I need some assistance with this procedure. I have researched video endoscopic procedures and I'm not sure how this should be coded. I know that I will have to use an unlisted code for excision of deep inguinal lymph nodes since there is no code for laparoscopic excision of deep inguinal lymph nodes but I'm kind of at a loss with the video endoscopic part. What this be considered a laparoscopic procedure? Thanks for your input.
PROCEDURE
Video endoscopic left superficial and deep inguinal lymph node
dissection.
BLOOD LOSS
25 mL.
SPECIMEN
One superficial and deep inguinal lymph node.
ANESTHESIA
General endotracheal anesthesia.
INDICATION FOR PROCEDURE
is a 50-year-old gentleman who I initially met when he was
referred to me with a intermediate thickness 1.47 mm melanoma of the
dorsum of his left foot. He underwent a wide excision and sentinel
lymphadenectomy of the left superficial inguinal basin. The final
pathologic analysis of his lymph nodes revealed 1/1 sentinel node with
metastatic melanoma. He underwent a metastatic workup which was
unrevealing. He was offered the aforementioned procedure. He underwent
a session in which the risks, benefits, and alternatives were explained
in detail. He signed a written consent form agreeing to this procedure.
PROCEDURE IN DETAIL
The patient was brought to the operating theater. Endotracheal
anesthesia was induced. His right lower extremity was circumferentially
prepped and draped in sterile fashion. A down drape was placed into a
stirrup, and his leg was then placed into the stirrup. His leg was then
draped in a sterile fashion. Markings were made on the skin outlying
his left sartorius muscle as well as his left adductor longus muscle,
and his leg was externally rotated. A transverse incision was made in the upper thigh about 3 cm distal to the apex of the femoral triangle.
This incision was deepened with cautery. A subdermal plane was then
created using finger blunt dissection and Metzenbaum scissors for a
distance of about 10 cm superiorly and laterally to this initial
incision. Two additional incisions were then placed into the thigh, one
about 3 cm lateral to the sartorius muscle and an additional one about 3
cm medial to the adductor longus muscle. The 12 mm balloon trocars were
inserted into all three incisions, and the subcutaneous space was then
insufflated to 20 mmHg. A 5 mm camera was then inserted into the apical
trocar. Using a combination of graspers, Kittner, and the Harmonic
Scalpel, a subdermal plane was then created extending superiorly along
the femoral triangle extending it all the way past the inguinal ligament
for a distance of about 5-6 cm proximal to the inguinal ligament on the
abdominal wall. Once this subdermal plane had been completely created,
the Harmonic scalpel was used to incise the fiber adipose tissue along
the lateral aspect of the sartorius muscle. Again, the dissection was
carried from inferior to superior fashion along the lateral aspect of
the sartorius muscle until this had been extended up over the inguinal
ligament and onto the external oblique aponeurosis. Once this was
completed, a similar technique was used to incise the fibroadipose
tissue along the medial aspect of the adductor longus muscle. In a
similar fashion, an incision was created in the tissue down to the
fascia of the adductor longus muscle in an inferior to superior fashion
up over the inguinal ligament and up to the external oblique
aponeurosis. In the process of this dissection, medially the saphenous
vein was identified and was able to be preserved. The fibroadipose
tissue harboring the lymphatic tissue was then rolled medially as the
Harmonic scalpel was used to divide this tissue off of the underlying
muscle. Continuing in a medial to lateral fashion, the lymphatic tissue
with the fibroadipose tissue was then rolled from the medial to lateral
fashion. In doing this, we were able to preserve the saphenous vein and
identify from the entire distance of the femoral triangle. Using this
as a landmark, we followed it superiorly, and we identified the femoral
vein. The fascia was incised directly over the femoral vein, and the
additional packet of lymph nodes lying immediately medial and somewhat
deep to the femoral vein was then removed and was rolled anteriorly and
laterally to be included in the specimen. The dissection then continued
laterally over the femoral artery. The nerve was not identified,
leaving a protective layer of adipose tissue on top of the nerve and on
top of the psoas muscle. When the dissection was completed at the
lateral border of the sartorius, the specimen was then placed into a
specimen bag and retrieved through one of the 12 mm trocars from the
leg. The subcutaneous space in the leg was then reinspected. The wound
was completely hemostatic. Satisfactory lymphadenectomy was assured as
the vasculature as well as the bellies of the muscle were completely
exposed and skeletonized. A #10 flat Jackson-Pratt drain was then inserted through the lateral 12 mm trocar and brought medially in a
dependent spot in the wound. At this point, we felt it reasonable to
terminate the case. The leg was desufflated. The three incisions were
reapproximated with Monocryl and Dermabond. The patient tolerated the
procedure without any immediate difficulty. Needle and sponge count
were accurate for the duration of the case. The patient was transferred
to the recovery room in satisfactory condition.
PROCEDURE
Video endoscopic left superficial and deep inguinal lymph node
dissection.
BLOOD LOSS
25 mL.
SPECIMEN
One superficial and deep inguinal lymph node.
ANESTHESIA
General endotracheal anesthesia.
INDICATION FOR PROCEDURE
is a 50-year-old gentleman who I initially met when he was
referred to me with a intermediate thickness 1.47 mm melanoma of the
dorsum of his left foot. He underwent a wide excision and sentinel
lymphadenectomy of the left superficial inguinal basin. The final
pathologic analysis of his lymph nodes revealed 1/1 sentinel node with
metastatic melanoma. He underwent a metastatic workup which was
unrevealing. He was offered the aforementioned procedure. He underwent
a session in which the risks, benefits, and alternatives were explained
in detail. He signed a written consent form agreeing to this procedure.
PROCEDURE IN DETAIL
The patient was brought to the operating theater. Endotracheal
anesthesia was induced. His right lower extremity was circumferentially
prepped and draped in sterile fashion. A down drape was placed into a
stirrup, and his leg was then placed into the stirrup. His leg was then
draped in a sterile fashion. Markings were made on the skin outlying
his left sartorius muscle as well as his left adductor longus muscle,
and his leg was externally rotated. A transverse incision was made in the upper thigh about 3 cm distal to the apex of the femoral triangle.
This incision was deepened with cautery. A subdermal plane was then
created using finger blunt dissection and Metzenbaum scissors for a
distance of about 10 cm superiorly and laterally to this initial
incision. Two additional incisions were then placed into the thigh, one
about 3 cm lateral to the sartorius muscle and an additional one about 3
cm medial to the adductor longus muscle. The 12 mm balloon trocars were
inserted into all three incisions, and the subcutaneous space was then
insufflated to 20 mmHg. A 5 mm camera was then inserted into the apical
trocar. Using a combination of graspers, Kittner, and the Harmonic
Scalpel, a subdermal plane was then created extending superiorly along
the femoral triangle extending it all the way past the inguinal ligament
for a distance of about 5-6 cm proximal to the inguinal ligament on the
abdominal wall. Once this subdermal plane had been completely created,
the Harmonic scalpel was used to incise the fiber adipose tissue along
the lateral aspect of the sartorius muscle. Again, the dissection was
carried from inferior to superior fashion along the lateral aspect of
the sartorius muscle until this had been extended up over the inguinal
ligament and onto the external oblique aponeurosis. Once this was
completed, a similar technique was used to incise the fibroadipose
tissue along the medial aspect of the adductor longus muscle. In a
similar fashion, an incision was created in the tissue down to the
fascia of the adductor longus muscle in an inferior to superior fashion
up over the inguinal ligament and up to the external oblique
aponeurosis. In the process of this dissection, medially the saphenous
vein was identified and was able to be preserved. The fibroadipose
tissue harboring the lymphatic tissue was then rolled medially as the
Harmonic scalpel was used to divide this tissue off of the underlying
muscle. Continuing in a medial to lateral fashion, the lymphatic tissue
with the fibroadipose tissue was then rolled from the medial to lateral
fashion. In doing this, we were able to preserve the saphenous vein and
identify from the entire distance of the femoral triangle. Using this
as a landmark, we followed it superiorly, and we identified the femoral
vein. The fascia was incised directly over the femoral vein, and the
additional packet of lymph nodes lying immediately medial and somewhat
deep to the femoral vein was then removed and was rolled anteriorly and
laterally to be included in the specimen. The dissection then continued
laterally over the femoral artery. The nerve was not identified,
leaving a protective layer of adipose tissue on top of the nerve and on
top of the psoas muscle. When the dissection was completed at the
lateral border of the sartorius, the specimen was then placed into a
specimen bag and retrieved through one of the 12 mm trocars from the
leg. The subcutaneous space in the leg was then reinspected. The wound
was completely hemostatic. Satisfactory lymphadenectomy was assured as
the vasculature as well as the bellies of the muscle were completely
exposed and skeletonized. A #10 flat Jackson-Pratt drain was then inserted through the lateral 12 mm trocar and brought medially in a
dependent spot in the wound. At this point, we felt it reasonable to
terminate the case. The leg was desufflated. The three incisions were
reapproximated with Monocryl and Dermabond. The patient tolerated the
procedure without any immediate difficulty. Needle and sponge count
were accurate for the duration of the case. The patient was transferred
to the recovery room in satisfactory condition.