Hi! Its been awhile since I coded procedures, can someone tell me why Percutaneous endoscopic would be the approach to this surgery? TIASurgery:
Robotic Assisted Radical Prostatectomy, bilateral Pelvic Lymph Node Dissection
A 12mm camera port was then placed Supraumbilically along with the two 8mm working ports in there routine position. The fourth 8mm working port was placed on the patient's right side and one 12mm ports were placed on the patients left for the assistants instruments. The robot was then docked and the surgeon went to the surgeons console with the assistant working from the patients left side.
Initially adhesion at right lower abdomen was taken down with cold scissor. The bowel is pulled superiorly and the rectum was identified. The peritoneal reflection is incised in the midline, and blunt dissection is used to identify the ampulla of the vas and the seminal vesicles. Care should be taken to stay in the midline, as the insertion of the ureters in the trigone of the bladder occurs laterally. The vasa can then be dissected and divided bilaterally. The peritoneal reflection is divided slightly more laterally; the seminal vesicles are then encountered. The seminal vesicles are then freed inferiorly and laterally and the vessels at the tip are divided bilaterally. By retracting the vasa and the seminal vesicles superiorly, the plane between the posterior prostate and the rectum can be easily developed under direct visualization. This plane is carried caudally towards the prostatic apex. Care is taken to avoid lateral dissection because of the proximity to the neurovascular bundles. After this plane is well developed, attention is again turned to the development of the extraperitoneal space.
A transverse peritoneal incision is made extending from the left to the right medial umbilical ligament and extended in an inverted U-shaped manner to the level of the vasa on either side. The vasa can also be divided at this point to aid in bladder mobility. The extraperitoneal space is developed after the medial and median umbilical ligaments are transected, allowing the bladder, prostate, and bowel to drop posterior and the remainder of the operation to be performed extraperitoneally
The tissue anterior to prostate was then gently removed after cauterized. The endopelvic fascia was then opened. The dorsal vein complex was then ligated with 2-0 vicryl. Attention was then placed on the bladder neck and the bladder neck was opened in the midline until the foley catheter was seen. The foley was then grasped with the fourth arm and elevated to the anterior abdominal wall. The bladder neck was then opened. Then posterior bladder neck was divided and the seminal vesicles and vas deferens were pulled upward. The prostate pedicles were then clipped with weck clips and transected. Bilateral nerve preserving surgery was preformed. The dorsal vein complex and urethra were then transected. The prostate were placed into a 15mm endocatch bag.
Left pelvic lymph node dissection was performed. The lymph node packet medial to right iliac vein was dissected bluntly, down to obturator nerve, hemolock was applied at distal end. The lymph node packets and prostate/seminal vesicle/vas were placed into endocatch bag.
The urethrovesical anastomosis was then preformed with two 3-0 V-Loc in a running fashion. One for lower half 3 o'clock-6 o' clock-9 o'clock, second for upper half 3 o'clock-12 o' clock-9 o'clock. Two ends were tied. At the completion of this a 20 French foley was placed and the bladder irrigated to evaluate the integrity of the anastomosis. There was no leak. The foley was left in place. #10 flat JP was placed and brought out from a 8mm working port. The robot was undocked and the endocatch bag was removed from peritoneal cavity via camera port site with small incision. The abdominal cavity was then evaluated for any bleeding points. All port sites were closed with 4-0 Monocryl at subcuticularly. Steristrips and 4x4 gauze were applied to cover wounds. Total Blood loss 200ml
Percutaneous Endoscopic Approach
Percutaneous endoscopic approach (character value 4) is defined as entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure. The access location for this approach is the skin or mucous membrane with visualization instrumentation being used to reach the operative site.Documentation doesn't describe an open approach, one that exposes the site of the procedure.An open approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. Procedures performed via an open approach have a fifth character value of 0. The access location for this approach is through either the skin or a mucous membrane; the type of instrumentation used is not applicable.There are a few hints here. 1.12mm camera port was then placed Supraumbilically along with the two 8mm working ports in there routine position. The fourth 8mm working port was placed on the patient's right side and one 12mm ports were placed on the patients left for the assistants instruments.The prostate was placed into a 15mm endocatch bag, endocatch bag was removed from peritoneal cavity via camera port site with small incision.There is an AHIMA article explaining the different approachesDifferentiating Procedure Approach in ICD-10-PCS: Fifth Character Captures Specificity