Hello OB/GYN Group,
This patient had critical medical surgeries within hours of all of them and I am needing guidance for this extremely difficult life saving procedure:
8/19/2025 8:49 AM
EXPLORATORY LAPAROTOMY,HYSTREROTOMY,EVACUATION OF IUFD CONTENTS, BILATERAL INTERNAL ILIAC ARTERY LIGATION,ABTHERA PLACEMENT.
WOUND VAC PLACEMENT / CHANGE / REMOVAL
1. Description of Procedure: The patient was prepped and draped in the standard sterile fashion. A large midline laparotomy incision was rapidly made to enter the abdominal cavity. I immediately packed the pelvis and all 4 quadrants after evacuating 1 to 2 L of blood. I then sequentially removed the packing. There was no noted bleeding from the spleen, liver, stomach, small bowel, colon, or abdominal retroperitoneum. All bleeding appeared to be emanating from the pelvis. The uterus was significantly dilated and difficult to mobilize. There appeared to be significant and persistent bleeding emanating from deep in the pelvis. After significant attempts at uterine salvage, Dr. A, OBGYN, and myself were unable to definitively localize or control the bleeding that was emanating from the deep uterus. The patient remained in hemorrhagic shock requiring continue MTP with prior cardiac arrest and we therefore decided to perform a resuscitative hysterotomy. A midline apical hysterotomy was made to enter the uterus. Two fetuses and the placenta were removed. The hysterotomy was then closed in a running locked fashion. After this we had significantly improved mobilization. We then took down the deep lateral peritoneal attachments of the uterus for exploration. At this time Dr. B, OBGYN, arrived to assist. At this point there were multiple sites of bloody oozing. The primary source appeared to be emanating from the uterus by the right uterosacral ligament. This was suture-ligated. There however was still significant bloody oozing from the region. We therefore ligated the bilateral internal iliac arteries with 0 silk suture. After this we appeared to have significantly improved hemostasis. There was no other overt area of hemorrhage. Given the developing coagulopathy and hemodynamic instability I elected to perform a temporary abdominal closure. Fibrillar was placed in the deeper pelvis at the site where there was the most significant bleeding. I then packed the pelvis with 2 laparotomy pads. An ABThera wound VAC was then placed in standard fashion. She was then sent to the ICU for continued resuscitation and monitoring.
8/19/2025 1:24 PM
EXPLORATORY LAPAROTOMY, HYSTERCTOMY WITH RIGHT FALLOPIAN TUBE
WOUND VAC PLACEMENT / CHANGE / REMOVAL
HYSTERECTOMY - ABDOMINAL
SALPINGECTOMY
2. Description of Procedure: The prior ABThera wound VAC was removed. The abdomen was then rapidly prepped prepped with Betadine. The internal ABThera drape was then removed. A significant volume of hemoperitoneum was evacuated. I then packed into the pelvis. This was able to control the bleeding. I again rapidly explored the abdominal cavity and found no bleeding in the liver, spleen, stomach, small bowel, colon, or abdominal retroperitoneum. I then removed the packing within the pelvis and there appeared to be significant bleeding from both the hysterotomy site and the deep lateral uterine wall. At this point I reached out to Dr. B, OBGYN, who was able to come back and assist with the remainder of the case. We then performed a hysterectomy by taking down the lateral peritoneal attachments of the uterus and transecting at the cervix. The uterus was handed off for pathology. The cervical cuff was then closed with multiple Vicryl sutures in a locked fashion. Additionally the right fallopian tube appeared engorged. This as well was resected and sent for pathology. At this point we appeared to have significantly improved hemostasis within the pelvis. The patient however remained significantly coagulopathic and there was continued slow oozing from multiple sites. The hysterectomy site was then covered in Floseal and fibrillar are was placed in the lateral retroperitoneal sites. The pelvis was then packed with 3 laparotomy pads. An ABThera wound VAC was again placed in standard fashion. She was sent back to the ICU for continued resuscitation and monitoring.
Date of Service: 8/19/2025 6:40 PM
EXPLORATORY LAPAROTOMY, BILATERAL INTERNAL ILIAC ARTERY LIGATION, REPAIR OF RIGHT UTEROSACRAL LIGAMENT AND POSTERIOR UTERINE BODY
3. Description of procedure: Upon presentation to the operating room the patient had already undergone exploratory laparotomy with classical cesarean delivery of a previable twin gestation. The right utero-ovarian ligament had been transected. The bilateral round ligaments had been transected. Given the brisk bleeding noted to be coming from the uterus as well as the right uterosacral and right cardinal ligament, the retroperitoneum was opened lateral and parallel to the gonadal vessels. The ureters were identified crossing the bifurcation of the common iliac artery. The paravesical and pararectal spaces were opened. An attempt was made to identify the right uterine artery proximal to the superior vesicle artery on the right. At this time the right uterine artery was noted to be avulsed with significant bleeding coming from this region as well as from the internal iliac artery. The internal iliac artery was isolated in the usual fashion and suture-ligated with a silk tie. Following this the ureter was placed on a vessel loop. The bleeding from the right uterosacral ligament was oversewn with running locking sutures of 0 Vicryl. Hemostasis was obtained. In a similar fashion the distal branches of the uterine artery along the right body of the uterus were oversewn with running locking hemostatic sutures and hemostasis of the lateral uterine wall was noted. The left utero-ovarian ligament was then transected and suture transfixed. Following this, there was noted to be significant bleeding from the left uterine artery within the distal portion of the cardinal ligament. This was rendered hemostatic following isolation and suture ligation of the internal iliac artery below the level of the posterior branch. At this time the bleeding was noted to be significantly improved. The patient was undergoing active resuscitation of blood products by anesthesia. Fibrillar was placed in the bilateral obturator spaces where venous bleeding was noted. Following this she was transferred back to the care of Dr. A for ABThera placement and transfer to the intensive care unit.
Date of Service: 8/19/2025 6:53 PM
PROCEDURE NOTE: EXPLORATORY LAPAROTOMY, SUPRACERVICAL HYSTERCTOMY, RIGHT SALPINGECTOMY
4. Description of Procedure: Following stabilization in the ICU with Abthera in place, the patient was noted to have increased blood in her wound management system. She was taken back to the operating room for exploration with findings of 1000 mL blood coagulum in the peritoneal cavity and persistent bleeding from the hysterotomy site. Upon arrival to the operating room, the abdomen was opened and the pelvis exposed. The broad ligament was divided and the anterior leaf of the broad ligament opened to create a bladder flap. Persistent bleeding was also noted from the rectovaginal septum at this time. The uterine vessels along the body of the uterus were transected and suture transfixed to the level of the cervix. At this time, the cervix was amputated from the uterus and the uterus removed. The remaining cervix was oversewn with hemostatic suture of 0-Vicryl incorporating the posterior pelvic peritoneum to close the rectovaginal septum and reinforce the right uterosacral ligament repair. Small volume bleeding was noted from the right adnexa. The fallopian tube was resected and the meso-ovarium oversewn. Hemostasis was noted of the right adnexa. The left adnexa was inspected and noted to be hemostatic. Small volume venous bleeding was noted in the obturator spaces bilaterally as well as over the anterior portion of the cervical stump. Vista-Seal was placed by Dr. A and fibrillar replaced in the obturator spaces. The care of the patient was transferred back to the care of Dr. A and the ICU team following completion of the hysterectomy.
From what I can see, I believe the 58180 would be one of my choices of codes and I know I'm missing more CPT codes, any guidance is greatly appreciated as I am challenged on this one. Could 59820 be used for the removal of the twin 14 wk fetuses?
Thank you all so much for taking the time to assist and educate me.
This patient had critical medical surgeries within hours of all of them and I am needing guidance for this extremely difficult life saving procedure:
8/19/2025 8:49 AM
EXPLORATORY LAPAROTOMY,HYSTREROTOMY,EVACUATION OF IUFD CONTENTS, BILATERAL INTERNAL ILIAC ARTERY LIGATION,ABTHERA PLACEMENT.
WOUND VAC PLACEMENT / CHANGE / REMOVAL
1. Description of Procedure: The patient was prepped and draped in the standard sterile fashion. A large midline laparotomy incision was rapidly made to enter the abdominal cavity. I immediately packed the pelvis and all 4 quadrants after evacuating 1 to 2 L of blood. I then sequentially removed the packing. There was no noted bleeding from the spleen, liver, stomach, small bowel, colon, or abdominal retroperitoneum. All bleeding appeared to be emanating from the pelvis. The uterus was significantly dilated and difficult to mobilize. There appeared to be significant and persistent bleeding emanating from deep in the pelvis. After significant attempts at uterine salvage, Dr. A, OBGYN, and myself were unable to definitively localize or control the bleeding that was emanating from the deep uterus. The patient remained in hemorrhagic shock requiring continue MTP with prior cardiac arrest and we therefore decided to perform a resuscitative hysterotomy. A midline apical hysterotomy was made to enter the uterus. Two fetuses and the placenta were removed. The hysterotomy was then closed in a running locked fashion. After this we had significantly improved mobilization. We then took down the deep lateral peritoneal attachments of the uterus for exploration. At this time Dr. B, OBGYN, arrived to assist. At this point there were multiple sites of bloody oozing. The primary source appeared to be emanating from the uterus by the right uterosacral ligament. This was suture-ligated. There however was still significant bloody oozing from the region. We therefore ligated the bilateral internal iliac arteries with 0 silk suture. After this we appeared to have significantly improved hemostasis. There was no other overt area of hemorrhage. Given the developing coagulopathy and hemodynamic instability I elected to perform a temporary abdominal closure. Fibrillar was placed in the deeper pelvis at the site where there was the most significant bleeding. I then packed the pelvis with 2 laparotomy pads. An ABThera wound VAC was then placed in standard fashion. She was then sent to the ICU for continued resuscitation and monitoring.
8/19/2025 1:24 PM
EXPLORATORY LAPAROTOMY, HYSTERCTOMY WITH RIGHT FALLOPIAN TUBE
WOUND VAC PLACEMENT / CHANGE / REMOVAL
HYSTERECTOMY - ABDOMINAL
SALPINGECTOMY
2. Description of Procedure: The prior ABThera wound VAC was removed. The abdomen was then rapidly prepped prepped with Betadine. The internal ABThera drape was then removed. A significant volume of hemoperitoneum was evacuated. I then packed into the pelvis. This was able to control the bleeding. I again rapidly explored the abdominal cavity and found no bleeding in the liver, spleen, stomach, small bowel, colon, or abdominal retroperitoneum. I then removed the packing within the pelvis and there appeared to be significant bleeding from both the hysterotomy site and the deep lateral uterine wall. At this point I reached out to Dr. B, OBGYN, who was able to come back and assist with the remainder of the case. We then performed a hysterectomy by taking down the lateral peritoneal attachments of the uterus and transecting at the cervix. The uterus was handed off for pathology. The cervical cuff was then closed with multiple Vicryl sutures in a locked fashion. Additionally the right fallopian tube appeared engorged. This as well was resected and sent for pathology. At this point we appeared to have significantly improved hemostasis within the pelvis. The patient however remained significantly coagulopathic and there was continued slow oozing from multiple sites. The hysterectomy site was then covered in Floseal and fibrillar are was placed in the lateral retroperitoneal sites. The pelvis was then packed with 3 laparotomy pads. An ABThera wound VAC was again placed in standard fashion. She was sent back to the ICU for continued resuscitation and monitoring.
Date of Service: 8/19/2025 6:40 PM
EXPLORATORY LAPAROTOMY, BILATERAL INTERNAL ILIAC ARTERY LIGATION, REPAIR OF RIGHT UTEROSACRAL LIGAMENT AND POSTERIOR UTERINE BODY
3. Description of procedure: Upon presentation to the operating room the patient had already undergone exploratory laparotomy with classical cesarean delivery of a previable twin gestation. The right utero-ovarian ligament had been transected. The bilateral round ligaments had been transected. Given the brisk bleeding noted to be coming from the uterus as well as the right uterosacral and right cardinal ligament, the retroperitoneum was opened lateral and parallel to the gonadal vessels. The ureters were identified crossing the bifurcation of the common iliac artery. The paravesical and pararectal spaces were opened. An attempt was made to identify the right uterine artery proximal to the superior vesicle artery on the right. At this time the right uterine artery was noted to be avulsed with significant bleeding coming from this region as well as from the internal iliac artery. The internal iliac artery was isolated in the usual fashion and suture-ligated with a silk tie. Following this the ureter was placed on a vessel loop. The bleeding from the right uterosacral ligament was oversewn with running locking sutures of 0 Vicryl. Hemostasis was obtained. In a similar fashion the distal branches of the uterine artery along the right body of the uterus were oversewn with running locking hemostatic sutures and hemostasis of the lateral uterine wall was noted. The left utero-ovarian ligament was then transected and suture transfixed. Following this, there was noted to be significant bleeding from the left uterine artery within the distal portion of the cardinal ligament. This was rendered hemostatic following isolation and suture ligation of the internal iliac artery below the level of the posterior branch. At this time the bleeding was noted to be significantly improved. The patient was undergoing active resuscitation of blood products by anesthesia. Fibrillar was placed in the bilateral obturator spaces where venous bleeding was noted. Following this she was transferred back to the care of Dr. A for ABThera placement and transfer to the intensive care unit.
Date of Service: 8/19/2025 6:53 PM
PROCEDURE NOTE: EXPLORATORY LAPAROTOMY, SUPRACERVICAL HYSTERCTOMY, RIGHT SALPINGECTOMY
4. Description of Procedure: Following stabilization in the ICU with Abthera in place, the patient was noted to have increased blood in her wound management system. She was taken back to the operating room for exploration with findings of 1000 mL blood coagulum in the peritoneal cavity and persistent bleeding from the hysterotomy site. Upon arrival to the operating room, the abdomen was opened and the pelvis exposed. The broad ligament was divided and the anterior leaf of the broad ligament opened to create a bladder flap. Persistent bleeding was also noted from the rectovaginal septum at this time. The uterine vessels along the body of the uterus were transected and suture transfixed to the level of the cervix. At this time, the cervix was amputated from the uterus and the uterus removed. The remaining cervix was oversewn with hemostatic suture of 0-Vicryl incorporating the posterior pelvic peritoneum to close the rectovaginal septum and reinforce the right uterosacral ligament repair. Small volume bleeding was noted from the right adnexa. The fallopian tube was resected and the meso-ovarium oversewn. Hemostasis was noted of the right adnexa. The left adnexa was inspected and noted to be hemostatic. Small volume venous bleeding was noted in the obturator spaces bilaterally as well as over the anterior portion of the cervical stump. Vista-Seal was placed by Dr. A and fibrillar replaced in the obturator spaces. The care of the patient was transferred back to the care of Dr. A and the ICU team following completion of the hysterectomy.
From what I can see, I believe the 58180 would be one of my choices of codes and I know I'm missing more CPT codes, any guidance is greatly appreciated as I am challenged on this one. Could 59820 be used for the removal of the twin 14 wk fetuses?
Thank you all so much for taking the time to assist and educate me.