Emmy Posted Thu 12th of March, 2020 13:02:03 PM
WE NEED ADVICE ON THE DX, CPT CODES FOR THIS CASE. PLEASE INCLUDE ADVICE ON SURGEON, CO-SURGEON AND/OR APPLICABLE RESIDENT SURGEONS. PREOPERATIVE DIAGNOSIS: Anaplastic thyroid cancer T3aN1M1, stage IVC, right thyroid lobe.
POSTOPERATIVE DIAGNOSIS: Anaplastic thyroid cancer T3aN1M1, stage IVC, right thyroid lobe.
OPERATION: Right hemithyroidectomy with isthmusectomy and subtotal left thyroid lobectomy, bilateral neck dissection.
ATTENDING PHYSICIAN: Baran Sumer, MD
SURGEON: Baran Sumer, MD
ASSISTANT: Charles Saadeh, MD
ESTIMATED BLOOD LOSS: 100 mL.
ANESTHESIA: General endotracheal.
NEEDLE COUNT: Correct.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old gentleman with a medical history significant for right-sided thyroid mass, which has been present for the last several weeks. This has been growing rapidly in size and a biopsy was consistent with anaplastic thyroid cancer. After discussing the risks, benefits and alternatives, he has opted for a right-sided hemithyroidectomy as well as neck dissections to remove presumed metastatic disease in the neck. The goals of the operation are:
1. Removal of the right thyroid lobe, which is pressing on his airway to obtain local control and prevent airway compromise with continued growth of this tumor.
2. Removal of lymphadenopathy in the head and neck for local regional control to prevent local complications from enlargement of metastatic disease, especially in a large node in level IB on the left-hand side.
3. Possibly improving his chance of a cure, although given PET findings suggestive of distant metastatic disease, this final goal may not be achievable.
The thyroidectomy portion of this case is being billed with a 22 modifier due to the complexity and difficulty of the dissection due to the anaplastic nature of the cancer and the fact that it was adherent to the great vessels as well as the recurrent laryngeal nerve, the thyroid bed and the trachea.
DESCRIPTION OF PROCEDURE: After the patient was anesthetized, intubated, rotated, prepped and draped in the usual fashion for this procedure, an apron incision was planned in a skin crease and injected with 1% lidocaine with 1:100,000 epinephrine. Next, the skin was incised and superior and inferior subplatysmal flaps were raised. Once this was completed, the strap muscles were divided vertically in the midline and the thyroid on the right-hand side was identified. The isthmus as well as the Delphian node were dissected free from the trachea, just past the midline onto the left-hand side. These were then dissected free from Berry's ligament and freed up from the airway. Once this was completed, the right thyroid lobe was dissected free from the mediastinum as well as the posterior attachments and the lateral attachments to the carotid artery and the jugular vein. There appeared to be a plane between the jugular vein and the carotid, which were able to be preserved during this dissection. The vagus nerve was identified and preserved during this portion of the thyroidectomy on the lateral portion of the thyroid. The superior pedicle was then identified and cut using the Harmonic scalpel and the dissection proceeded along the posterior portion of the thyroid where the superior and inferior parathyroids were identified and left in the wound bed along with the inferior thyroid artery. The recurrent laryngeal nerve was cut during this portion of the dissection. Once the tumor was lifted off the thyroid bed, it was dissected free from the airway and removed. The carotid artery as well as the innominate artery, jugular vein and vagus nerve were preserved as was the airway. The trachea was not entered during this dissection, although the tumor was closely adherent to it. Once this was completed, levels I through IV neck dissection was performed on the contralateral left-hand side starting with level IA. Level IA was dissected between the anterior heads of the digastric muscles and reflected laterally onto the mylohyoid and dissected free along with the perifacial nodes and submandibular gland from level IB. Once this was removed, levels II through IV were dissected by removing the fibrofatty tissue off the anterior portion of this SCM muscle and reflecting this off the floor of the neck, dissecting it free from the jugular vein and carotid artery. The X, XI and XII cranial nerves were identified and preserved during this dissection as were the great vessels. The major branches including the facial were cut during this dissection. The inferior limit of this dissection was the supraclavicular fossa. The superior limit was the patient's mandible. The posterior limit was the posterior border of the SCM muscle and deep neck muscles were the deep limits of the dissection.
Next, attention was directed towards the contralateral right-hand side, which was dissected in identical fashion with the exception of level IB. This was left intact as there did not appear to be metastatic disease in this area. In addition, level IIB was also left in place in order to preserve the XI cranial nerve. Levels II, III and IV were then dissected by removing the fibrofatty tissue off the SCM muscle, dissecting this free from the floor of the neck, dissecting it from the great vessels and removing it. Once again, the superior limits of this dissection was the digastric, the inferior limit was the supraclavicular fossa, the posterior limit was the posterior border of the SCM muscle and the deep neck muscles were the deep limits of the neck dissection. The X, XI and XII cranial nerves were identified and preserved during this dissection on the right-hand side as well. Once this was completed, two 15 round Blake drains were left in the wound beds on either neck and a 10 round Blake drain was left in the thyroid bed. These were secured to the skin using 2-0 nylons after they were brought out from separate stab incisions. The skin was then closed using 3-0 and 4-0 Monocryl for the deep dermis and skin and Dermabond as a final dressing.
Baran D. Sumer, MD