vmounce
Guru
Could someone help me out with the op note below? I thought CPT 58662 would be correct. I appreciate any reply.
Vickie Mounce, CPC
PREOPERATIVE DIAGNOSIS:
Unwanted fertility
POSTOPERATIVE DIAGNOSES:
Unwanted fertility.
Extensive pelvic adhesions.
Bilateral large noncommunicating hydrosalpinx.
PROCEDURE: Laparoscopy with bilateral tubal ligation.
ANESTHESIA: General.
INDICATION: This is a 41-year-old patient who had a tubal ligation, a tubal reversal, and a total of three deliveries. She had a Mirena in place that had been removed on her last visit. She opted for repeat tubal ligation. Options were explained to her and she elected to proceed with the procedure. The procedure and risks were explained to her and all of her questions were answered. The possibility of trauma, bleeding, infection, the need for a second surgery, the need for laparotomy, failure rate, and difficulty of reversal, etc., were all addressed with her.
OPERATIVE PROCEDURE: After general anesthesia with endotracheal intubation, the patient was placed in gynecological position in Allen stirrups. Betadine prep was done. Bladder catheterization and sterile drapes were placed as usual. The uterus was examined and it is anteverted. There is no adnexal mass. There is no string as the IUD had been removed. A weighted speculum is inserted. The uterine manipulator is put in place and the anterior lip of the cervix was grasped with a single-toothed tenaculum. I infiltrated the infraumbilical area with a few ml of Marcaine 0.5% with Epinephrine. A small transverse incision was made through which I inserted a Veress needle, the position of which was checked by instilling a few mL of saline with no return. The drops of saline flowed in easily. I created a pneumoperitoneum with 2.5 liters of CO2 under a pressure of less than 15 mmHg.
The Veress needle was withdrawn and a 5 mm trocar was inserted along with the laparoscope, which enabled me to see that I was well inside the abdominal cavity. There are extensive adhesions so a suprapubic trocar was then inserted just lateral to midline on the right. This was inserted under direct vision after local anesthesia and skin incision with the cold knife. A 5 mm trocar was also inserted lateral to the left epigastric vessels in paraumbilical fashion again under direct visualization. Meticulous dissection was carried out. The pelvis is completely obliterated by adhesions. Attention was done to the adhesions of the rectosigmoid and bowel that are in the midline. I was finally able to visualize the pelvis on both sides. There are bilateral noncommunicating hydrosalpinx about 5-6 cm on each side. I was able to visualize the ovaries underneath. The adhesions are mobilized and hemostasis was achieved with the bipolar forceps at a power of 30 watts. I was able to cauterize the proximal part of the tube on both sides with the bipolar forceps at a power of 30 watts. It was cauterized at multiple areas always being sure that I was away from the ureters, bowel, or any other structures. During dissection, the hydrosalpinx were opened and fluid came out which was suctioned. With the distal hydrosalpinx being opened and with proximal cauterization I was very pleased with the results. Hemostasis was achieved perfectly. It was verified also while decreasing the abdominal pressure to less than 10. Hemostasis was perfect. Irrigation of the pelvic cavity was done with saline. All the fluid was suctioned. I am pleased with the results.
The patient will be seen tomorrow for close surveillance and she will be kept longer in the recovery room for monitoring.
Vickie Mounce, CPC
PREOPERATIVE DIAGNOSIS:
Unwanted fertility
POSTOPERATIVE DIAGNOSES:
Unwanted fertility.
Extensive pelvic adhesions.
Bilateral large noncommunicating hydrosalpinx.
PROCEDURE: Laparoscopy with bilateral tubal ligation.
ANESTHESIA: General.
INDICATION: This is a 41-year-old patient who had a tubal ligation, a tubal reversal, and a total of three deliveries. She had a Mirena in place that had been removed on her last visit. She opted for repeat tubal ligation. Options were explained to her and she elected to proceed with the procedure. The procedure and risks were explained to her and all of her questions were answered. The possibility of trauma, bleeding, infection, the need for a second surgery, the need for laparotomy, failure rate, and difficulty of reversal, etc., were all addressed with her.
OPERATIVE PROCEDURE: After general anesthesia with endotracheal intubation, the patient was placed in gynecological position in Allen stirrups. Betadine prep was done. Bladder catheterization and sterile drapes were placed as usual. The uterus was examined and it is anteverted. There is no adnexal mass. There is no string as the IUD had been removed. A weighted speculum is inserted. The uterine manipulator is put in place and the anterior lip of the cervix was grasped with a single-toothed tenaculum. I infiltrated the infraumbilical area with a few ml of Marcaine 0.5% with Epinephrine. A small transverse incision was made through which I inserted a Veress needle, the position of which was checked by instilling a few mL of saline with no return. The drops of saline flowed in easily. I created a pneumoperitoneum with 2.5 liters of CO2 under a pressure of less than 15 mmHg.
The Veress needle was withdrawn and a 5 mm trocar was inserted along with the laparoscope, which enabled me to see that I was well inside the abdominal cavity. There are extensive adhesions so a suprapubic trocar was then inserted just lateral to midline on the right. This was inserted under direct vision after local anesthesia and skin incision with the cold knife. A 5 mm trocar was also inserted lateral to the left epigastric vessels in paraumbilical fashion again under direct visualization. Meticulous dissection was carried out. The pelvis is completely obliterated by adhesions. Attention was done to the adhesions of the rectosigmoid and bowel that are in the midline. I was finally able to visualize the pelvis on both sides. There are bilateral noncommunicating hydrosalpinx about 5-6 cm on each side. I was able to visualize the ovaries underneath. The adhesions are mobilized and hemostasis was achieved with the bipolar forceps at a power of 30 watts. I was able to cauterize the proximal part of the tube on both sides with the bipolar forceps at a power of 30 watts. It was cauterized at multiple areas always being sure that I was away from the ureters, bowel, or any other structures. During dissection, the hydrosalpinx were opened and fluid came out which was suctioned. With the distal hydrosalpinx being opened and with proximal cauterization I was very pleased with the results. Hemostasis was achieved perfectly. It was verified also while decreasing the abdominal pressure to less than 10. Hemostasis was perfect. Irrigation of the pelvic cavity was done with saline. All the fluid was suctioned. I am pleased with the results.
The patient will be seen tomorrow for close surveillance and she will be kept longer in the recovery room for monitoring.