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Scenario Week of July 12, 2012:
View Current Scenario

Preoperative diagnosis: 2 cm mass in tail of pancreas – presumed neuroendocrine tumor

Postoperative diagnosis: 2 cm mass in tail of pancreas – pathology pending

Operation performed: Robotically assisted laparoscopic distal pancreaticosplenectomy

Anesthesia: General anesthetic plus epidural

Specimen: Two folds, one is the body and tail of the pancreas separated by the spleen as well as the splenic and perisplenic nodal tissue

Indication: Patient is a 45-year-old male seen for an incidental finding of a mass in the tail of the pancreas during a CT scan secondary to trauma. The reading of the CT scan suggested ruling out a neuroendocrine tumor. The patient was tested and found to have nonfunctioning nerve, but had not responded to treatment and subsequently discussed the possibility of following up with an endoscopic ultrasound biopsy. After discussion with the patient he expressed concern for having it in place and that even with a negative biopsy he requested removal of the mass, so we scheduled him for surgery.

EBL: Minimal

Findings: Intraoperative ultrasounds revealed this 2 cm mass in the tail of the pancreas, easily identifiable and photos were taken for permanent record.

Operation Description:
Patient was brought to the operating room, an epidural catheter was placed, and the patient was subsequently placed under general anesthetic. He was shaved with the right arm out and left arm tucked. The A-Line was placed with two large-bore IVs and painted with chlorhexidine paint. Patient was given preoperative antibiotics.

An incision was made. Patient was given 5 mL of 0.5% Marcaine around the lateral aspect of his umbilicus approximately 19-20 cm distal from the xiphoid and using two Kocher’s and a Kelly. The abdomen was opened under direct vision atraumatically. A 0 Vicryl suture was placed on each side of the fascia and Hasson trocar was inserted. The abdomen was insufflated to 15 mm of pressure. The patient was placed in steep reversed Trendelenburg exposing the upper abdomen. At the point, under direct vision, three robotic ports were placed. The first 15 cm from the xiphoid into the subcostal margin bilaterally as well as one left lateral position in the mid-axillary line percutaneously under direct vision. At that point, we placed another 5 mm Hasson trocar subcostally in the right upper quadrant for the liver retractor.

Using the open Harmonic scalpel the lesser sac was opened and short gastrics were taken down. The snake retractor was placed and we irrigated, elevating the posterior wall toward the left lateral segment and cephalad. Once the retractor was in place we proceeded with bringing in and docking the robot. A 30-degree scope was inserted. Robot arms were inserted with a ProGrasp and a grafter ball handler and then the hooked Bovie instrument.

We proceeded, starting inferiorly and identified the pancreas. We mobilized the inferior margin of the pancreas starting from the midline and going toward the tail, dissecting with the avascular plane without difficulty with the hook instrument. We identified the most cephalad portion of the pancreatic margin from the inferior approach. We identified the splenic artery, dissecting it approximately 2 cm. We also identified the splenic artery from inferior to the pancreas and posterior to the pancreas as well. We identified the right cephalic vein. This was all contained and attached to the pancreas. The laparoscopic ultrasound probe was inserted into the assist port in the right lower quadrant. Ultrasound was used to identify a 2 cm mass in the location as expected based upon preoperative imaging studies. The remainder of the pancreas appeared normal. We located this tumor and traveled approximately 1 cm proximal, toward the superior mesenteric vein toward the head of the pancreas. Due to the concern for malignancy we elected to do a splenectomy. We were unable to place the stapler due to the angle and curvature of the splenic artery. Controlling the splenic artery we placed two Hem-o-lok proximal in the remaining part and one distal on the resection marking.

We opened the most cephalad portion of the celiac access, identifying both the right hepatic artery and the soft tissues in the celiac trunk. We then had a window of approximately 2 to 3 cm cephalad and having previously dissected inferiorly. We elevated with vessel loop and placed an Endo GIA 60 mm white load just toward the head, away from the tumor and across the pancreas. The pancreas was fairly thick and enlarged, and a second line of staples was placed. Upon inspection, Bovie electrocautery was used on the staple edge for hemostasis.

The pancreas was elevated posteriorly. Using the Harmonic scalpel the pancreas was freed. The patient had an extremely large spleen and we elected to transect the splenic hilum to send the pancreas specimen separately, in total, for frozen section. Harmonic scalpel was used to excise the soft tissue around the hilum and lymph node bases and mobilize the spleen and place in a large EndoCatch bag. This was removed via the right lower quadrant assisted port that was opened to 2-3 cm.

The right lower quadrant assist port site was closed with intermittent #1 CTX suture. The abdomen was re-insufflated, and a small amount of irrigation fluid introduced. Inspection revealed no sign of pancreatic duct leak or bleeding. The splenic artery had both Hem-o-lok intact and appeared secure. Copious irrigation was then performed in the left upper quadrant until clear. SurgiFlo was applied around the whole edges of the pancreas. A 19-French round Blake drain was placed through the left lower quadrant port site, laid posterior to the stomach, next to the staple line.

Needle and sponge counts were correct. The splenic retractor and all trocars were removed and the abdomen dis-inflated. The 5 mm laparoscopic 10 degree scope was reinserted; final inspection found no bleeding and was removed. The skin was closed using staples throughout.

The patient tolerated the procedure well, was extubated and transferred to recovery.

Chart note by surgeon: Pathology report confirmed malignant, well-differentiated endocrine carcinoma in the tail of the pancreas. No abnormalities noted in the splenic tissue.

Code this!
Assign the appropriate ICD-9-CM diagnosis code, and the appropriate CPT code(s).


ICD-9-CM Code
157.2 Malignant neoplasm of tail of pancreas

ICD-9-CM Rationale
Pancreas is not a site identified in the index under the term carcinoma. Instructional notes direct the user to see malignant neoplasms in the neoplasm table. The mass was noted to be in the tail of the pancreas, and the note regarding the pathology report indicates only the tail of the pancreas. No other diagnosis is appropriate as no notations are made regarding the spleen.

CPT Codes
48999 Unlisted procedure, pancreas
S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)

CPT Rationale
The tail and part of the body of the pancreas with the spleen were removed laparoscopically. Code 48140 describes the open procedure for pancreatectomy and splenectomy. Code 48999 is used to report the laparoscopic pancreaticosplenectomy procedure. This is in accordance with the CPT Assistant February 2006, page 18. This guidelines states, “if a laparoscopic procedure is performed but no CPT code accurately describes the laparoscopic procedure, the corresponding open procedure code should not be reported. Instead, the appropriate unlisted code should be reported. An open procedure code should never be reported to describe a procedure that was performed laparoscopically.”

Code S2900 is required by the Centers for Medicare and Medicaid Services (CMS) to indicate that the service was performed with the aid of a robotic surgical system. It is important to note that CMS does not reimburse any additional amount for the use of a robotic surgical system. Private payers may require the use of code S2900, and the provider should check with individual payers for their guidelines and reimbursement policies.

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