VATS Wedge Resection and Pleurodesis for Pneumothorax

CPT 32655
Approach Minimally Invasive
Add-on / Variant CPTs
  • 32650 — Thoracoscopy with pleurodesis (chemical or mechanical)
  • 32656 — Thoracoscopy with pleurectomy
  • 32662 — Thoracoscopy with resection of mediastinal cyst, tumor, or mass
Preoperative Diagnosis:

Right [left] [primary / secondary] spontaneous pneumothorax — [first recurrence / second episode / persistent air leak / bilateral simultaneous]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] VATS blebectomy / wedge resection with [mechanical pleurodesis / talc pleurodesis / pleurectomy]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal — double-lumen tube with single-lung ventilation

Indications:

The patient is a [age]-year-old [male/female] with [first recurrence / second ipsilateral / persistent air leak > 5 days] right [left] spontaneous pneumothorax. Chest CT demonstrates [apical blebs / bullae] at the [right upper lobe apex]. Operative intervention was indicated to prevent further recurrence. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

Thoracoscopic inspection identified [apical blebs / bullae] at the [right / left upper lobe apex] measuring [X × X] cm. [X] bleb(s) were identified. The remaining lung parenchyma and pleural surface were [normal / with minor pleural adhesions]. Following blebectomy and pleurodesis, the lung re-expanded fully with no air leak.

Description of Procedure:

The patient was positioned in the lateral decubitus position with the operative side up. Double-lumen tube position was confirmed. Single-lung ventilation was established.

Three [5-mm] port sites were placed — one posterior for the camera and two for working instruments. The pleural space was inspected. [Apical adhesions were lysed with cautery.]

The apical bleb(s) were identified at the lung apex. A [45-mm] endoscopic stapler with a [blue / green] load was used to perform wedge resection encompassing all blebs with [1–2]-cm margins of normal lung. The specimen was removed in a retrieval bag. The staple line was inspected — no air leak on saline submersion.

[Mechanical pleurodesis: The parietal pleural surface was abraded with a [dry gauze / cautery scratching] from the apex to the base, creating a diffuse inflammatory reaction to promote adhesion.]

[Pleurectomy: The parietal pleura was stripped from the apex to the [4th / 5th] rib level using ring forceps.]

[Talc pleurodesis: [5 g] sterile talc was insufflated through a [port] to coat all pleural surfaces.]

Complete lung re-expansion was confirmed. A [24 Fr] chest tube was placed via the inferior port site and brought to water seal.

Complications:

None

Specimens:

Resected bleb/lung tissue — sent to pathology

Estimated Blood Loss:

Minimal

Drains:

[24 Fr] chest tube to water seal

Disposition:

The patient was taken to the PACU in stable condition. Post-operative chest X-ray confirmed full lung re-expansion. The chest tube was removed when air leak resolved and drainage was [<150 mL/day]. Smoking cessation counseling was provided.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left *** spontaneous pneumothorax — ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left VATS blebectomy with *** pleurodesis
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation

INDICATIONS: .PTAGE-year-old .PTSEX with *** PSP — ***. CT: apical blebs/bullae ***. Consent obtained.

FINDINGS: Apical bleb(s) *** × *** cm, *** identified. Remaining pleura ***. Post-blebectomy: no air leak, full expansion.

PROCEDURE:
Lateral decubitus, *** up. DLT confirmed. Single-lung ventilation. 3 × 5 mm ports. Pleural inspection — *** blebs at apex. [Adhesions lysed.] Wedge resection with *** mm stapler encompassing all blebs, *** cm margins. Specimen in bag. Staple line: no air leak. [Mechanical pleurodesis: gauze abrasion apex to base.] [Pleurectomy: parietal pleura stripped to *** rib level.] [Talc: *** g insufflated.] Full re-expansion confirmed. *** Fr chest tube inferior port, water seal.

EBL: Minimal
SPECIMENS: Bleb to pathology
COMPLICATIONS: None
DISPOSITION: PACU. CXR: full re-expansion. Chest tube when air leak resolves.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Bilateral Simultaneous PSP (Prone / Sequential VATS)

Given bilateral simultaneous pneumothorax [/ patient preference for single anesthetic], bilateral VATS blebectomy and pleurodesis were performed sequentially in a single session. After right-sided intervention, the patient was repositioned to right lateral decubitus for left-sided VATS. Single-lung ventilation was maintained on the contralateral lung throughout each side's procedure. Bilateral simultaneous PSP is uncommon (<5% of PSP); bilateral surgery carries higher respiratory risk and is typically reserved for bilateral disease, high-risk occupation, or remote location preventing treatment access.

Charting Tips
  • Document the pleurodesis technique chosen and rationale. Mechanical pleurodesis, pleurectomy, and talc have similar recurrence rates (~3–5%) for primary PSP. Document which was used. Talc is generally avoided in young patients (<40 years) who may need future lung resection, as it creates dense adhesions.
  • Document the number and location of blebs resected. If a bleb is visible but not resected (too deep, near the hilum), document this and the reason. Incomplete resection of blebs is associated with recurrence.
  • Document air leak status at case completion. Confirm the staple line was submerged in saline and no bubbles were seen. An undocumented persistent air leak at the time of closure becomes a postoperative complication by default.
Billing Tips
  • 32655 (VATS bullectomy/bleb resection, 15.77 wRVU) is the primary code for operative pneumothorax treatment with stapled bleb resection. This is the most common procedure for recurrent PSP.
  • Add 32650 (VATS pleurodesis, 10.56 wRVU) if mechanical pleurodesis or talc insufflation is performed in addition to bullectomy. Document the pleurodesis as a separately performed step.
  • Chest tube placement (32551, 2.96 wRVU) performed at a prior admission and still in place at time of VATS is not separately billable; a new placement during VATS is bundled.
  • Global period is 90 days (major). Post-op chest tube management and routine follow-up within 90 days are bundled.
  • For secondary spontaneous pneumothorax (SSP) with underlying lung disease, document the primary pathology (COPD, LAM, etc.). ICD-10 coding should reflect both PTX and etiology for DRG accuracy.
  • Open bullectomy/pleurectomy (32320) applies if thoracotomy is required. Do not use VATS codes for open procedures.
  • Modifier -22 (increased complexity) is appropriate if extensive pleural symphysis, dense adhesions, or exceptional blood loss is documented. Include a cover letter to the payer.