NVobgynCoder
Contributor
I'm trying to determine if the best way to code this case would be to report:
58571
38571-59
49329-51
or
58548-52 the only reason I would report -52 is because they DID NOT do any para-aortic sampling. Otherwise this code would fit what they did perfectly!
PREOPERATIVE DIAGNOSIS: Stage IB2 squamous cell carcinoma of the cervix.
POSTOPERATIVE DIAGNOSIS: Stage IB2 squamous cell carcinoma of the cervix.
PROCEDURE PERFORMED: Da Vinci assisted radical hysterectomy, bilateral
salpingo-oophorectomy, and bilateral pelvic lymph node dissection.
SPECIMENS: Uterus, cervix, upper vagina, parametrium, bilateral tubes and
ovaries, right pelvic lymph nodes, and left pelvic lymph nodes.
PROCEDURE IN DETAIL: The patient was taken to the operating room, where
general anesthesia was found to be adequate. She was prepped and draped in a
normal sterile fashion in a dorsal lithotomy position on a beanbag with the
arms tucked. Foley catheter was inserted into the bladder. Weighted speculum
and the right-angle retractor was used to visualize the cervix. Again, there
were no ectocervical lesions, but it was noted to be somewhat enlarged in the
upper portion of the cervix, lower portion of the uterus. She was sequentially
dilated without difficulty and the uterine manipulator was stitched to the
cervix at the 12 and 6 o'clock position. After gown and gloves were changed,
attention was then turned to the abdomen.
An 8 mm incision was made halfway between the xiphoid and the umbilicus with
the scalpel. This was then opened with Bovie cauterization. The subcutaneous
fat bluntly dissected with a Kocher. The fascia grabbed, tented up, and a
Veress needle was inserted into the abdomen, and the abdomen was insufflated
with CO2 gas.
The 8.5 mm robotic camera trocar was then placed through this incision without
difficulty. The camera was inserted, and there was noted to be no injury to
the underlying tissues. Two bilateral trocars were then placed under direct
visualization without difficulty. The patient was then placed in steep
Trendelenburg position in the omentum and the bowels were then gently moved
into the upper abdomen without difficulty. Attention was then turned to the
pelvis. The left round ligament was identified, doubly sealed and cut, and the
peritoneal reflection along the IP ligament was then extended using Bovie
cauterization. The retroperitoneal space was opened. The ureter was
identified well below the level of the IP ligament. It was doubly sealed, cut,
and ligated with the EnSeal. The posterior peritoneal reflection was then
extended toward the uterine ovarian ligament. In the process of moving from
the left side to the right side, there was some traction placed on the round
ligament attached to the uterus and there was some tearing in this area. The
myometrium was then thinned in this area and the uterine manipulator did
perforate at this area. A 0 Vicryl suture was then placed to obtain moderate
hemostasis. Attention was then turned to the right where the same procedure
was done. Attention was then turned anteriorly where the anterior leaf of the
peritoneum was then extended towards the midline bilaterally. The bladder was
tented up and then dissected off of the lower uterine segment, cervix, and
upper vagina using blunt and electrocautery dissection. Attention was then
turned to the left ureter, which was dissected off of the medial aspect of the
peritoneal reflection towards the parametrial tissue. The ureter was then
tunneled out and the uterine vessels were identified, skeletonized, sealed, and
cut just lateral to the ureter. This was then tented up and the ureter was
continued to be dissected out towards the bladder tunneled by taking the
parametrial tissue above this using the EnSeal and Bovie cauterization. This
was done until the ureter was dissected out to the level of the bladder, which
was well below the level of the external os freeing the parametrium. Attention
was then turned to the right where the same procedure was done. Attention was
then turned to the right uterosacral ligament, which was then skeletonized
keeping the ureter lateral and visualized at all times. The uterosacral
ligament was then sealed and cut using the EnSeal device towards the upper
vagina. The same was done on the left. A circumferential incision was then
made at the inferior aspect of the green covering around the vagina freeing the
upper vagina, cervix, uterus, bilateral tubes and ovaries, and bilateral
parametrium. This was then delivered through the vagina and sent for permanent
evaluation. The pelvis was copiously irrigated and then the vagina was
reapproximated using a V-Loc suture in a running fashion with 2 back-end
stitches after the right apex. Attention was then turned to the left pelvic
lymph node dissection. The perivesical space was then additionally opened and
the left lymph nodes were dissected off of the lower common, the left external
iliac, the left internal iliac above the level of the obturator nerve superior
to the circumflex artery, lateral to the ureter, and superior vesical artery
and medial to the genitofemoral nerve. It was then placed in an EndoCatch bag.
Attention was then turned to the right where the same procedure was done.
These were also placed in a bag. At this point in time, the abdomen and pelvis
were re-irrigated and good hemostasis was noted. This was ensured using
FloSeal in the pelvic lymph node dissection bed as well as along the vaginal
cuff and the posterior bladder. Before we did this, we did backfill the
bladder with 120 mL of blue dyed normal saline, and there was no injury or
denuding of the bladder appreciated. The patient was then given IV indigo
carmine, and there was no expulsion of blue dye in the pelvis. Attention was
then turned to the upper abdomen, which was inspected and there was no injury
noted to the bowel or other organs. Attention was then returned to the pelvis.
This was hemostatic and there was no evidence of blue dye from the ureters or
the bladder. At this point in time, the procedure was ended. All instruments
were removed and all counts were correct x2. The 12 mm accessory port in the
right upper quadrant was then inspected. The fascial edges were grasped and
reapproximated with an 0 Vicryl suture. The skin was then reapproximated with
4-0 Vicryl and covered with Dermabond glue. All counts were correct the 2nd
time. The patient was extubated and taken to the recovery room in stable
condition.
58571
38571-59
49329-51
or
58548-52 the only reason I would report -52 is because they DID NOT do any para-aortic sampling. Otherwise this code would fit what they did perfectly!
PREOPERATIVE DIAGNOSIS: Stage IB2 squamous cell carcinoma of the cervix.
POSTOPERATIVE DIAGNOSIS: Stage IB2 squamous cell carcinoma of the cervix.
PROCEDURE PERFORMED: Da Vinci assisted radical hysterectomy, bilateral
salpingo-oophorectomy, and bilateral pelvic lymph node dissection.
SPECIMENS: Uterus, cervix, upper vagina, parametrium, bilateral tubes and
ovaries, right pelvic lymph nodes, and left pelvic lymph nodes.
PROCEDURE IN DETAIL: The patient was taken to the operating room, where
general anesthesia was found to be adequate. She was prepped and draped in a
normal sterile fashion in a dorsal lithotomy position on a beanbag with the
arms tucked. Foley catheter was inserted into the bladder. Weighted speculum
and the right-angle retractor was used to visualize the cervix. Again, there
were no ectocervical lesions, but it was noted to be somewhat enlarged in the
upper portion of the cervix, lower portion of the uterus. She was sequentially
dilated without difficulty and the uterine manipulator was stitched to the
cervix at the 12 and 6 o'clock position. After gown and gloves were changed,
attention was then turned to the abdomen.
An 8 mm incision was made halfway between the xiphoid and the umbilicus with
the scalpel. This was then opened with Bovie cauterization. The subcutaneous
fat bluntly dissected with a Kocher. The fascia grabbed, tented up, and a
Veress needle was inserted into the abdomen, and the abdomen was insufflated
with CO2 gas.
The 8.5 mm robotic camera trocar was then placed through this incision without
difficulty. The camera was inserted, and there was noted to be no injury to
the underlying tissues. Two bilateral trocars were then placed under direct
visualization without difficulty. The patient was then placed in steep
Trendelenburg position in the omentum and the bowels were then gently moved
into the upper abdomen without difficulty. Attention was then turned to the
pelvis. The left round ligament was identified, doubly sealed and cut, and the
peritoneal reflection along the IP ligament was then extended using Bovie
cauterization. The retroperitoneal space was opened. The ureter was
identified well below the level of the IP ligament. It was doubly sealed, cut,
and ligated with the EnSeal. The posterior peritoneal reflection was then
extended toward the uterine ovarian ligament. In the process of moving from
the left side to the right side, there was some traction placed on the round
ligament attached to the uterus and there was some tearing in this area. The
myometrium was then thinned in this area and the uterine manipulator did
perforate at this area. A 0 Vicryl suture was then placed to obtain moderate
hemostasis. Attention was then turned to the right where the same procedure
was done. Attention was then turned anteriorly where the anterior leaf of the
peritoneum was then extended towards the midline bilaterally. The bladder was
tented up and then dissected off of the lower uterine segment, cervix, and
upper vagina using blunt and electrocautery dissection. Attention was then
turned to the left ureter, which was dissected off of the medial aspect of the
peritoneal reflection towards the parametrial tissue. The ureter was then
tunneled out and the uterine vessels were identified, skeletonized, sealed, and
cut just lateral to the ureter. This was then tented up and the ureter was
continued to be dissected out towards the bladder tunneled by taking the
parametrial tissue above this using the EnSeal and Bovie cauterization. This
was done until the ureter was dissected out to the level of the bladder, which
was well below the level of the external os freeing the parametrium. Attention
was then turned to the right where the same procedure was done. Attention was
then turned to the right uterosacral ligament, which was then skeletonized
keeping the ureter lateral and visualized at all times. The uterosacral
ligament was then sealed and cut using the EnSeal device towards the upper
vagina. The same was done on the left. A circumferential incision was then
made at the inferior aspect of the green covering around the vagina freeing the
upper vagina, cervix, uterus, bilateral tubes and ovaries, and bilateral
parametrium. This was then delivered through the vagina and sent for permanent
evaluation. The pelvis was copiously irrigated and then the vagina was
reapproximated using a V-Loc suture in a running fashion with 2 back-end
stitches after the right apex. Attention was then turned to the left pelvic
lymph node dissection. The perivesical space was then additionally opened and
the left lymph nodes were dissected off of the lower common, the left external
iliac, the left internal iliac above the level of the obturator nerve superior
to the circumflex artery, lateral to the ureter, and superior vesical artery
and medial to the genitofemoral nerve. It was then placed in an EndoCatch bag.
Attention was then turned to the right where the same procedure was done.
These were also placed in a bag. At this point in time, the abdomen and pelvis
were re-irrigated and good hemostasis was noted. This was ensured using
FloSeal in the pelvic lymph node dissection bed as well as along the vaginal
cuff and the posterior bladder. Before we did this, we did backfill the
bladder with 120 mL of blue dyed normal saline, and there was no injury or
denuding of the bladder appreciated. The patient was then given IV indigo
carmine, and there was no expulsion of blue dye in the pelvis. Attention was
then turned to the upper abdomen, which was inspected and there was no injury
noted to the bowel or other organs. Attention was then returned to the pelvis.
This was hemostatic and there was no evidence of blue dye from the ureters or
the bladder. At this point in time, the procedure was ended. All instruments
were removed and all counts were correct x2. The 12 mm accessory port in the
right upper quadrant was then inspected. The fascial edges were grasped and
reapproximated with an 0 Vicryl suture. The skin was then reapproximated with
4-0 Vicryl and covered with Dermabond glue. All counts were correct the 2nd
time. The patient was extubated and taken to the recovery room in stable
condition.