VATS Wedge Resection
3266632667wRVU: 2.93 — Each additional resection (same lobe, same session)32668wRVU: 2.93 — Each additional resection (different lobe, same session)32500— Open wedge resection of lung
Right [left] [upper / lower / middle] lobe pulmonary nodule, [indeterminate / suspicious for malignancy / known metastasis], [X] cm, requiring tissue diagnosis [or resection]
Same
Right [left] VATS wedge resection of [upper / lower / middle] lobe pulmonary nodule [with intraoperative frozen section]
[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 [indeterminate / PET-avid / biopsy-proven] pulmonary nodule in the right [left] [upper / lower / middle] lobe identified on [CT chest / PET-CT]. [Prior CT-guided biopsy was [non-diagnostic / not feasible].] [Multidisciplinary tumor board recommended surgical resection for [diagnosis / curative metastasectomy / definitive treatment].] VATS wedge resection was planned for [tissue diagnosis / complete resection with margins]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
A [X]-cm [subpleural / parenchymal] nodule was identified in the [right / left upper / lower / middle] lobe. The nodule was [palpable / located with [hook-wire / fiducial marker / CT-guided marking] preoperatively / identified by direct visualization]. [Frozen section demonstrated [adenocarcinoma / squamous cell carcinoma / metastatic disease / benign tissue / deferred to permanent].] [A [X]-cm gross margin was confirmed.]
The patient was positioned in the lateral decubitus position with the operative side up. Double-lumen tube position was confirmed by bronchoscopy. Single-lung ventilation was established.
Three port sites were placed under direct visualization: a [12-mm] camera port in the [7th intercostal space mid-axillary line] and two [5-mm] working ports in the [anterior and posterior] chest. The thoracic cavity was inspected; no pleural effusion, no pleural implants. [The existing [hook-wire / fiducial] was identified in the [upper / lower] lobe, confirming the target nodule location.]
The target nodule in the [right / left upper / lower / middle] lobe was identified [by palpation / direct visualization]. A wedge resection was performed using sequential [green / purple / blue load] Endo-GIA stapler firings, excising the nodule with a margin of [at least 1–2 cm] of normal parenchyma. The specimen was placed in an impermeable retrieval bag and extracted.
[Frozen section was performed and returned as [result] — the procedure was [completed / converted to anatomic resection].]
The staple line was submerged in saline; no air leak was identified. A [24 Fr] chest tube was placed through the inferior port site and connected to water-seal with −20 cmH₂O suction. The port sites were closed with [0-Vicryl] at the fascia and [4-0 Monocryl] subcuticular sutures.
None
Right [left] [upper / lower / middle] lobe wedge resection specimen sent to pathology [for frozen section and permanent].
Minimal (less than 50 mL)
[24 Fr] chest tube to water seal with −20 cmH₂O suction
The patient was taken to the PACU in stable condition. Post-operative chest X-ray confirmed lung re-expansion. Chest tube was removed when air leak resolved and drainage was [<150 day]< ml span>. Multiple pulmonary metastases were identified and resected. [X] nodules were removed from the [upper / lower / middle] lobe with individual wedge resections using sequential Endo-GIA stapler firings. [An additional [X] nodules were resected from the [other lobe] — bill 32667 for additional same-lobe nodules, 32668 for additional different-lobe nodules.] Each nodule was placed in a separate labeled specimen container for pathologic correlation. The decision to proceed with complete metastasectomy vs. sampling was made per [multidisciplinary tumor board recommendation / operative discretion based on lesion count and distribution]. Given the subcentimeter or non-subpleural location of the target nodule, preoperative CT-guided localization was performed by [interventional radiology] on the day of surgery. Microcoil localization is now the preferred technique at most centers (fewer displacements and complications than hook-wire in large series; 2024 meta-analysis of 1,059 patients demonstrated equivalent safety and efficacy). Alternative techniques: hook-wire (simpler but higher displacement rate), fiducial marker, methylene blue injection (degrades quickly, same-day surgery required), or indocyanine green (ICG). If using ICG: intravenous ICG was injected and near-infrared thoracoscopy was used to confirm nodule fluorescence before stapling — ICG is an emerging complementary technique particularly useful for non-palpable nodules. The localizing device was confirmed in place at the time of port placement. The nodule was resected with the localization device included in the specimen, confirming adequate excision. Given [dense adhesions / inability to achieve adequate margins thoracoscopically / nodule not localized / frozen section requiring anatomic resection], the procedure was converted to open thoracotomy through a [posterolateral / muscle-sparing] incision in the [4th / 5th] intercostal space. The wedge resection [or anatomic resection] was completed as described in open fashion. Bill 32500 (open wedge) for converted cases.Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** lobe *** cm pulmonary nodule, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left VATS wedge resection, *** lobe [+ frozen section]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation
INDICATIONS: .PTAGE-year-old .PTSEX with *** cm *** nodule *** lobe. [MTB/CT-guided biopsy non-diagnostic.] VATS wedge resection for [diagnosis/metastasectomy/resection]. Consent obtained.
FINDINGS: *** cm nodule *** lobe, [subpleural/parenchymal], identified by ***. Frozen: ***. Margin *** cm.
PROCEDURE:
Lateral decubitus, *** up. DLT confirmed bronchoscopy. Single-lung ventilation. Camera port *** ICS, *** working ports. Pleural cavity: no effusion, no implants. Nodule identified by ***. Wedge resection with *** load Endo-GIA staplers, margin *** cm. Specimen in bag. Staple line submerged, no air leak. *** Fr chest tube inferior port, water seal + suction. Closed.
EBL: Minimal
SPECIMENS: *** lobe wedge to pathology [frozen + permanent]
COMPLICATIONS: None
DISPOSITION: PACU stable. CXR: lung re-expanded.
Signed: .ME, .MYDEGREE
.TODAYVariants
Multiple Nodules / Pulmonary Metastasectomy
Preoperative CT-Guided Localization
Conversion to Open Thoracotomy
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