mbort
True Blue
I'm trying to avoid using an unlisted lap code. Anyone have any ideas??
POSTOPERATIVE DIAGNOSES: 1. This is a XX-year-old female with pelvic pain and dysmenorrhea. She also has unexplained abdominal pain. In addition, she has some staples, which have wandered from the appendectomy site down to the serosa of the uterus and the peritoneum of the cul-de-sac. She also has a staple on the left ovary. She also has a spot of possible endometriosis on the cul-de-sac.
PROCEDURES PERFORMED: 1. Laparoscopy with excision of staples, which have wandered into the pelvic area.
2. She also has a laparoscopic peritoneal biopsy done of some abnormal tissue in the cul-de-sac.
The patient went to the operative suite. She got a general endotracheal tube anesthetic. She was then placed in the dorsal lithotomy position and given the usual sterile prep and drape. Exam under anesthesia revealed a normal vulva and vagina. The cervix looked normal. The uterus was normal in size and shape. The adnexa revealed no masses bilaterally. Next, an acorn cannula and single tooth tenaculum were applied to the cervix. She than had 0.5-cm incision made in the umbilicus through which an Optiview trocar was placed under direct vision using the laparoscope. Then, accessory incisions were made in the right and left lower quadrants through which 5-mm trocars were placed under direct vision using the laparoscope. Visualization of the upper abdomen revealed normal looking liver, omentum, and intestines. She had surgical absence of her gallbladder. She had surgical absence of her appendix. There were staples around the appendectomy site. In the pelvis, the patient had normal looking fallopian tubes bilaterally. She had normal looking ovaries bilaterally. She did, however, have one staple on her left ovary on the superficial aspect of that ovary and that staple was removed. She also had staples on the serosa of the fundus of the uterus and these were likewise removed with laparoscopic grasping instruments to remove these staples. She also had staples deep in the cul-de-sac, and these were also removed from the cul-de-sac using laparoscopic grasping instrument. She had one tiny little spot of brownish tissue deep in the cul-de-sac. The size of this area was about 1 to 2 mm. This area was grasped with a laparoscopic grasping instrument and then cut free and excised using laparoscopic scissors. The specimen was sent to pathology. Otherwise, her entire pelvis looked completely normal. Her uterus looked normal. The pelvic sidewalls were normal. There was no sign of any obvious endometriosis. The bladder area looked normal. The sigmoid colon and rectal area looked normal. The pelvis was irrigated, and the irrigation was done using saline. The saline was then removed, and then, the patient had a chromohydrotubation done using dilute methylene blue dye just to make sure that our fallopian tubes were normal. There was easy fill and spill of dye from each fallopian tube thus documenting normal tubal patency bilaterally. The operation was then terminated by removing the instruments from the abdomen. The single-tooth tenaculum and acorn cannula were removed from the cervix. The incisions were closed using 4-0 Vicryl. The patient then went to the recovery room in excellent condition. There were no complications.
(Biopsy still pending)
I have the 58350 for the chromotubation, looking for assitance for the staple removal done laproscopically
POSTOPERATIVE DIAGNOSES: 1. This is a XX-year-old female with pelvic pain and dysmenorrhea. She also has unexplained abdominal pain. In addition, she has some staples, which have wandered from the appendectomy site down to the serosa of the uterus and the peritoneum of the cul-de-sac. She also has a staple on the left ovary. She also has a spot of possible endometriosis on the cul-de-sac.
PROCEDURES PERFORMED: 1. Laparoscopy with excision of staples, which have wandered into the pelvic area.
2. She also has a laparoscopic peritoneal biopsy done of some abnormal tissue in the cul-de-sac.
The patient went to the operative suite. She got a general endotracheal tube anesthetic. She was then placed in the dorsal lithotomy position and given the usual sterile prep and drape. Exam under anesthesia revealed a normal vulva and vagina. The cervix looked normal. The uterus was normal in size and shape. The adnexa revealed no masses bilaterally. Next, an acorn cannula and single tooth tenaculum were applied to the cervix. She than had 0.5-cm incision made in the umbilicus through which an Optiview trocar was placed under direct vision using the laparoscope. Then, accessory incisions were made in the right and left lower quadrants through which 5-mm trocars were placed under direct vision using the laparoscope. Visualization of the upper abdomen revealed normal looking liver, omentum, and intestines. She had surgical absence of her gallbladder. She had surgical absence of her appendix. There were staples around the appendectomy site. In the pelvis, the patient had normal looking fallopian tubes bilaterally. She had normal looking ovaries bilaterally. She did, however, have one staple on her left ovary on the superficial aspect of that ovary and that staple was removed. She also had staples on the serosa of the fundus of the uterus and these were likewise removed with laparoscopic grasping instruments to remove these staples. She also had staples deep in the cul-de-sac, and these were also removed from the cul-de-sac using laparoscopic grasping instrument. She had one tiny little spot of brownish tissue deep in the cul-de-sac. The size of this area was about 1 to 2 mm. This area was grasped with a laparoscopic grasping instrument and then cut free and excised using laparoscopic scissors. The specimen was sent to pathology. Otherwise, her entire pelvis looked completely normal. Her uterus looked normal. The pelvic sidewalls were normal. There was no sign of any obvious endometriosis. The bladder area looked normal. The sigmoid colon and rectal area looked normal. The pelvis was irrigated, and the irrigation was done using saline. The saline was then removed, and then, the patient had a chromohydrotubation done using dilute methylene blue dye just to make sure that our fallopian tubes were normal. There was easy fill and spill of dye from each fallopian tube thus documenting normal tubal patency bilaterally. The operation was then terminated by removing the instruments from the abdomen. The single-tooth tenaculum and acorn cannula were removed from the cervix. The incisions were closed using 4-0 Vicryl. The patient then went to the recovery room in excellent condition. There were no complications.
(Biopsy still pending)
I have the 58350 for the chromotubation, looking for assitance for the staple removal done laproscopically
