Surgery Case-005
week 5 Surgery for Outpatient
assign CPT and ICD

Surgery Case-005
week 5 Surgery for Outpatient
assign CPT and ICD-10-CM codes
LOCATION: Inpatient, Hospital PATIENT: Dorothy Fredrick SURGEON: Gregory Dawson, M.D. PREOPERATIVE.DIAGNOSES: Right middle lobe mass. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES PERFORMED: Bronchoscopy, right thoracotomy, right middle lobectomy, mediastinal lymphadenectomy. INDICATIONS: Dorothy is a 65-year-old female who was admitted with complaints of chest pain. The patient had undergone a medical workup for her chest pain which identified a lung lesion on the right side on chest x-ray. A CT scan had been done which identified a right middle lobe lesion. The patient had then undergone a bronchoscopic biopsy procedure which identified adenocarcinoma harboring in the lesion. The patient’s case was discussed at Pulmonary Conference and the patient had a workup which was consistent with disease isolated and localized to the right middle lobe. A PET scan had also been done preoperatively which did not identify any suspicious disease in her mediastinum. The procedure was explained to the patient and the patient consented for a bronchoscopy, right thoracotomy and a possible middle lobectomy versus a bilobectomy. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in stable condition. The patient was placed supine on a beanbag. The patient was placed under general anesthesia via an ET double-lumen endotracheal tube. Bronchoscopy was used to confirm ideal placement of the double-lumen ET tube. Once the patient was well placed under general anesthesia an A-line and Foley catheter were inserted to complete the hemodynamic monitoring. A thoracic epidural had been placed prior to intubation by Anesthesia. Once this was done the patient was placed in left lateral decubitus position on a beanbag. Surgery Case-005 2 | P a g e The patient’s lateral right chest was prepared and draped in usual standard thoracotomy fashion. An incision was made on the right chest wall in a typical posterolateral thoracotomy incision. The incision was carried down to the subcutaneous tissue as well as through the latissimus dorsi. The serratus anterior muscle was identified and spared, and retracted laterally. The incision was carried down to the chest wall. The rib spaces were counted off and clean dissection was made into the fifth intercostal space. Once the fifth intercostal space was dissected free, and entered in via electrocautery, hemostasis was noted to be adequate and lung was noted to be well-deflated. Once we were in the right chest cavity, there were no gross lesions noted along the diaphragmatic surface, the parietal pleura or the mediastinal pleura. Upon gross inspection the lesion itself could not be identified. There was no puckering of the visceral pleura. Upon manual palpation of the middle lobe, a large region was clearly identified which represent Surgery Case-005 3 | P a g e At this point the chest was thoroughly irrigated out using warm saline and suctioned free. The lung on this side was then ventilated and no air-leak was noted along the staple line. All staple lines were noted to be pneumostatic. At this point of the procedure, we paid particular attention to the mediastinal lymph-node dissection. The entire lymphatic packet between the superior vena cava and trachea was dissected out and sent off as a group of lymph nodes labeled as right-sided station 4 lymph nodes. Further dissection just inferior to the azygous allowed for identification of the hilar lymph nodes. Three specific lymph nodes were identified in this area and were dissected free and sent off as level 10 right-sided lymph nodes, specifically hilar lymph nodes. During the dissection of the level 10 lymph nodes, inadvertent injury to the right PA had been identified. This was easily repaired using a 4-0 Prolene figure-of-eight. No further bleeding was noted from this site. Both lymphatic beds had thrombin spray topically placed for hemostasis as well as Gelfoam. However, at the end of the case, both Gelfoam strips were removed since both areas of lymph node dissection were noted to be completely free of any bleeding. At this point of the procedure, again, the entire chest cavity was again irrigated with warm saline and suctioned out. Pathology was able to call into the room and discerned that it was difficult to give pathological confirmation of cancer-free margins. They did suggest that the staple-line itself made it difficult to discern on frozen section but that a confirmation of the actual status of the margins would be complete with the final pathological review. At this point a decision was made to close the chest, and not to proceed with further resection. At this point of the procedure, two tunneled 32-French chest tubes were inserted into the right chest cavity. The straight 32-French chest tube was placed anteriorly along the chest wall close to the mediastinum. Another 32 right-angled chest tube was inserted into the chest cavity, also at the level of the seventh intercostal space anterior to the iliac crest, with its path just along the right diaphragmatic leaflet. After both chest tubes were inserted and sutured in place, 4 pericostal No. 1 Vicryls were used in a figure-of-eight fashion to close the fifth intercostal space. After the fifth intercostal space was closed using these paracostal stitches, the overlying latissimus was approximated using a running No. 1 Vicryl. After the latissimus was approximated the fascia of the latissimus was approximated using a 0 running Vicryl. The dermis was then approximated using a running 2-0 Vicryl. The skin itself was closed using a running 3-0 Monocryl subcuticular stitch. Surgery Case-005 4 | P a g e Once the skin of the chest wall was closed, the patient was then placed in supine position. Dermabond had already been applied to the skin edges. The patient was removed from general anesthesia and underwent reversal of the paralyzing agent. The patient was safely removed from general anesthesia and was extubated without any problems. Needle count, lap pad count and instrument count were noted to be accurate at the end of the case. Estimated blood loss was 130 ml. The thoracic epidural was noted to be functioning well at the end of the case. The patient was safely transported to the recovery room in stable condition without any problems. Both chest tubes were connected to separate Pleurovacs. No air-leak was identified in either Pleurovac after 30 minutes from the conclusion of the procedure. The patient tolerated the procedure well. Pathology Report Later Indicated: Middle lobe carcinoma. Lymph node biopsies are pending. – Nursing