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DEPARTMENT OF SURGERY
REQUEST FOR SPECIFIC PRIVILEGES
GROUP 11
1.00
1.01
1.02
1.03
1.04
1.05
1.06
1.07
1.08
1.09
1.10
General Surgery
Abdominal Procedures
Abdominal Perineal Resection
Appendectomy
Hernia Repair, Diaphragmatic
Hernia Repair, Femoral
Hernia Repair, Incisional
Hernia Repair, Inguinal
Hernia Repair, Umbilical
Other Hernia
Staging Laparotomy
1.20
1.21
1.22
1.23
1.24
1.25
1.26
1.27
1.28
1.29
1.30
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1.35
1.36
1.37
1.38
1.39
1.40
1.41
1.42
1.43
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Breasts
Excision of Cyst or Tumor
Incision and Drainage of Abscess
Mastectomy, Simple
Mastectomy, Radical
Reduction/Augmentation Mammoplasty
Subcutaneous Mastectomy
Post-Mastectomy Breast Reconstruction
Gynecomastia
1.50
1.51
1.52
1.53
1.54
1.55
1.56
1.57
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Esophagus
Repair Trauma of Esophagus
Dilation with Bougies
Esophageal Resection
Trauma & Repair of Lacerations
Esophagectomy
Tracheoesophageal Fistula
Esophageal Atresia Repair, Excise Duplications
Operations on Biliary Tract
Gallbladder
Intestinal Tract
Pancreas
Peritoneum, Omentum
Spleen
Paracentesis
Stomach
Liver
Vagotomy
Cystotomy
1
1.60
1.61
1.62
1.63
1.64
1.65
1.66
1.67
1.68
1.69
1.70
1.71
1.72
1.73
1.75
1.76
1.77
1.78
1.79
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Blood Vessels - Anastomoses
Aneurysmectomy
Embolectomy
Phlebectomy
Phlebotomy
Thrombectomy
Vein Ligation
Trauma & Repair of Blood Vessel Lacerations
Endarterectomy
Extra-Anatomical Bypass
Carotid Surgery
Surgery for Occlusive Disease
AV Fistulae
Angioplasty; Diagnostic/Catheter Directed Arteriography;
Endovascular Stenting
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Lymph Channels & Nodes
Biopsy
Incision and Drainage
Excision
Regional Node Dissection
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Skin and Subcutaneous Tissue
Biopsy
Burns, First
Burns, Second and Third Degree
Excision Lesion (Cyst, Lipomata, Polyps, etc.)
Graft, Pedicle
Graft, Tubular
Incision and Drainage (Abscesses, Paronychia)
Deep Abscess (Thyroglossal Cyst, etc.)
Suture, Uncomplicated Wounds
Repair Complicated Wounds
Myocutaneous Flaps
1.95
1.96
1.97
1.98
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Thyroid
Reopening of Wound for Hemorrhage Control
Thyroidectomy
Parathyroid Surgery
2.00
2.01
2.02
2.03
2.04
2.05
2.06
2.07
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Chest Surgery
Cardiovascular Surgery
Collapse Therapy
Drainage, Closed
Drainage, Open
Lobectomy
Phrenic Nerve Surgery
Pneumonectomy
1.80
1.81
1.82
1.83
1.84
1.85
1.86
1.87
1.88
1.89
1.90
1.91
2
2.08
2.09
2.10
2.11
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
2.21
2.22
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Scalenotomy
Thoracentesis
Thoracic-Abdominal Incision
Major Chest Surgery
Emergency Thoracotomy (Open/Closed)
Major Chest Surgery for Trauma
Ligation of Ductus Arteriosus
Median Sternotomy
Pericardiotomy
Repair Heart Wound
Resection of Lump
Varicocele
Vesicotomy
Thorascopy
Video Assisted Thoracic Surgery
3.00
3.01
3.02
3.03
3.04
3.05
3.06
3.07
3.08
3.09
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
3.21
3.22
3.23
3.24
3.25
3.26
3.27
3.28
3.29
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Ears, Nose and Throat Surgery
Adenoidectomy
Excision Lesions, Local (Brachial, Thyroglossal Cysts, Polyps, etc.)
Major Lesions
Laryngectomy
Mastoidectomy, Simple
Mastoidectomy, Radical
Rhinoplasty
Sinus - Incision
Sinus - Excision (Submucous Resection)
Tonsillectomy
Otoscopy
Otoplasty
Tympanoplasty
Stapedectomy
Audio Meatoplasty
Otolaryngological Facial Nerve Surgery
Blepharoplasty
Rhytidectomy
Nasal and Nasal/Septal Reconstruction
Microtia & Traumatic Ear Defects
Eyelid Reconstruction
Radical Neck Dissection
Laryngectomy, Partial or Total
Functional Endoscopic Sinus Surgery
Myringotomy
Tracheotomy
Trauma and Repair of Blood Vessel Lacerations – Neck
Deep Abscess - Neck
Tracheal Reconstruction
3
4.00
4.01
4.02
4.03
5.00
6.00
7.00
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
(6)
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Maxillofacial and Oral Surgery
All Oral Surgery Including Excision of Lesions
Fractures Reduction
Tongue Tie Release
5.01
5.02
5.03
5.04
5.05
5.06
5.07
5.08
5.09
5.10
5.11
5.12
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Eye
Enucleation
Extraocular - Excision of Lesion (Pterygium, Nevus, etc.)
Removal of Foreign Body
Suture
Eyelid - Excision of Lesion (Chalazion, Xanthoma, etc.)
Plastic Repair of Eyelid
Orbit, Excision Lesion
Evisceration
Plastic Repair
Cataract, Glaucoma, Retinal Detachment; Intraocular Lens Implant
Intraocular & Extraocular Eye Surgery
Laser Procedures, Retinal
1.00
1.01
1.02
1.03
1.06
1.08
1.09
1.10
1.11
1.12
1.17
1.19
1.20
1.21
1.25
1.26
1.28
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Gynecological Surgery
Amputation, Cervix
Cauterization Cervix
Closure - Rectovaginal Fistula
Closure - Vesicovaginal Fistula
Dilation and Curettage
Excision of Glands (Bartholin’s, Skene’s)
Hymenotomy
Hysterectomy - Total
Hysterectomy - Subtotal (Paracervical)
Hysterectomy, Vaginal
Repair - Cystocele
Repair - Rectocele
Salpingectomy (Ectopic Pregnancy)
Salpingo-oophorectomy
Abdominal Sterilization
Hysteropexy
Hysteroscopy
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Neurosurgery
Craniectomy
Craniotomy
Laminectomy
Neurotomy
Peripheral Nerve Surgery
Sympathectomy, Cervical
Sympathectomy, Lumbar
Sympathectomy, Thoracic
Carpal Tunnel Decompression
7.01
7.02
7.03
7.04
7.05
7.06
7.07
7.08
7.09
4
8.00
9.00
10.00
7.10
7.11
7.12
7.13
7.14
7.15
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Stereotaxis Surgery on Brain
Percutaneous Cordotomy
Extracranial Carotid and Vertebral Surgery
Trans-Sphenoidal Surgery
Extracranial/Intracranial Bypass
Percutaneous Radiofrequency for Trigeminal Neuralgia
8.01
8.02
8.03
8.04
8.05
8.06
8.07
8.08
8.09
8.10
8.11
8.12
8.13
8.14
8.15
8.16
8.17
8.18
8.19
8.20
8.21
8.22
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Orthopedic Surgery
Amputations, Simple (Fingers, Toes)
Amputations, Major
Arthrodesis
Arthroplasty
Drainage, Bone
Graft, Bone
Reduction Dislocation or Fracture – Dislocation Closed
Dislocation Open with Suture
Dislocation Open with Metal Screw, Nail, Pin, Band, Plate, etc.
Repair Tendons - Primary
Repair Tendons - Secondary
Spinal Fusion
Tenotomy
Wounds Sufficient to Result in Permanent Disability or Death
Hip Replacement/Reconstruction
Arthroscopic Surgery
Laminectomy
The Ilizarov Method
Knee Anterior Cruciate Ligament
Radial Shortening Osteotomy Wrist
Graft, Skin
Lumbar Disc Replacement
9.01
9.02
9.03
9.04
9.05
9.06
9.07
9.08
9.09
9.10
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9.11
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Rectal Surgery
Anal Fissure
Anal Fistula
Anoscopy, Proctoscopy, Sigmoidoscopy
Excision Lesion, Local
Excision Lesion, Malignant
Hemorrhoidectomy, Internal
Hemorrhoidectomy, External
Incision and Drainage
Pilonidal Cyst
Pull-through Operation for Hirschsprung's Disease in Imperforate
Anus
Colectomy
10.01
10.02
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Urological Surgery
Adrenalectomy
Anterior Urethropexy
5
10.03
10.04
10.05
10.06
10.07
10.08
10.09
10.10
10.11
10.12
10.13
10.14
10.15
10.16
10.17
10.18
10.19
10.20
10.21
10.22
10.23
10.24
10.25
10.26
10.27
10.28
10.29
10.30
10.31
10.32
10.33
10.34
10.35
10.36
10.37
10.38
10.39
10.40
10.41
10.42
10.43
10.44
10.45
10.46
10.47
10.48
10.49
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Augmentation Cecal Cystoplasty
Cavernosum
Circumcision
Continent Diversion with Colon Loop or Ileal Loop
Cutaneous Ureterostomy
Cystectomy
Cystolithotomy
Cystoscopy, Ureteroscopy
Cystostomy
Cystolithotripsy
Epididymectomy
Exploration of Testis
Hydrocele
Hydrocelectomy
Hypospadias Repair
Ileal & Colon Urinary Conduits
Ileal Loop
Insertion of Artificial Sphincter
Meatoplasty
Microscopic Vasovasotomy
Needle Bladder Suspension, Stamey Procedure, etc.
Nephrectomy, Donor
Nephrectomy, Harvest for Transplant
Nephrectomy, Partial
Nephrectomy, Total
Nephrectomy, Transplant
Nephrolithotomy
Nephroureterectomy
Orchidectomy
Orchiopexy
Percutaneous Nephrolithotomy
Percutaneous Nephrolithotripsy
Penile Insert
Penile Prosthesis Insertion
Plastic Operations on Kidney
Plastic Surgery of Penis
Prostatectomy
Pyeloplasty
Radical Prostatectomy
Renal Autotransplantation
Renal Trauma & Repair of Lacerations
Renal Vascular Surgery
Retroperitoneal & Pelvic Lymphadenectomy
Revascularization of the Corpora
Spermatocelectomy
Testicular Autotransplantation
Thoracoabdominal Approach to the Adrenal Gland/Kidney
6
11.00
10.50
10.51
10.52
10.53
10.54
10.55
10.56
10.57
10.58
10.59
10.60
10.61
10.62
10.63
10.64
10.65
10.66
10.67
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Total & Partial Adrenalectomy
Total Cystectomy
Transurethral Resection
Ureteroscopy
Ureterolithotomy
Ureterolithotripsy
Urethral Surgery
Urethrectomy
Urethrotomy, External
Urethrotomy, Internal
Varicocele/Varicocelectomy
Vesicotomy
Vasectomy
Ureterectomy
Renal Cyst Drainage
ESWL
Vasectomy Reversal
Prostatic Seeding Procedure
11.01
11.02
11.03
11.04
11.05
11.06
11.07
11.08
11.09
11.10
11.11
11.12
11.13
11.14
11.15
11.16
11.17
11.18
11.19
11.20
11.21
11.22
11.23
11.24
11.25
11.26
11.27
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Other Procedures
Reimplantation
Free Tissue Transfer
Translumbar Aortography
Peripheral Vascular System Operative Procedures
Femoral Arteriography
Brachial Arteriography
Angiography
Venogram
Microvascular Tissue Transplant
Implantation Alloplastic Material; Soft Tissue & Bone
Head and Neck Reconstruction
Repair of Congenital Deformities
Reconstruction of Scalp, Forehead, Calvaria
Cosmetic Surgery of the Aging Face
Abdominoplasty
Suction Assisted Lipectomy
Orbital Exenteration for Malignancy
Pelvic Exenterations (Total, Anterior, Posterior)
Hemipelvectomy & Forequarter Amputation
Infusaid Pump, Hepatic Artery Cath for Long Term Chemo
Chemical Peeling
Microsurgery
Liposuction of the Abdomen, Thighs, and Hips Only
Excision of Superficial Cutaneous Lesions Anywhere on the Body
Muscle Flap Harvesting
Deep Abscess (Pelvic, etc.)
Endovascular Deployment of Aortic Grafts for Treatment of
7
11.28
13.00
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(12)
(12)
(12)
1.00
1.01
1.02
1.03
1.04
1.05
1.06
1.07
1.08
1.09
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
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(12)
(12)
(12)
(12)
1.19
1.20
1.23
1.24
1.25
2.00
3.00
3.01
3.02
3.03
3.04
3.05
3.06
3.07
3.08
3.09
3.10
3.11
3.12
3.13
3.14
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Abdominal Aortic Aneurysm
Septoplasty
CRITICAL CARE MANAGEMENT (includes Bronchoscopy,
Laryngoscopy, Ventilator Care, TPN, etc.)
Special Privileges *
Culdoscopy
Gastroscopy
Peritoneoscopy
Bronchoscopy
Laryngoscopy (Flexible/Rigid)
Tracheoscopy
Sigmoid, Flexible Diagnostic
Sigmoid, Rigid Diagnostic
Laparoscopy
Colonoscopy
GI Endoscopy with Gen. Anesthesia
Colonoscopy with Polypectomy
Sigmoid, Flexible With Biopsy and Polypectomy
Sigmoid, Rigid With Biopsy and Polypectomy
Laparoscopic Cholecystectomy
Laparoscopic Appendectomy
Laparoscopic Hysterectomy
Laparoscopic Lysis of Adhesions
Laparoscopic Exam. of Abdominal Cavity/Common Duct
Exploration
Laparoscopic Inguinal Herniorrhaphy
Laparoscopic Suturing Techniques
Laparoscopic Bowel/Hernia Repair
Laparoscopic Stapling
Laparoscopic Inguinal Hernia Repair
TPN/PPN*
Yag Laser*
CO 2 Laser*
Colposcopy
Anoscopy
Proctoscopy
Midas Rex Bone Scalpel
Esophagoscopy
Myelogram
Admin. of IV Anesthesia/Analgesia When Loss of Reflex May Occur
Lithotripsy
Endoscopic Carpal Tunnel Release
Automated Percutaneous Lumbar Discectomy
Arteriovenous Fistula for Renal Access
Tissue Welding (Skin Lesions)*
Repair of Uncomplicated Bowel Perforation
8
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(12)
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(12)
(12)
(12)
3.15
3.16
3.17
3.18
3.19
3.20
3.21
3.27
3.42
3.43
3.44
3.45
3.46
3.47
3.48
3.49
3.52
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(12)
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3.54
3.55
3.56
3.57
3.58
3.61
3.62
3.64
3.65
3.66
3.67
3.68
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(12)
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3.69
3.70
3.71
3.72
3.73
3.75
3.79
3.80
3.81
3.82
3.83
3.88
3.89
3.90
3.91
3.92
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Repair of Bladder Perforation
Laparoscopic Pelvic Lymph Node Dissection
KTP/Yag Laser*
Resectoscope
Hysteroscopy
Laser of Cervix, Vagina, Vulva, Abdomen
Laparoscopic Ovarian Cystectomy
Diagnostic Laparoscopy
Laparoscopic Bowel Resection
Laparoscopic Vagotomy
Laparoscopic Fundoplication
Laparoscopic Colon Resection
Sigmoid, Flexible with Biopsy
Sigmoid, Rigid with Biopsy
PEG
Cystoscopy
Laparoscopic Examination of Abdominal Cavity with Varicocele
Treatment
Laparoscopic Nissen Fundoplication
Trans-Abdominal Preperitoneal (TAPP) Herniorrhaphy
Properitoneal Herniorrhaphy
Sigmoid Colon Resection
Laparoscopic Colectomy
Laser Assisted Uvulopalatoplasty
Laser Urological Surgery
Interstitial Laser Ablation of the Prostate
Upper GI Endoscopy (incl wall stents)
Endoscopic, FAST & Abdominal/Ultrasonography
Photodynamic Therapy for Cancer
Distal Esophagectomy (for distal esophageal tumors with
esophagogastrectomy)
Radiofrequency Ablation of Liver Tumors
Thoracoscopic Sympathectomy
PEJ
Bronchoscopy, Flexible for Traumatic Diagnosis
Extracorporeal Lithotripsy
Intradiscal Electrothermal Therapy
Inferior Vena Cava Filter Placement
Vertebroplasty
Kyphoplasty
Laparoscopic Bariatric Surgery
Roux-en-Y Gastric Bypass Surgery
Bariatric Lap-Banding Surgery
Nucleoplasty/Plasma Disc Decompression
Open Roux-en-Y Gastric Bypass Surgery
Laparoscopic Gastric Roux-en-Y
Adjustable Laparoscopic Gastric Banding
9
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(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
1.04
1.11
3.04
3.05
3.07
3.11
5.07
5.08
5.10
5.11
8.08
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Placement of Swan-Ganz Catheters
Intra-aortic Balloon Pump
ERCP
Sphincterotomy
Endoscopic Sphincterotomy w/biliary drainage & stone removal
Endoscopic Sphincterotomy w/Stone Removal
Placement of CVP Lines
Placement of Art Lines
Placement/Removal of Tenckhoff Catheter
Placement/Removal Double Lumen Medi-Port
Ventilator Care*
_____________________________________________________________________________________________
Signature
Date
********************************************************************************************
Department:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed, but not recommended:_____
___________________________________________________________________________________________
Chairperson
Date
Medical Staff Executive Committee:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed, but not recommended:_____
Board of Hospital Managers:
Reviewed and approved, as requested:_____
Reviewed and approved, with exception:_____
Reviewed but not approved:_____
Date____________________
Date____________________
* Requires written documentation of training and demonstrated competency.
Note: If privileges are denied, limited, or granted other than as requested, documentation must
be provided.
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