Emmy Posted Thu 12th of March, 2020 14:46:16 PM
WE SEEK ADVICE FOR DX AND CPT CODES FOR SURGEON, COSURGEONS,ASSISTANTS AND/OR RESIDENTS PREOP DIAGNOSIS: R. Renal Cell Carcinoma
POSTOP DIAGNOSIS: Same
PROCEDURE: Nephrectomy, Partial, Robot-Assisted (Intraoperative ultrasound)
SURGEON: YALE, MD
FELLOW: WHITE, MD
ASSISTING: JOHNSON, MD (NO QUALIFIED RESIDENT)
SPECIMEN: R renal mass
BLOOD LOSS: <50CC
FINDINGS: 2cm lower pole renal mass, grossly negative margins and good hemostasis.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. After general anesthesia was provided, the patient was placed in modified flank position, right side up. Upper and lower extremities were well secured in well padded. He was prepped and draped in standard surgical fashion. Veress needle was introduced into the peritoneum, through the umbilicus. Water test was performed in the abdomen insufflated to 15 mmHg. Superior and lateral to the umbilicus, on the right, we made a 1cm incision. We then entered the peritoneum under direct vision and with a dilating trocar, no evidence of injury was noted from either the trocar or from the veress needle. We subsequently placed an assistant port in the right upper midline. We placed three robotic arms, one in the right upper quadrant two finger breaths under the costal margin, and one right lower quadrant medially, and one in the right lower quadrant laterally. Prior to this the table was rotated so the right side was up . Another 5 mm trocar was placed in the upper midline for the liver retractor.
The robot was docked. We opened the white line of Toldt from the hepatic flexure, towards the right lower quadrant, mobilized the intestines off of the right kidney and off of the retroperitoneum. We continued to mobilize the colon medially until we were able to see the hilar vessels and the ureter and gonadal vessels. We also developed a plane between the liver and kidney. The duodenum was identified and carefully mobilized medially. At this point we identified the gonadal vessels and the ureter and elevated them off of the psoas muscle. We then dissected towards the hilum and elevated the kidney of the psoas muscle as well with sweeping motions. We used the 4th arm to elevate the kidney. We released the gonadal vessels medially. We then identified the renal vein and renal artery. We dissected around each anteriorly and posteriorly, and we were able to have a plane around the renal artery to allow placement of a clamp. At this point we opened garage does and identify the right lower pull mass. We freed up the lower pole of the kidney. We dissected circumferentially around the mass, we introduced an intraoperative ultrasound and identified the margins of the mass. We mobilized the lateral aspect of the kidney to allow it to be rotated medially to allow exposure to the mass circumferentially.
We defined the border circumferentially around the mass. At this point we placed clamp on the artery. It should be noted the total clamp time was 17 minutes. We then preceded to open the capsule of circumferentially around the mass and dissected around it keeping good parenchymal margin. The mass was excised and there was a well-defined margin.
There was no evidence that we entered into the mass and we had grossly negative margins. We placed the mass in a bag. We cauterized the base of the tumor. We then preceded to use VLoc sutures to oversew the base of the tumor. We used 2 VLocs for this. We unclamped the artery. There was good hemostasis. We proceeded to place capsular sutures and applied FloSeal and pledgets and then secured our capsular sutures. The pressure was lower to 5MMHG. There was no evidence of bleeding. We inspected the field. There appeared to be good hemostasis. There was no evidence of any bleeding from the hilar area. The vessels appeared healthy. The kidney was nice and pink.
We covered repair with perirenal fat. We inspected gonadals and ureters and they were healthy. We placed a drain through one of our trocarr in the right lower quadrant laterally. We removed the trocars under direct vision with no evidence of bleeding. We enlarged the camera port and removed the mass and closed the fascia there. There was no evidence of bleeding and a good fasical closure. We closed the subcutaneous tissues and skin. The patient was that awakened, take into recovery room in stable condition.
Attestation: I was present for in supervised all portions of this procedure.