Pulmonary Lobectomy (VATS / Open)
3266332480wRVU: 25.17 — Open lobectomy, single lobe32670wRVU: 27.81 — VATS bilobectomy32482wRVU: 26.75 — Open bilobectomy32486wRVU: 41.81 — Sleeve lobectomy (open)
Right [left] [upper / middle / lower] lobe [lung mass / adenocarcinoma / squamous cell carcinoma / carcinoid], resectable, clinical stage [IA–II]
Same
Right [left] [upper / lower / middle] lobe VATS [/ open] lobectomy with mediastinal lymph node dissection
[Attending name], MD/DO
[Resident/PA name]
General endotracheal with double-lumen [left-sided] endobronchial tube for single-lung ventilation
The patient is a [age]-year-old [male/female] with a [X]-cm [upper / lower] lobe lung mass, clinical stage [IA/IB/IIA]. PFTs demonstrated [FEV1 X% predicted / DLCO X% predicted], consistent with adequate pulmonary reserve for lobectomy. PET-CT demonstrated [FDG-avid / indeterminate] mass without mediastinal or distant disease. The risks, benefits, and alternatives including wedge resection, SBRT, and observation were discussed and informed consent was obtained.
The [upper / lower] lobe mass was identified. There was [no / minimal] pleural adhesion. The fissure was [complete / incomplete]. Mediastinal lymph nodes from [stations 4R, 7, 9, 10R / 5, 6, 7, 9, 10L] were sampled for N2 staging. The [upper / lower] lobe pulmonary artery branches, pulmonary vein, and bronchus were divided as described.
The patient was positioned in the lateral decubitus position with the operative side up and the table flexed. Double-lumen tube position was confirmed with bronchoscopy. Single-lung ventilation was established.
[VATS APPROACH:]
A [4]-cm utility thoracotomy was made in the [4th / 5th] intercostal space (anterior axillary line). Two [5-mm] port sites were placed posteriorly. A thoracoscope was inserted.
The inferior pulmonary ligament was divided. The pleura overlying the hilum was incised. The mediastinal lymph nodes were dissected and sent for frozen section and permanent pathology.
[RIGHT UPPER LOBE:]
The right upper lobe branches of the pulmonary artery (anterior trunk, posterior ascending) were divided between [Endo GIA stapler / hem-o-lok clips and division]. The upper lobe vein was divided with a [vascular load stapler]. The upper lobe bronchus was divided with a [bronchial load stapler / blue 4.8-mm stapler]. The fissures were completed with [green stapler loads]. The specimen was extracted in an impermeable bag.
[OTHER LOBES: described using same anatomic sequence as above. Note: PA-first is typical for the right upper lobe (anterior trunk is the most anterior structure); PV-first [vein-first] is often used for lower lobes and left-sided procedures to prevent tumor cell shedding on manipulation. Document the sequence used.]
The bronchial stump was tested with saline; no air leak. Mediastinal lymph node dissection was completed. A [28 Fr] chest tube was placed and tunneled anteriorly. The utility incision was closed in layers.
None
[Right upper lobe / resected lobe] lung specimen sent to pathology. Mediastinal lymph nodes from stations [X] sent to pathology.
[X] mL
[28 Fr] chest tube to water seal [/ −20 cmH₂O suction]
The patient was taken to the PACU / thoracic step-down in stable condition with the chest tube to water seal. Post-operative chest X-ray confirmed lung re-expansion. Ambulation and incentive spirometry were initiated on postoperative day 1.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** lobe lung mass, clinical stage ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left *** lobe VATS lobectomy + mediastinal LND
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation
INDICATIONS: .PTAGE-year-old .PTSEX with *** cm *** lobe mass, stage ***. FEV1 ***%, DLCO ***%. Consent obtained.
FINDINGS: Mass identified, *** adhesions. Fissure ***. LNs sampled from stations ***.
PROCEDURE:
Lateral decubitus, *** up. DLT confirmed bronchoscopy. Single-lung ventilation. VATS: *** cm utility thoracotomy *** ICS, *** port sites. Inferior pul. ligament divided. Hilar pleura incised. LND stations *** dissected, sent path. PA branches ***; PV ***; bronchus ***; fissure ***. Specimen in impermeable bag. Bronchial stump tested; no air leak. Chest tube *** Fr, anterior. Closed.
EBL: *** mL
SPECIMENS: *** lobe to pathology; LNs stations *** to pathology
COMPLICATIONS: None
DISPOSITION: Stepdown, chest tube water seal. CXR confirmed re-expansion. Ambulate POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
Open Lobectomy via Posterolateral Thoracotomy
Given [dense adhesions / tumor proximity to hilum / prior chest surgery / surgeon preference], an open posterolateral thoracotomy was performed. A [5th intercostal] muscle-sparing incision was made. The chest was entered through the [5th / 6th] intercostal space with a rib spreader. The lobectomy was performed as described above via open technique. The chest was closed with pericostal [0-PDS] sutures, re-approximating the ribs. Intercostal muscle closure, fascial layers, and skin were closed sequentially. An epidural catheter [/ paravertebral blocks / rib cryoablation] was used for post-operative analgesia.
VATS Wedge Resection (Benign / Diagnostic)
For a peripheral nodule requiring tissue diagnosis or a small peripheral malignancy in a patient with compromised pulmonary function, VATS wedge resection was performed rather than lobectomy. The target nodule was palpated [/ located by pre-operative CT-guided hook-wire / fiducial marker / dye injection]. The nodule was resected with [2–3] stapler loads to achieve [1–2]-cm margins. The specimen was extracted in a bag. Wedge resection carries a higher local recurrence rate than lobectomy for NSCLC; it is appropriate for benign disease, diagnostic resection, and patients with severely compromised lung function.
Charting Tips
- Document mediastinal lymph node station dissection for lung cancer cases. Complete mediastinal LND (stations 4, 7, 9, 10 for right; 5, 6, 7, 9, 10 for left) is required for accurate pathologic staging. Document which stations were sampled. 'Mediastinal lymph node sampling was performed' without station detail is inadequate for oncologic staging.
- Document bronchial stump air leak test. Every lobectomy requires intraoperative testing of the bronchial stump by filling the chest with saline and performing a Valsalva maneuver or positive pressure breath. Document the result. Missed air leaks are the leading cause of prolonged chest tube output.
- Document single-lung ventilation quality and any ventilatory issues. If the operative lung deflation was incomplete and visibility was compromised, document how this was managed (retraction, CO₂ insufflation, etc.). This establishes context if the patient has postoperative pulmonary complications.
Billing Tips
- VATS lobectomy: 32663 (24.02 wRVU); open lobectomy: 32480 (25.17 wRVU). Use the approach-specific code. VATS and open rates are nearly equivalent under CMS 2026.
- Bilobectomy: open 32482 (26.75 wRVU); VATS 32670 (27.81 wRVU). Segmentectomy: open 32484 (24.75 wRVU); VATS 32669 (22.94 wRVU). Document the anatomic extent of resection precisely, as each has its own code and RVU value.
- Completion pneumonectomy (32488, 41.92 wRVU) is for removal of remaining lung tissue after prior resection. Do not use for primary pneumonectomy (32440, 26.60 wRVU open; 32671, 31.12 wRVU VATS).
- Mediastinal lymph node dissection performed concurrently is separately billable (38746, 4.02 wRVU). Document systematic vs sampling approach and stations removed.
- Global period is 90 days. Post-op chest tube management and bronchoscopy for mucus plugging are bundled. Return to OR for bleeding or air leak uses modifier -78.
- Conversion from VATS to open: bill the open code (32480). Do not bill 32663 for a converted case. Modifier -22 is appropriate if conversion was due to exceptional difficulty.