Emmy Posted Thu 12th of March, 2020 13:43:53 PM
Need advice on DX and CPTs for surgeon, cosurgeons and/or residents. SURGEON: WEBER, MD
RESIDENT: SMITH, MD
PREOPERATIVE DIANGOSIS: Metastatic kidney cancer emanating from the right kidney
PROCEDURE: Right radical nephrectomy
FINDINGS: Uncomplicated right radical nephrectomy
BLOOD LOSS: 50ML
SPECIMENS: Right kidney
ATTESTATION: I was present for all portions of this case.
DISPOSITION: The patient admitted to our service for convalescence.
INDICATIONS FOR SURGERY: The patient is a 43-year-old male with recently diagnosed metastatic kidney cancer. He had received induction immunotherapy with evidence of oligoprogression. Notably his primary tumor significantly enlarged. He was counseled on management options an elected for right radical nephrectomy me period risks comma benefits in alternatives extensively.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, was confirmed by name, date of birth, an MRN. He was placed on the operating table. General anesthesia induced. Appropriate lines were placed. IV antibiotic was given. The patient was placed in the left lateral de cubitus, right side up modified plank position. Extreme care was taken to panel pressure points. He was prepped and draped in the standard sterile fashion. A time out was performed. Pneumoperitoneum was established with Veress needle. Abdominal entry with 8 mm robotic port. Three robotic arms and assist port replaced in the standard configuration. The robot was docked.
We incised the white line of Toldt, medialized the colon, kocherized the duodenum until the anterior surface of the cava was identified. We split and rolled all the lymphatic tissue until the anterior and lateral aspect of the cava and the renal vein were identified. We elevated the kidney off the psoas fascia. We made pillars marching towards the renal hilum. The renal artery was below the renal vein. This was stapled with a 45 mm vascular load stapler. We then stapled the vein separately. The adrenal gland was spared. Clips and cautery were used to separate the upper pole attachments. The lower pole free tail of Gerota was stapled with a 45 mm vascular stapler. lateral attachments taken down with clips and cautery.
We inspected for hemostasis. We placed hemostatics within the nephrectomy bed. The specimen was placed in EndoCatch bag. Gibson incision was used for extraction. This was closed in one layer with #1 PDS, beginning at both apices, reinsufflated and inspected for hemostasis and checked her wound. Ports were removed under direct visualization. Subcutaneous tissue reapproximated with vicryl and skin with Monocryl. The patient was extubated and taken to PACU in good condition.