From 3M Health Information Systems
ICD-10 coding challenge: Extra-adrenal pheochromocytoma
A 62-year old female presented to the Emergency Department with a chief complaint of severe headaches that had been worsening in intensity/frequency over the past three weeks. The patient was found to be hypertensive as well. Laboratory investigation revealed elevated urinary metanephrines. A CT scan of the abdomen and pelvis revealed a 4.7 cm mass located between the vena cava and the aorta consistent with an extra-adrenal pheochromocytoma. A follow up nuclear medicine study demonstrated that this was a solitary lesion. The patient was offered an open resection of the tumor. The decision was made to surgically remove the lesion as outlined in the operative report below.
PREOPERATIVE DIAGNOSIS: Extra-adrenal pheochromocytoma
POSTOPERATIVE DIAGNOSIS: Paraganglioma PATHOLOGICAL DIAGNOSIS: Paraganglioma
PATHOLOGICAL DIAGNOSIS: Paraganglioma
PROCEDURE: Exploratory laparotomy with excision of extra-adrenal pheochromocytoma
The patient was brought to the Operating Room, underwent preoperative preparation, was anesthetized and placed on the table in a slightly flexed position. A right-sided chevron incision was made using the skin knife and Bovie. The peritoneum was opened. The falciform ligament was divided between 2 0 ties. The peritoneum was incised out laterally in the right colon and mesocoln reflected off the anterior surface of the kidney exposing the duodenum which was Kocherized and eventually the vena cava. The vena cava was then cleaned off and we isolated the left renal vein which was the lower margin of this tumor. The mass was palpable through the vein. The vena cava was then circumferentially dissected from the right renal vein up to the caudate vein. An umbilical tape was placed around it. This allowed the cava to be reflected laterally. The mass was now somewhat in view. We readjusted our Bookwalter retractor. We began first by taking down the attachments between the renal vein and this mass which were mostly fibrous. Obvious blood vessels were either tied off with 2 0 silk or divided between clips. We worked our way around the left side of this tumor where there were several small arterial attachments. At this point the tumor was rather tense and oozing freely. As we came across the top of this lesion the bleeding suddenly ceased. We had divided a rather large pedicle after a silk tie was placed.
We were now able to lift the tumor up and the retroperitoneal attachments were minimal. We now had it attached by a right sided pedicle. We could now see a vein coming out of the tumor and wrapping around the lateral edge of the vena cava. We stapled this pedicle using the endovascular GIA stapler. The tumor was now soft and almost free. The remaining attachments were bovied and the specimen delivered. There were several small little bleeders now on the arterial side of the tumor cavity. These were dealt with with a series of small clips. On the vena cava side there was one venous bleeder with the fat with we tied off using a right angle and 2 0 silk. We closed our incision in two layers using a series of 1 PDS sutures. We closed the skin with staples. A dressing was applied. The patient was taken to the Recovery Room.
Sue Belley, RHIA is a clinical content development manager with the consulting services business of 3M Health Information Systems.