Emmy Posted Thu 12th of March, 2020 12:58:56 PM
NEED DX, CPT codes. PLEASE INCLUDE ADVICE ON THE CODING FOR ALL SURGEONS, CO-SURGEONS, RESIDENTS, ETC. WE ARE HAVING A DIFFCULT TIME DETERMINING PROPER CODING FOR THIS SCENARIO.
DATE OF PROCEDURE: 11/22/2019
PREOPERATIVE DIAGNOSIS: Left cerebellopontine angle neoplasm
POSTOPERATIVE DIAGNOSIS: Left cerebellopontine angle neoplasm
1) Left translabyrinthine craniotomy for excision of cerebellopontine angle mass
2) Left abdominal fat graft
4) Intraoperative facial nerve monitoring
SURGEON: Brandon Isaacson, MD
FELLOW PHYSICIAN: Daniel Killeen, MD
RESIDENT PHYSICIAN: Carly Atwood, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 200 mL.
COMPLICATIONS: None apparent.
CONDITION: Stable to the postanesthesia care unit.
Tegmen position: 5 mm above ear canal
Tegmen dehiscence: None
Mastoid pneumatization: Pneumatized
Sigmoid sinus: Posterior
Mastoid mucosa: Normal
Facial nerve: Intact, stimulated 0.05 mAmps at brainstem
Nerve of origin: Inferior vestibular nerve
Jugular bulb position: 8 mm below IAC
Completeness of resection: Near total
Size and location of residual tumor: Small cuff on CPA facial nerve
Tumor adhesiveness to facial nerve: Significant
Porus expansion: Yes
Immediate postoperative House-Brackmann facial nerve function: 2- Slight weakness, Eye closure with minimal effort
DISPOSITION: The patient was transferred to the surgical ICU in stable condition.
INDICATIONS FOR PROCEDURE: XXXXXXXX is a pleasant 50y/o-year-old male who presented with hearing loss. MRI revealed a Left cerebellopontine angle mass. Treatment options were discussed including observation, radiosurgery, or microsurgery. The patient opted for microsurgery.
PROCEDURE IN DETAIL: The patient was brought to the operating room where she was placed on table in supine position. General endotracheal anesthesia had been induced and IV lines had been placed. The head of the bed was then turned 180 degrees from the anesthesia team. At this time, facial nerve monitors were placed to monitor the function of the left facial nerve. Impedances from the facial nerve monitor were confirmed using a tap test. In addition, the patient's head was placed in a Mayfield head holder with pins. A postauricular incision was then marked out about 2 fingerbreadths behind the ear and injected with 0.25% Marcaine and 1:200,000 epinephrine. An incision was also marked in the Left lower quadrant of the abdomen for fat graft. The patient was then prepped and draped in sterile fashion.
An incision was created in the postauricular area down to the temporalis fascia and periosteum. The skin flap was elevated 1 cm anterior and posterior to the incision line. A stair-stepped incision was made in the periosteum parallel to the skin incision. The skin/periosteal composite flap was then elevated off the bone up to the osseous external auditory canal. The mastoid cortex was widely exposed with as much exposure as needed for the translabyrinthine approach. Smaller cutting and diamond burs were used as necessary to skeletonize the middle fossa tegmen, as well as the sigmoid sinus. Care was also taken to thin out the external auditory canal adequately so as to enter the mastoid antrum. The mastoid antrum was thus entered and the short process of the incus, lateral semicircular canal were identified. With these 2 landmarks in view, the descending segment of the facial nerve was then identified from the 2nd genu to the stylomastoid foramen. Next, a labyrinthectomy was carried out with a #4 cutting bur. This was done by opening the lateral semicircular canal, superior semicircular canal, and posterior semicircular canal as well as the utricle and saccule. This was done to expose the vestibule for access to the internal auditory canal.
Next, attention was then turned to decompressing the middle fossa and the posterior fossa. First, the bone was removed posterior to the sigmoid sinus anteriorly all the way to the posterior fossa dura. Care was taken to remove the bone posterior to the sigmoid sinus about a centimeter behind. Next, the middle fossa dura was decompressed. Upon removal of the middle fossa bone, there was not noted to be any tears in the dura. The bone over the posterior fossa dura was then further elevated and removed towards the porus acousticus. The petrous ridge bone was then removed after dissecting the superior petrosal sinus and dura off it.
Next, attention was then turned toward identifying the internal auditory canal. First, a superior trough was drilled with the subarcuate artery as a landmark for beginning of the superior trough. Next, an inferior trough was drilled between the internal auditory canal and jugular bulb. The jugular bulb was noted to be in a low position not obstructing visualization of the internal auditory canal. The superior and inferior trough was deepened as much as possible so as to create as close to 270 degrees of exposure as possible of the internal auditory canal. Next, the bone was thinned over the internal auditory canals starting with the porus acousticus and then progressing towards the fundus. Care was taken to not go anterior to the superior semicircular canal ampulla, so as to avoid injuring the facial nerve. When the bone over the internal auditory canal was thinned enough, the bone was then removed. Upon circumferential exposure of the internal auditory canal, the superior vestibular nerve was then further identified anteriorly as it entered near the superior semicircular canal ampulla. Using a facial nerve probe, the facial nerve was then identified in the internal auditory canal at the level of the fundus. This facial nerve then stimulated at 0.05 milliamps. The nerve was then traced to Bill bar and was separated from the superior vestibular nerve. Carefully, the superior vestibular nerve was separated and reflected posteriorly. At this point, the neurosurgical team entered the case for tumor resection. A near total tumor removal was accomplished. Upon removal of the tumor, there was noted to be facial nerve stimulation at 0.05 milliamps at the brainstem. This part will be dictated separately by the neurosurgical team.
The posterior fossa dura was then partially closed with sutures of 4-0 Nurolon. Fat was then harvested from the incision marked in the left lower quadrant and used for reconstruction. This was closed with 3-0 vicryl deep dermal and 4-0 monocryl running subcuticular stitch. Next, the incus was removed from the antrum and fat was used to seal the antrum. The antrum was then sealed off using bone wax. Next, the fat was then further placed so as to plug off the area of the jugular foramen. Lastly, bone wax was used to seal off air cells that might communicate to the middle ear such as the zygomatic root cells, retrofacial air cells, mastoid tip air cells, and lateral EAC cells. Fat was then further used to fill the mastoid defect from the translabyrinthine approach. Next, the wound was then thoroughly irrigated with bacitracin containing solution. The Palva flap was then reapproximated to the posterior mastoid periosteum using 2-0 Vicryl suture. Next, the subcutaneous layer was closed meticulously using 3-0 vicryl suture. Lastly, the scalp was closed using a running locking 4-0 Prolene suture. Facial nerve monitors were then removed and the patient was taken out of the Mayfield head holder. A compressive dressing was then placed over the left incision. The patient was then allowed to emerge from general endotracheal anesthesia and did so without complication.
Dr. Isaacson was present for and supervised all significant portions of the surgery with the assistance of his fellow, Daniel Killeen, MD and resident Carly Atwood, MD.
Daniel Killeen, MD, PGY-6
Department of Otolaryngology
University of Texas Southwestern Medical Center
I was present for the entire procedure and scrubbed in and performed the key portions of the procedure.
Brandon Isaacson, MD, FACS