lindacoder
Guest
DATE OF PROCEDURE: 06/16/14.
PREOPERATIVE DIAGNOSIS: Recurrent left pleural effusion, history of lung cancer.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Left video-assisted thoracoscopy with talc pleurodesis and pleural biopsy.
ANESTHESIA: General.
DRAINS: Chest tube x2.
BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient has a history of lung cancer. He is undergoing chemotherapy. He has had a pleural effusion on the left. This has been requiring drainage. He is referred for pleurodesis.
DESCRIPTION: After the risks, benefits, alternatives, potential complications were explained in detail to the patient, consent was given. The patient was identified, brought to the operative suite and placed supine in the bed. After adequate anesthesia was obtained, the patient was placed in right lateral decubitus position. The left chest was prepped with chlorhexidine and draped in normal fashion. With the left lung not ventilated, a stab incision was made at approximately the 8th intercostal interspace in the posterior axillary line. The pleural space was entered utilizing a visual trocar. There was obvious pleural fluid and obvious tumor studding in the pleura. Under direct vision with the laparoscope, two additional trocars, one 5 and one 10 mm, were inserted cephalad and anterior to the initial insertion. The pleural fluid was evacuated in entirety. There was a large area of tumor studding on the pleura and this was biopsied with the tissue passed as specimen. With this complete, the parietal pleural surface was mechanically abraded with a grasper as well as with cautery. 12 grams of sterile talc were then instilled using an aerosolized system into the pleural space, giving good coverage of the pleural surface. Two chest tubes were then placed through the existing trocar sites, 1 anterior and 1 posterior. These were secured in place with 0 silk suture. The lung was then allowed to reinflate with good ventilation. Hemostasis was assured. With hemostasis assured, the wounds were closed, a deep layer of 2-0 Vicryl. The skin of all incisions closed with subcuticular 4-0 Monocryl. A dressing, Steri-Strips and gauze were applied. The patient tolerated the procedure well. There were no complications. All counts reported as correct. Transferred to the recovery area stable.
can I do more than the 32650 cpt??
Thanks
PREOPERATIVE DIAGNOSIS: Recurrent left pleural effusion, history of lung cancer.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Left video-assisted thoracoscopy with talc pleurodesis and pleural biopsy.
ANESTHESIA: General.
DRAINS: Chest tube x2.
BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient has a history of lung cancer. He is undergoing chemotherapy. He has had a pleural effusion on the left. This has been requiring drainage. He is referred for pleurodesis.
DESCRIPTION: After the risks, benefits, alternatives, potential complications were explained in detail to the patient, consent was given. The patient was identified, brought to the operative suite and placed supine in the bed. After adequate anesthesia was obtained, the patient was placed in right lateral decubitus position. The left chest was prepped with chlorhexidine and draped in normal fashion. With the left lung not ventilated, a stab incision was made at approximately the 8th intercostal interspace in the posterior axillary line. The pleural space was entered utilizing a visual trocar. There was obvious pleural fluid and obvious tumor studding in the pleura. Under direct vision with the laparoscope, two additional trocars, one 5 and one 10 mm, were inserted cephalad and anterior to the initial insertion. The pleural fluid was evacuated in entirety. There was a large area of tumor studding on the pleura and this was biopsied with the tissue passed as specimen. With this complete, the parietal pleural surface was mechanically abraded with a grasper as well as with cautery. 12 grams of sterile talc were then instilled using an aerosolized system into the pleural space, giving good coverage of the pleural surface. Two chest tubes were then placed through the existing trocar sites, 1 anterior and 1 posterior. These were secured in place with 0 silk suture. The lung was then allowed to reinflate with good ventilation. Hemostasis was assured. With hemostasis assured, the wounds were closed, a deep layer of 2-0 Vicryl. The skin of all incisions closed with subcuticular 4-0 Monocryl. A dressing, Steri-Strips and gauze were applied. The patient tolerated the procedure well. There were no complications. All counts reported as correct. Transferred to the recovery area stable.
can I do more than the 32650 cpt??
Thanks