rockylopez
Networker
Hello fellow coders. I wanted to ask for any advice on the surgery that i am coding. I am coming up with 49320 and 58660 but i wanted to see if anyone has any input. Thank you
Pre-procedure diagnosis:
ruptured ectopic pregnancy vs ruptured corpus luteum
Post-procedure diagnosis:
possible ruptured omental pregnancy
Procedures performed:
laparascopy with evacuation of hemoperitoneum and Lysis of Left tubal adhesion
(partial omentectomy by general surgery)
Technique/Procedure:
Patient taken to the operating room placed on the operating table. General anesthesia was induced. Patient was placed in the lithotomy position in yellowfin stirrups. Patient was prepped and draped in usual sterile fashion after Foley catheter was placed to continuous drainage. Timeout was performed. Sponge forceps was inserted in the posterior vaginal vault. I then changed my outer gloves and directed my attention to the abdomen. The inferior aspect of the umbilicus was infiltrated with 5 cc of local anesthetic. A vertical incision was made in the inferior umbilicus. Varies needle was inserted and the abdominal cavity was insufflated to pressure 15 mmHg after hanging drop test implied appropriate placement. 12 mm bladed trocar was placed the laparoscope was placed under direct visualization was apparent that the peritoneum had not been entered. The fascial edges of the incision were grasped and pulled up and the trocar was again placed in peritoneum was entered and the laparoscope was placed under direct visualization and it was apparent that the port had been completely placed at that point. The balloon collar was insufflated with air. There was immediately noted to be a significant hemoperitoneum.
5 mm ports were placed in the right and left lower quadrant after infiltration with local anesthetic using transillumination and direct visualization to avoid injury to vascular structures. The pelvis was thoroughly explored and no source of bleeding could be found. Both tubes appeared normal with the exception of a dense adhesion from the left tube to bowel. This incision was fairly elongated and was easily desiccated and divided using LigaSure device. There were noted to be adhesions of the uterus to the anterior abdominal wall obliterating the anterior cul-de-sac. Are also noted to be vesicular appearing lesions in the right ovarian fossa. Further evacuation of blood and clots revealed that there there was what initially appeared to be very adherent blood clot to the omentum. On further inspection this blood clot could not easily be peeled or washed off of the omentum and therefore's thought to possibly be a side effect and ectopic pregnancy. General surgeon was called in and performed a partial omentectomy to remove that suspected implantation site. Pelvis once then again carefully inspected and no further bleeding was noted. The lower abdominal ports were removed under direct visualization and good hemostasis was apparent. The gas was desufflated and the umbilical port was removed. The fascial edges were reapproximated using 2-0 Vicryl on a UR 6 needle. The skin incisions were closed with 3-0 Monocryl and covered with Dermabond. The sponge stick was removed from vagina.
Operative findings:
right corpus luteum cyst, normal left ovary dense adhesion of left tube to large bowel, o/w normal bilateral tubes, vesicular implants in Right ovarian fossa suspicious for endometriosis, adhesion in anterior culdsac. Normal appearing uterus. Adherent clots vs ectopic pregnancy on omentum
Complications: none
Estimated blood loss in ml's: none, ~450cc hemoperitoneum evacuated.
Specimens removed/altered: portion of omentum
Implant(s): none
Urine output:
clear
Pre-procedure diagnosis:
ruptured ectopic pregnancy vs ruptured corpus luteum
Post-procedure diagnosis:
possible ruptured omental pregnancy
Procedures performed:
laparascopy with evacuation of hemoperitoneum and Lysis of Left tubal adhesion
(partial omentectomy by general surgery)
Technique/Procedure:
Patient taken to the operating room placed on the operating table. General anesthesia was induced. Patient was placed in the lithotomy position in yellowfin stirrups. Patient was prepped and draped in usual sterile fashion after Foley catheter was placed to continuous drainage. Timeout was performed. Sponge forceps was inserted in the posterior vaginal vault. I then changed my outer gloves and directed my attention to the abdomen. The inferior aspect of the umbilicus was infiltrated with 5 cc of local anesthetic. A vertical incision was made in the inferior umbilicus. Varies needle was inserted and the abdominal cavity was insufflated to pressure 15 mmHg after hanging drop test implied appropriate placement. 12 mm bladed trocar was placed the laparoscope was placed under direct visualization was apparent that the peritoneum had not been entered. The fascial edges of the incision were grasped and pulled up and the trocar was again placed in peritoneum was entered and the laparoscope was placed under direct visualization and it was apparent that the port had been completely placed at that point. The balloon collar was insufflated with air. There was immediately noted to be a significant hemoperitoneum.
5 mm ports were placed in the right and left lower quadrant after infiltration with local anesthetic using transillumination and direct visualization to avoid injury to vascular structures. The pelvis was thoroughly explored and no source of bleeding could be found. Both tubes appeared normal with the exception of a dense adhesion from the left tube to bowel. This incision was fairly elongated and was easily desiccated and divided using LigaSure device. There were noted to be adhesions of the uterus to the anterior abdominal wall obliterating the anterior cul-de-sac. Are also noted to be vesicular appearing lesions in the right ovarian fossa. Further evacuation of blood and clots revealed that there there was what initially appeared to be very adherent blood clot to the omentum. On further inspection this blood clot could not easily be peeled or washed off of the omentum and therefore's thought to possibly be a side effect and ectopic pregnancy. General surgeon was called in and performed a partial omentectomy to remove that suspected implantation site. Pelvis once then again carefully inspected and no further bleeding was noted. The lower abdominal ports were removed under direct visualization and good hemostasis was apparent. The gas was desufflated and the umbilical port was removed. The fascial edges were reapproximated using 2-0 Vicryl on a UR 6 needle. The skin incisions were closed with 3-0 Monocryl and covered with Dermabond. The sponge stick was removed from vagina.
Operative findings:
right corpus luteum cyst, normal left ovary dense adhesion of left tube to large bowel, o/w normal bilateral tubes, vesicular implants in Right ovarian fossa suspicious for endometriosis, adhesion in anterior culdsac. Normal appearing uterus. Adherent clots vs ectopic pregnancy on omentum
Complications: none
Estimated blood loss in ml's: none, ~450cc hemoperitoneum evacuated.
Specimens removed/altered: portion of omentum
Implant(s): none
Urine output:
clear
