I have a patient that underwent a lap hysterectomy with bil salpingectomy back in June and now is having another procedure done and I am unsure what to code :?
/P: 37yo G3P3003 with vaginal cuff dehiscence and prolapse of ovary through vaginal cuff. I discussed this condition and need for displacement of ovary and repair of vaginal cuff. Risks of not doing this discussed.
Risks of surgery discussed as well including infection, bleeding, need for transfusion, injury to adjacent organs, need for more surgery, pain, pelvic pain, pain with sex, possible need for laparoscopy, possible removal of ovary if nonviable etc.
Discussed postop care, postop rx's and postop recovery. Avoid intercourse for 6plus weeks etc.
op note:
Repair of vaginal cuff, displacement of ovary from vaginal cuff prolapse into abdomen, biopsy of ovary Procedure Note
Indications: 37yo G3P3003 with vaginal cuff dehiscence and prolapse of ovary through vaginal cuff.
Pre-operative Diagnosis: same
Post-operative Diagnosis: same
Operation: Total vaginal hysterectomy????? I believe this is incorrect
Surgeon: , MD
Assistants LSA. No qualified resident available
Anesthesia: General endotracheal anesthesia
Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The patient was taken to Operating Room # 2, identified x 2 and the procedure verified as total vaginal hysterectomy. A Time Out was held and the above information confirmed.
After induction of anesthesia, the patient was placed in high leg holders position and draped and prepped in the usual sterile manner. In and out bladder drainage performed with straight catheter.
Weighted speculum placed and 2cm of ovary noted to be prolapsing through vaginal cuff. A 2-3cm defect noted at vaginal cuff, vaginal cuff appeared healthy/viable with spotting noted around edges. Allis clamps used to grasp angles of cuff and then ring forcep and sponge stick used to assess ovary. Small piece of ovary denuded off, sent to pathology. Ovary was advanced past cuff and noted to be not bleeding, Vaginal cuff inspected circumferentially and no bowel or ovarian tissue noted.
The vesicoperitoneal reflection was inspected and a right angle retractor was placed to lift the bladder out of the operative field. Intraabdominal contents were confirmed and the bladder was again I/O drained.
Both ovaries appeared normal and were left in situ, no bleeding noted from ovaries.
Vaginal cuff angle sutures were placed incorporating the utero-sacral ligaments that had been previously tagged for support. The vaginal cuff was then closed with a series of interrupted stitches of 0 Vicryl.Hemostasis was observed.
A foley catheter was placed with clear urine at completion of cuff closure.
Instrument, sponge, and needle counts were correct prior to cuff closure and at the conclusion of the case.
Findings: ovary, white and viable appearing prolapsed through vaginal cuff, 2-3cm defect at vaginal cuff, ovary replaced into abdominal cavity appeared viable/white healthy appearing.
Estimated Blood Loss: less than 10cc mL
Drains: foley
Total IV Fluids: 400 ml
Specimens: ovarian tissue from left ovary
Complications: None; patient tolerated the procedure well.
Disposition: stable to the PACU
Condition: stable
Attending Attestation: I was present and scrubbed for the entire procedure.
Path results: Left ovarian tissue.
GROSS:
Specimen labeled left ovarian tissue is a 2.1 x 2.0 x 1.0 cm aggregate
of glistening pink-tan to tan-white fragments. Representatively
submitted in 1A-1B.
LMG/sc
MICROSCOPIC DIAGNOSIS:
Left ovarian tissue, excision: Benign fibroadipose tissue with
granulation tissue, fibrinous
material, acute inflammation and focal bacterial overgrowth; no ovarian
tissue identified.
/P: 37yo G3P3003 with vaginal cuff dehiscence and prolapse of ovary through vaginal cuff. I discussed this condition and need for displacement of ovary and repair of vaginal cuff. Risks of not doing this discussed.
Risks of surgery discussed as well including infection, bleeding, need for transfusion, injury to adjacent organs, need for more surgery, pain, pelvic pain, pain with sex, possible need for laparoscopy, possible removal of ovary if nonviable etc.
Discussed postop care, postop rx's and postop recovery. Avoid intercourse for 6plus weeks etc.
op note:
Repair of vaginal cuff, displacement of ovary from vaginal cuff prolapse into abdomen, biopsy of ovary Procedure Note
Indications: 37yo G3P3003 with vaginal cuff dehiscence and prolapse of ovary through vaginal cuff.
Pre-operative Diagnosis: same
Post-operative Diagnosis: same
Operation: Total vaginal hysterectomy????? I believe this is incorrect
Surgeon: , MD
Assistants LSA. No qualified resident available
Anesthesia: General endotracheal anesthesia
Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The patient was taken to Operating Room # 2, identified x 2 and the procedure verified as total vaginal hysterectomy. A Time Out was held and the above information confirmed.
After induction of anesthesia, the patient was placed in high leg holders position and draped and prepped in the usual sterile manner. In and out bladder drainage performed with straight catheter.
Weighted speculum placed and 2cm of ovary noted to be prolapsing through vaginal cuff. A 2-3cm defect noted at vaginal cuff, vaginal cuff appeared healthy/viable with spotting noted around edges. Allis clamps used to grasp angles of cuff and then ring forcep and sponge stick used to assess ovary. Small piece of ovary denuded off, sent to pathology. Ovary was advanced past cuff and noted to be not bleeding, Vaginal cuff inspected circumferentially and no bowel or ovarian tissue noted.
The vesicoperitoneal reflection was inspected and a right angle retractor was placed to lift the bladder out of the operative field. Intraabdominal contents were confirmed and the bladder was again I/O drained.
Both ovaries appeared normal and were left in situ, no bleeding noted from ovaries.
Vaginal cuff angle sutures were placed incorporating the utero-sacral ligaments that had been previously tagged for support. The vaginal cuff was then closed with a series of interrupted stitches of 0 Vicryl.Hemostasis was observed.
A foley catheter was placed with clear urine at completion of cuff closure.
Instrument, sponge, and needle counts were correct prior to cuff closure and at the conclusion of the case.
Findings: ovary, white and viable appearing prolapsed through vaginal cuff, 2-3cm defect at vaginal cuff, ovary replaced into abdominal cavity appeared viable/white healthy appearing.
Estimated Blood Loss: less than 10cc mL
Drains: foley
Total IV Fluids: 400 ml
Specimens: ovarian tissue from left ovary
Complications: None; patient tolerated the procedure well.
Disposition: stable to the PACU
Condition: stable
Attending Attestation: I was present and scrubbed for the entire procedure.
Path results: Left ovarian tissue.
GROSS:
Specimen labeled left ovarian tissue is a 2.1 x 2.0 x 1.0 cm aggregate
of glistening pink-tan to tan-white fragments. Representatively
submitted in 1A-1B.
LMG/sc
MICROSCOPIC DIAGNOSIS:
Left ovarian tissue, excision: Benign fibroadipose tissue with
granulation tissue, fibrinous
material, acute inflammation and focal bacterial overgrowth; no ovarian
tissue identified.