Pulmonary Lobectomy (VATS / Open)

CPT 32663
Approach Minimally Invasive
Add-on / Variant CPTs
  • 32480 — Open lobectomy, single lobe
  • 32671 — VATS lobectomy, total (separate procedure)
  • 32670 — VATS bilobectomy
  • 32482 — Open bilobectomy
  • 32486 — Sleeve lobectomy (open)
Preoperative Diagnosis:

Right [left] [upper / middle / lower] lobe [lung mass / adenocarcinoma / squamous cell carcinoma / carcinoid] — resectable, clinical stage [IA–II]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] [upper / lower / middle] lobe VATS [/ open] lobectomy with mediastinal lymph node dissection

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal — double-lumen [left-sided] endobronchial tube with single-lung ventilation

Indications:

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.

Findings:

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.

Description of Procedure:

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 — vein, artery, bronchus, fissure.]

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.

Complications:

None

Specimens:

[Right upper lobe / resected lobe] lung specimen sent to pathology. Mediastinal lymph nodes from stations [X] sent to pathology.

Estimated Blood Loss:

[X] mL

Drains:

[28 Fr] chest tube to water seal [/ −20 cmH₂O suction]

Disposition:

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
.TODAY
Variants

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 is 32482 (26.75 wRVU); segmentectomy is 32484 (24.75 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).
  • VATS pneumonectomy: 32671 (31.12 wRVU); open pneumonectomy: 32440. Use the approach-specific code.
  • Mediastinal lymph node dissection performed concurrently is separately billable (38746). 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.