Chapter 12 Practical Applications
CASE 9 Preoperative diagnosis: Large right inguinal hernia. Bilateral undescended testes. Postoperative diagnosis: Bilateral inguinal hernias. Undescended testes. Procedure performed: Bilateral orchiopexy and bilateral inguinal hernia repairs as well as circumcision on a 10 year-old patient. Estimated blood loss: Less than 5 ml. Complications: None. Description of procedure: After informed consent had been obtained previously and reviewed again in the preoperative area, the patient was brought back to the OR, placed supine and general anesthesia was induced without problems. It was somewhat difficult to find an IV site, because of the patient's body habitus. However, there were no complications with anesthesia. The patient was then appropriately padded and prepped and draped in sterile fashion. 0.25% Marcaine plain was used for bilateral inguinal blocks as well as injected in the sub-q in the inguinal crease. I began on the right-hand side, where he had an intermittent right inguinal bulge for several months. A scalpel was used to make a skin incision following the creases and this was extended down through very generous subcutaneous fat and Scarpa's fascia to expose the external oblique aponeurosis. The external ring was identified as was the ilioinguinal ligament. The ring was opened for a short distance. The testis was high in the scrotum and was brought through. The gubernaculum was then divided. A very large hernia sac was carefully opened and very carefully dissected down to the level of the internal ring. There did not appear to be abdominal contents within the hernia sac., It was then twisted and suture ligated at the base. The hernia sac was then sent to pathology. The testis was pink and viable. A dartos pouch was created and the testis brought through it. The neck of the pouch was tightened with a few interrupted sutures of 3-0 Vicryl. Care was taken to make sure it did not twist the testicle that the testis lay in a normal anatomical position. The scrotal incision was then closed with 5-0 plain gut. The external ring was recreated by approximating the aponeurosis of the external oblique. The underlying ilioinguinal nerve was identified and spared. Scarpa's was approximated with 3-0 Vicryl and the skin closed with 5-0 Monocryl in a running subcuticular stitch. Steri-strips and dressing were placed over this. On the left-hand side initially his testis was felt to be almost nonpalpable but on exam under anesthesia it again was within the high scrotum. With gentle pressure, I could make this essentially disappear into his abdomen suggesting a large communicating hydrocele. I made the decision to proceed with inguinal hernia repair and exploration. Again, he had a Marcaine inguinal block and the skin was also anesthetized with 0.25% Marcaine. A matching incision was made with a scalpel following the skin creases. This was extended down through subcutaneous tissues and Scarpas to expose the external oblique and the external ring. It was then twisted and suture ligated at the base with 3-0 Vicryl. The hernia sac was also sent to pathology. At this point, there was sufficient length to easily bring the testis into the scrotum. A dartos pouch was created and the testis was brought into it with care taken to make sure we did not twist the cord structures. The neck of the pouch was tightened with 3-0 Vicryl, and then the scrotal incision closed with 5-0 plain gut in an identical fashion. The external oblique was approximated with a few interrupted sutures of 3-0 Vicryl, to recreate the ring. Again, care was taken to preserve the underlying ilioinguinal nerve. Scarpa's was approximated 3-0 Vicryl, as well, and the skin was closed with Monocryl. Steri-Strips and dressing were placed over, this as well. 0.25% Marcaine plain was then used for a penile block. A circumcising incision was made approximately 3mm below the coronal margin and the penis partially degloved. Meticulous hemostasis was obtained with Bovie cautery. The excess prepuce was trimmed. It was then discarded. The skin edges were approximated with 5-0 plain gut in a running fashion x 2. Hemostasis was excellent. The glans head appeared normal. A dressing of conform and Vaseline gauze was applied. The patient was then extubated and sent to the recovery in stable condition. No complications.
CPT: 49505-50, 54640-50-51, 54161-51 ICD 10 CM: K40.20, Q53.23, Z41.2
CASE 7 Preoperative diagnosis: Left renal calculus. Postoperative diagnosis: Left renal calculus. Procedure: ESWL 2300 shocks at 22kV. Description of Procedure: The KUB was reviewed, revealing a lower caliceal calculi on the left. The patient was anesthetized and positioned on the lithotripsy table. The stone was targeted and treated with 60 shocks for 2 minutes, and then a 2-minute pause was carried out. We then resumed at 60 slowly working up to 120, for a total of 1800 shocks on the lower pole, which completely disappeared. We then shocked the tip of the stent with 500 shocks as calcification was seen there on the prior KUB, but it was unclear on today's KUB with fluoro whether that was still present. The patient appeared to tolerate the procedure well, and he was brought to the recovery room in stable condition. He will follow up in 1 week for possible stent removal as KUB prior to the procedure.
CPT: 50590-LT ICD 10 CM: N20.0
CASE 5 Preoperative Diagnosis: RT ureteral stones. Postoperative Diagnosis: RT ureteral stones. (This is the diagnosis to report as the pre and post-operative diagnoses match and the diagnosis is supported in the operative report.) Operation: Open right ureterolithotomy. Intraoperative Findings: The patient had marked inflammatory reaction around the proximal ureter, just below the renal pelvis. Multiple stone fragments were embedded in the edematous ureteral lining. Procedure: The patient was placed on the operating room table in the supine position. General anesthesia was induced. He was then placed in a right flank up position. An incision was made off the tip of the 12th rib, and dissection was carried down through skin, fat and fascia to open the lumbodorsal fascia entering the retroperitoneal space.(This indicates the surgery was performed by open approach.) The peritoneum was swept anteriorly. Careful dissection was then carried down in the retroperitoneal space to first identify the vena cava and then to identify the renal vein. Once these structures were localized, the ureter was identified. Careful dissection was done to mobilize the ureter and to identify the area of the stone impaction by palpation. The ureter was then opened longitudinally and the ureteral stent was identified. The multiple embedded stone fragments were then removed from the ureteral lumen. (Surgical removal of the stone from the ureter.) The ureteral lumen was then irrigated copiously, and no other stone fragments were identifiable. The ureterotomy was then re-approximated with interrupted sutures of 5-0 chromic. Inspection showed good hemostasis. Sponge and needle counts were correct, and closure was begun after placement of a Blake drain through separate inferior stab wound. Marcaine 0.5% with no epinephrine was used to infiltrate the intercostal nerves. The wound was then closed in layers with muscle and fascial approximation with #1 Vicryl. The skin was closed with staples. Sterile dressings were applied. The patient returned to the recovery area in satisfactory condition.
CPT: 50610 ICD 10 CM: N20.1
CASE 10 Preoperative diagnosis: Intrinsic sphincter deficiency. Stress Incontinence. Postoperative diagnosis: Intrinsic sphincter deficiency. Stress Incontinence. Procedure: Cystoscopy with Durasphere injection. Estimated Blood Loss: Less than 5cc. Complications: None. Counts: Correct. Indications: This is a very pleasant female with intrinsic sphincter deficiency causing urinary incontinence. She understood the risks and benefits of the procedure, and she elected to proceed. Procedure Description: The patient was brought to the operating room and placed on the operating room table in the supine position. After adequate LMA anesthesia was accomplished, she was prepped and draped in the usual sterile fashion. A 21-French cystoscope was introduced in the patient's urethra. Her urethra was fairly pale, not well approximated, and was patulous. We injected 2 ½ syringes of Durasphere material into the urethra but were unable to get anymore than that amount into the tissue. There was moderate approximation of the urethral mucosa. The bladder was emptied and lidocaine jelly instilled. She was extubated and taken to the recovery room in good condition. Disposition: The patient was taken to the post anesthesia care unit and then discharged home.
CPT: 51715 ICD 10 CM: N36.42, N39.3
CASE 3 Preoperative diagnosis: Ta grade 3 transitional cell carcinoma (TCC) (TCC = transitional cell carcinoma.) bladder CA in January 2010 Postoperative diagnosis: Ta grade 3 transitional cell carcinoma (TCC) bladder CA in January 2010; now 2 new bladder lesions. (This is the stated diagnosis and is documented in the body of the operative note.) Operation: Cystoscopy. Anesthesia: Local. Findings: There were 2 tiny papillary lesions in the posterior wall of the bladder; otherwise, the cystoscopy was negative. Procedure description: A flexible cystoscope was introduced into the patient's urethra. A thorough cystoscopic examination (Indication of a diagnostic cystoscopy.) was done. Bilateral ureteral orifices were visualized effluxing clear yellow urine. All sides of the bladder were inspected, and retroflexion was performed. Cytology was sent. Plan: We will schedule the patient for a bladder biopsy (Indication that a surgical endoscopy was planned for later.) at the next available date.
CPT: 52000 ICD 10 CM: N32.9, Z85.51
Case 1 Preoperative diagnosis: Transitional cell carcinoma in the bladder Postoperative diagnosis: Transitional cell carcinoma in the bladder. Procedure: Cystoscopy; Excision bladder tumor- 1 cm. Bilateral retrograde pyleogram. Cytology of bladder. Anesthesia: General Estimated Blood Loss: 10cc Complications: None Counts: Correct Indications: The patient is a 58 year-old male status post partial cystectomy for transitional cell carcinoma of the bladder. He understood the risks and benefits of today's procedure, and elected to proceed. Procedure Description: The patient was brought to the operating room, placed on the operating room table, and placed in the supine position. After adequate LMA anesthesia was accomplished he was put in the dorsal lithotomy position and prepped and draped in the usual sterile fashion. A 21- French rigid cystoscope was introduced through the urethra and a thorough cystourethroscopy was performed. A 1 cm tumor was noted on the posterior bladder wall. The tumor was resected without complications. We obtained bladder cytology and performed a retrograde pyelogram, which showed no filling defects or irregularities. The bladder was emptied, and lidocaine jelly was instilled in the urethra. He was extubated and taken to the recover room in good condition. Disposition. The patient was taken to the post anesthesia care unit and then discharged home. Bilateral Retrograde Pyelogram Interpretation A bilateral retrograde pyelogram was performed, which showed no filling defects or irregularities.
CPT: 52234, 74420-26 ICD 10 CM : C67.4
Case 2 Preoperative diagnosis: Gross hematuria Postoperative diagnosis: Bladder/Prostate tumor. Operation: Transurethral resection bladder tumor (TURBT) large (5.3 cm). Anesthesia: General. Findings: The patient had extensive involvement of the bladder with solid and edematous-appearing hemorrhagic tumor completely replacing the trigone and extending into the bladder neck and prostatic tissue. The ureteral orifices were not identifiable. Digital rectal examination revealed nodular, firm mass per rectum. Procedure description: The patient was placed on the operating room table in the supine position, and general anesthesia was induced. He was then placed in the lithotomy position and prepped and draped appropriately. Cystoscopy was done which showed evidence of the urethral trauma due to the traumatic removal of the Foley catheter (patient stepped on the tubing and the catheter was pulled out). The bladder itself showed extensive clot retention. There was papillary and necrotic-appearing nodular tissue mass extensively involving the trigone and the bladder neck and the prostate area. The eureteral orifices were not identified. After consulting with the patient's wife and obtaining an adjustment to the surgical consent, the tumor was resected from the trigone, bladder neck and prostate. Obvious edematous and hemorrhagic tissue was removed. (Transurethral resection of the bladder tumor.) Extensive electrocauterization was done for bleeding vessels. Several areas of necrotic-appearing tissue were evacuated. Care was taken to avoid extending resection into the area of the external sphincter. Digital rectal examination revealed the firm, nodular mass in the anterior rectum. No impacted stool was identified. At the end of the procedure, hemostasis appeared good. Tissue chips were evacuated from the bladder. Foley catheter was inserted. Patient was taken to the recovery room in satisfactory condition. Addendum: The patient had a previous partial prostatectomy and had been found to have T2b N0 MX prostate cancer. On the physical examination today and on the endoscopic exam, it was unclear as to whether the tumor mass was related to the bladder or recurrent prostate cancer. Pathology revealed bladder carcinoma in the trigone and bladder neck, and recurrent prostate cancer.
CPT: 52240 ICD 10 CM: C67.0, C67.5, C61
CASE 4 Preoperative diagnosis: Desire for circumcision. Postoperative diagnosis: Desire for circumcision. (This is the diagnosis to report for this surgery if there are no further findings in the operative note.) Procedure: Circumcision. Anesthesia: General. Indications: The patient is a 19 year-old (The age of the patient.) white male, sexually active for two years. He requests circumcision. He understands the risks and benefits of circumcision. Procedure Description: The patient was brought to the operating room and placed on the operating room table in the supine position. After adequate LMA anesthesia was accomplished he was given a dorsal penile block and a modified ring block with 0.25% Marcaine plain. (This is the type of penile nerve block provided for the circumcision.) Two circumferential incisions (Surgical incision is made, as using a clamp or device is usually reserved for infants.) were made around the patient's penis to allow for the maximal aesthetic result. Adequate hemostasis was then achieved with the Bovie, and the skin edges were reapproximated using 4-0 chromic simple interrupted sutures with a U-stitch at the frenulum. The patient was extubated and taken to the recovery room in good condition. Disposition: The patient was taken to the post anesthesia care unit and then discharged home.
CPT: 54161 ICD 10 CM: Z41.2
CASE 6 Preoperative diagnosis: Prostate cancer. Postoperative diagnosis: Prostate cancer. Procedure: Radical retropubic prostatectomy with bilateral pelvic lymph node dissection. Statement of Medical Necessity: The patient is a very pleasant 58 year-old gentleman with Gleason 7 prostate cancer. He understood the risks and benefits of radical retropubic prostatectomy including failure to cure, recurrence of cancer, need for future procedures, impotence and incontinence. He understood these risks, and he elected to proceed. Statement of Operation: The patient was brought to the operating room and placed on the operating table in the supine position. After adequate general endotracheal anesthesia was accomplished, he was put in the dorsal lithotomy position and was prepped and draped in the usual sterile fashion. A 20 French Foley catheter was introduced in the patient's urethra, and the balloon was inflated with 20ml of sterile water. Made a mid-line infraumbilical incision and dissected down to the rectus fascia. Then transected the rectus fascia between the bellies of the rectus muscle and dissected into the retropubic space. Placed a Bookwalter retractor to aid in visualization and to protect the surrounding structures. Performed a bilateral pelvic lymph node dissection, taking care to avoid the hypogastric and obturator nerves bilaterally. The node packets were sent off the field for permanent section and frozen section. Then dissected the prostate free from its lateral side wall and dorsal attachments superficially and placed a right-angle clamp behind the dorsal venous complex and tied off the dorsal venous complex with two free ties of #1 Vicryl. Sewed some back bleeding sutures over the prostate and we placed a right-angle again behind the dorsal venous complex and then transected it with a long handled blade. Carefully inspected the dorsal venous complex for any bleeding and no bleeding was noted. Then placed a right angle clamp behind the urethra and transected the anterior aspect of the urethra, exposing the Foley catheter. We grasped this with a tonsil and then cut off the Foley catheter at the urethral meatus and pulled the Foley catheter into the urethral incision that had been made. Then transected the posterior urethra, freeing the prostate from its apical attachment. This allowed us to apply upward retraction to the prostate and dissect it free from the rectal anterior wall. Then clipped and cut the lateral pedicles to free the prostate up to the level of the bladder neck. Then transected Denonvilliers' fascia and identified the bilateral vas deferens, which were clipped and cut accordingly. Also, dissected the seminal vesicles leaving the tips of the seminal vesicles in place in the hopes of improving his incontinence. Once this was complete, dissected the prostate free from the bladder neck using electrocautery. Opened the anterior aspect of the bladder, able to identify the bilateral ureteral orifices effluxing indigo carmine that had been administered about 10 minutes earlier by the anesthesiologist. Once the prostate was sent off the field for permanent section, attention was turned to recapitulating the bladder neck. Everted the bladder mucosa with 4-0 Monocryl and then closed the bladder neck in a tennis racquet closure using 2-0 Vicryl. Then placed a Roth sound in the patient's urethra after ensuring adequate hemostasis in the pelvis and placed five anastomotic sutures of 2-0 Monocryl surrounding the urethra. Then placed them in the corresponding location in the bladder neck after a Foley catheter, 20 French in size, had been placed through the urethra and into the bladder, and the balloon was inflated with 20ml of sterile water. Then cinched down these anastomotic sutures and tied them off. Irrigated the Foley catheter and ensured that there was no bladder leak. Then placed a JP drain in the patient's left lateral quadrant, taking care to avoid the epigastric vessels. Stitched the drain in place with a 2-0 silk. Closed the fascia with #1 Vicryl in a running fashion and closed the subcutaneous tissues with 3-0 Vicryl. The skin was stapled closed and a sterile dressing was applied. His catheter was again irrigated with return of blue urine. No clots. The patient was extubated, and taken to the recovery room in good condition.
CPT: 55845 ICD 10 CM: C61
CASE 8 Preoperative diagnosis: Prostate cancer. Postoperative diagnosis: Prostate cancer. Procedure: Ultrasound guidance placement of gold fiducial markers. Description of procedure: The patient is a 62 year-old male with prostate cancer. He is to undergo external beam radiation therapy, and radiation therapy, and radiation oncology asked me to place the fiducial gold markers. Informed consent was obtained. The patient was brought to the procedure room. He received oral sedation prior to the procedure. Ultrasound was performed, and utilizing 20ml of lidocaine, the prostate was numbed with lidocaine. Next, position markers were placed at the right and left bases, as well as the left apex of the prostate gland without difficulty. He had an excellent appearance and ultrasound. The patient did not suffer any pain or other problems during the procedure. The hospital ultrasound department assisted me in imaging.
CPT: 55876 ICD 10 CM: C61
