rockylopez
Networker
Hello! I am hoping someone can give me any insight if the codes that I selected for this procedure are correct. CPT codes 59514, 58925, and 58700
Operative Report
POSTOPERATIVE DIAGNOSES:
1. G4, P2 female with IUP at 38 1/7 weeks.
2. Previous CS x 2
3. Abdominoplasty
4. Torsion of the right fallopian tube with necrosis
5. 8cm mature teratoma of left ovary
6. Suspected placental abruption
7. Extensive pelvic adhesions between anterior abdominal wall and uterus
PROCEDURE PERFORMED:
1. Repeat low segment transverse cesarean delivery via a Pfannensteil skin incision
2. Extensive lysis of adhesions
3. Right salpingectomy
4. Left ovarian cystectomy
SPECIMEN for PATHOLOGY:
1. Placenta with TVC.
2. Portion of right fallopian tube
3. Left ovarian cyst / Mature teratoma
FINDINGS:
1. Extensive dense scarring from Abdominoplasty and previous CS
2. Torsion of the right fallopian tube with necrosis
3. 8cm mature teratoma of left ovary
4. Suspected placental abruption
INDICATIONS:
The patient is a 30-year-old G4, P2 female with IUP at 38 1/7 weeks and 2 previous CS.
EDD: 7/7/23
The patient presented on 6/24/23 with complaints of severe RLQ pain and uterine contractions.
She had been thoroughly evaluated twice in the same week with no specific findings.
In light of the unrelenting severe, uterine contractions and history of previous CS x 2, an urgent cesarean delivery was recommended.
The risks, benefits and alternatives to a repeat cesarean delivery were discussed with the patient and her family.
All questions were answered.
Consent was obtained.
Procedure:
After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was placed.
She was placed supine position with a leftward tilt. The Foley catheter was inserted.
The perineum and abdomen were prepped and draped in the usual sterile fashion.
A time out was performed and the OR team agreed to the planned procedure.
After adequate anesthesia was verified, the abdominal skin was opened with a knife via a Pfannensteil skin incision after excision of the previous dense scar.
The Bovie was used to dissect down to the underlying fascia which was also opened using electrocautery
The superior aspect of the fascial incision was grasped with Kocher clamps and elevated.
Dissection was carried out with the Bovie. Dense adhesions were encountered due to a history of abdominoplasty.
The rectus muscles were then bluntly separated in the midline and the peritoneum identified in a clear area and entered bluntly.
The peritoneum was stretched manually.
Exposure of the lower uterine segment required extensive lysis of dense adhesions between the anterior abdominal wall and the anterior uterus.
The Alexis-O retractor was then placed.
The vesicouterine peritoneum was then identified and the lower uterine segment of the uterus was incised in a transverse fashion with the scalpel.
The incision was then extended laterally with the fingers.
The fetal head was grasped , elevated and delivered from the cephalic presentation atraumatically.
The vigorous famale infant was allowed a one minuite delayed cord clamping.
The cord was then clamped and cut, and infant was handed off to waiting neonatal team.
No cord gases were indicated.
Upon delivery of the infant, a large amount of bloody fluid suspicious for an abruption was noted.
The placenta was manually delivered and indeed appeared to have had a small abruption.
The uterus was then exteriorized and was cleared of all clots and debris.
The hysterotomy was then repaired with 0-Monocryl in a running locking fashion.
Excellent hemostasis noted.
A second layer of running 0-Monocryl was placed.
The pelvis was flushed with copious amounts of normal saline and inspected.
The right fallopian tube from midportion to the fimbria was noted to be torsed around a dense band of scar tissue and necrotic.
The base was clamped with a hemostat and double tied.
The edematous tube was removed and sent to pathology. The right ovary is WNL.
Next, the left ovary was inspected and found to have an approximately 8 cm mature teratoma.
In light of the high risk of torsion, the decision was taken to perform an ovarian cystectomy.
Using the metzenbaum scissors, the cyst was completely shelled out and sent to pathology.
The ovarioplasty was completed with 2-0 Vicryl sutures. Excellent hemostasis was obtained.
The hysterotomy and bladder were then reinspected and found to be oozing from the adhesions.
Powdered surgicell was then applied. Hemostasis was obtained.
The peritoneum was then reapproximated with a single purse string suture of 0-Vicryl.
The muscle and fascia were then examined and found to be hemostatic.
The fascial incision was reapproximated with 0-Vicryl suture in a running fashion.
The subcutaneous fatty layer was then reapproximated using 3-0 Vicryl suture.
The skin closure was made in a subcuticular fashion with 4-0 Monocryl suture.
The skin was sealed with dermabond.
This concluded the procedure.
Sponge, lap and needle and instrument counts were stated to be correct times 2.
Hemostasis was excellent.
The patient tolerated the procedure well.
She was then taken to the recovery room in stable condition.
The infant was taken to the new born nursery.
Operative Report
POSTOPERATIVE DIAGNOSES:
1. G4, P2 female with IUP at 38 1/7 weeks.
2. Previous CS x 2
3. Abdominoplasty
4. Torsion of the right fallopian tube with necrosis
5. 8cm mature teratoma of left ovary
6. Suspected placental abruption
7. Extensive pelvic adhesions between anterior abdominal wall and uterus
PROCEDURE PERFORMED:
1. Repeat low segment transverse cesarean delivery via a Pfannensteil skin incision
2. Extensive lysis of adhesions
3. Right salpingectomy
4. Left ovarian cystectomy
SPECIMEN for PATHOLOGY:
1. Placenta with TVC.
2. Portion of right fallopian tube
3. Left ovarian cyst / Mature teratoma
FINDINGS:
1. Extensive dense scarring from Abdominoplasty and previous CS
2. Torsion of the right fallopian tube with necrosis
3. 8cm mature teratoma of left ovary
4. Suspected placental abruption
INDICATIONS:
The patient is a 30-year-old G4, P2 female with IUP at 38 1/7 weeks and 2 previous CS.
EDD: 7/7/23
The patient presented on 6/24/23 with complaints of severe RLQ pain and uterine contractions.
She had been thoroughly evaluated twice in the same week with no specific findings.
In light of the unrelenting severe, uterine contractions and history of previous CS x 2, an urgent cesarean delivery was recommended.
The risks, benefits and alternatives to a repeat cesarean delivery were discussed with the patient and her family.
All questions were answered.
Consent was obtained.
Procedure:
After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was placed.
She was placed supine position with a leftward tilt. The Foley catheter was inserted.
The perineum and abdomen were prepped and draped in the usual sterile fashion.
A time out was performed and the OR team agreed to the planned procedure.
After adequate anesthesia was verified, the abdominal skin was opened with a knife via a Pfannensteil skin incision after excision of the previous dense scar.
The Bovie was used to dissect down to the underlying fascia which was also opened using electrocautery
The superior aspect of the fascial incision was grasped with Kocher clamps and elevated.
Dissection was carried out with the Bovie. Dense adhesions were encountered due to a history of abdominoplasty.
The rectus muscles were then bluntly separated in the midline and the peritoneum identified in a clear area and entered bluntly.
The peritoneum was stretched manually.
Exposure of the lower uterine segment required extensive lysis of dense adhesions between the anterior abdominal wall and the anterior uterus.
The Alexis-O retractor was then placed.
The vesicouterine peritoneum was then identified and the lower uterine segment of the uterus was incised in a transverse fashion with the scalpel.
The incision was then extended laterally with the fingers.
The fetal head was grasped , elevated and delivered from the cephalic presentation atraumatically.
The vigorous famale infant was allowed a one minuite delayed cord clamping.
The cord was then clamped and cut, and infant was handed off to waiting neonatal team.
No cord gases were indicated.
Upon delivery of the infant, a large amount of bloody fluid suspicious for an abruption was noted.
The placenta was manually delivered and indeed appeared to have had a small abruption.
The uterus was then exteriorized and was cleared of all clots and debris.
The hysterotomy was then repaired with 0-Monocryl in a running locking fashion.
Excellent hemostasis noted.
A second layer of running 0-Monocryl was placed.
The pelvis was flushed with copious amounts of normal saline and inspected.
The right fallopian tube from midportion to the fimbria was noted to be torsed around a dense band of scar tissue and necrotic.
The base was clamped with a hemostat and double tied.
The edematous tube was removed and sent to pathology. The right ovary is WNL.
Next, the left ovary was inspected and found to have an approximately 8 cm mature teratoma.
In light of the high risk of torsion, the decision was taken to perform an ovarian cystectomy.
Using the metzenbaum scissors, the cyst was completely shelled out and sent to pathology.
The ovarioplasty was completed with 2-0 Vicryl sutures. Excellent hemostasis was obtained.
The hysterotomy and bladder were then reinspected and found to be oozing from the adhesions.
Powdered surgicell was then applied. Hemostasis was obtained.
The peritoneum was then reapproximated with a single purse string suture of 0-Vicryl.
The muscle and fascia were then examined and found to be hemostatic.
The fascial incision was reapproximated with 0-Vicryl suture in a running fashion.
The subcutaneous fatty layer was then reapproximated using 3-0 Vicryl suture.
The skin closure was made in a subcuticular fashion with 4-0 Monocryl suture.
The skin was sealed with dermabond.
This concluded the procedure.
Sponge, lap and needle and instrument counts were stated to be correct times 2.
Hemostasis was excellent.
The patient tolerated the procedure well.
She was then taken to the recovery room in stable condition.
The infant was taken to the new born nursery.
