed in the left abdominal wall. Hand port was then placed through the existing incision and pneumoperitoneum was created. White line of Toldt was opened. The kidney was dissected out circumferentially. There was a lot of perinephric fat around the kidney. The hilum was dissected down and stapled with the Ethicon stapling device. Once the kidney was completely freed, it was removed through the hand port incision. Inspection revealed good hemostasis and no injury to any of the surrounding tissues. The fascia with a 12 mm port was then closed with a #1 Tycron stitch. The fascial layers of the HandPort were then closed with 2 layers of #1 PDS stitch. The skin edges were then approximated with 3-0 Vicryl and the skin edges were then closed with a 4-0 subcuticular Vicryl stitch. Marcaine was injected into all the incisions. Benzoin, Steri-Strips followed by Band-Aids were placed over the port sites and benzoin, Steri-Strips followed by island dressing were placed over the hand port incision. The patient was then awakened from anesthesia, extubated, brought to recovery room in stable condition and tolerated procedure well. NR 20211206