Good Morning,
What CPT would be used for the Hysterectomy done by Gyn/Onc immediately after C/Section Delivery done by OB/Gyn? CPT 59525 is an Add-On code, which would not be correct to use for the Gyn/Onc who performed the Hysterectomy.
Indication for Surgery:
The patient is a 28 year old G3P2 at 39w2d who presented for a scheduled repeat cesarean section. During her cesarean section while closing the hysterotomy uterine tone was was noted to be very poor. She received a pitocin bolus, Methergine and hemabate without any improvement in tone. There was concern for bleeding if attempted to place compression stitches due to oozing at hysterotomy. Her cervix was only 1 cm dilated there the Jada system could not be inserted. EBL was about 2L at this time and the massive transfusion protocol was initiated. GYN ONC was consulted. The decision was made to proceed with a hysterectomy, verbal consent was obtained from the patient's husband. The patient was converted to general anesthesia with intubation.
Preoperative Diagnosis
39w2d intrauterine pregnancy
Previous cesarean section x2
Postoperative Diagnosis
s/p cesarean hysterectomy and bilateral salpingectomy
Postpartum hemorrhage 2/2 uterine atony
same
Operation
REPEAT CESAREAN SECTION, Supracervical hysterectomy and bilateral salpingectomy
Findings
After closure of the hysterotomy during the cesarean section tone was noted to be poor. The uterus was very boggy despite IM methergine, IM hemabatex2, pitocin, TXA and intrauterine methergine
There was a dense adhesion of the abdominal wall to the right lower uterine segment
The pedicles and cervical stump were noted to be hemostatic at the end of the case and Surgicell was placed over these sites
Urine was clear at the end of the case
Specimen(s) Uterus, bilateral fallopian tubes
Complications Postpartum hemorrhage
Technique
See separate op note for cesarean section portion of the case. On arrival the uterus was exteriorized and noted to be very boggy despite uterotonics with EBL at 2L. A Jada system was not an option as her cervix was only 1cm dilated. Due to the difficulty controlling bleeding at the hysterotomy, compression sutures were not attempted. Therefore the decision was made to proceed with a hysterectomy. An additional dose of antiobiotics was given due to high blood loss. The massive transfusion protocol was initiated and she received 2u pRBCs and 2u FFP. There were dense adhesions from the abdominal wall to the right lower uterine segment which were taken down with the bovie and the Ligasure to expose the lower uterine segment and bladder. The round ligament on the right side was grasped and divided with the Ligasure. This was carried down anteromedially to the level of the lower uterine segment with the bovie. The fallopian tube and utero ovarian ligament were isolated from the uterine body, ligated and divided with the Ligasure. The broad ligament was ligated and divided using the Ligasure down to the level of the uterine arteries. This process was repeated on the contralateral side. We then skeletonized the uterine vessels on either side and carefully dissected the bladder flap anteriorly. Heaney clamps were then placed where the uterine arteries adjoined the uterus. These were clamped using a Heaney clamp, ligated and divided using #0 Vicryl suture. The cervix was palpated deep in the pelvis therefore the decision was made to perform a supracervical hysterectomy. Heaney clamps were placed across the lower uterine segment and the uterus was amputated using the bovie. The small amount of remaining lower uterine segment was closed horizontally with a series of figure of eight stitches of 0-vicryl. The posterior edge of the stump was noted to be bleeding therefore a running locked suture of 0-monocryl was placed with good hemostasis. Good hemostasis was noted at the cervical stump. Attention was then turned to removing the fallopian tubes. The right fallopian tube was elevated with Babcocks and the Ligasure was used to serially ligate and transect the underlying mesosalpinx. The same was performed on the left side. Both fallopian tubes were sent to pathology. The abdomen was copiously irrigated. Good hemostasis was noted at all the major pedicles. Surgicell was placed over the major pedicles and cervical stump. The peritoneum was closed with running 3-0 plain gut. The fascia and rectus muscles were examined and areas of oozing were controlled with electrocautery. There was bleeding noted to be coming from below the peritoneum, therefore the peritoneal closure was opened. There was bleeding noted on the right anterior abdominal wall where adhesiolysis was performed. Two figure of eight stitches of 0-Monocryl were placed to achieve hemostasis. The abdomen was inspected again and good hemostasis was noted. The fascia was reapproximated with running suture of 0-Monocryl. The subcutaneous tissue was irrigated and non-hemostatic areas were electro-cauterized. The subcutaneous tissue was greater than 2 cm in thickness, and was therefore closed with 2-0 plain gut. An abdominal xray was performed due to two surgeons and a complete count was not performed. Radiology confirmed no retained objects. The skin was reapproximated with 4-0 Monocryl. Mepelix dressing was applied over the incision.
Instrument, sponge, and needle counts were correct prior to the abdominal closure and at the conclusion of the case.
Thank You
What CPT would be used for the Hysterectomy done by Gyn/Onc immediately after C/Section Delivery done by OB/Gyn? CPT 59525 is an Add-On code, which would not be correct to use for the Gyn/Onc who performed the Hysterectomy.
Indication for Surgery:
The patient is a 28 year old G3P2 at 39w2d who presented for a scheduled repeat cesarean section. During her cesarean section while closing the hysterotomy uterine tone was was noted to be very poor. She received a pitocin bolus, Methergine and hemabate without any improvement in tone. There was concern for bleeding if attempted to place compression stitches due to oozing at hysterotomy. Her cervix was only 1 cm dilated there the Jada system could not be inserted. EBL was about 2L at this time and the massive transfusion protocol was initiated. GYN ONC was consulted. The decision was made to proceed with a hysterectomy, verbal consent was obtained from the patient's husband. The patient was converted to general anesthesia with intubation.
Preoperative Diagnosis
39w2d intrauterine pregnancy
Previous cesarean section x2
Postoperative Diagnosis
s/p cesarean hysterectomy and bilateral salpingectomy
Postpartum hemorrhage 2/2 uterine atony
same
Operation
REPEAT CESAREAN SECTION, Supracervical hysterectomy and bilateral salpingectomy
Findings
After closure of the hysterotomy during the cesarean section tone was noted to be poor. The uterus was very boggy despite IM methergine, IM hemabatex2, pitocin, TXA and intrauterine methergine
There was a dense adhesion of the abdominal wall to the right lower uterine segment
The pedicles and cervical stump were noted to be hemostatic at the end of the case and Surgicell was placed over these sites
Urine was clear at the end of the case
Specimen(s) Uterus, bilateral fallopian tubes
Complications Postpartum hemorrhage
Technique
See separate op note for cesarean section portion of the case. On arrival the uterus was exteriorized and noted to be very boggy despite uterotonics with EBL at 2L. A Jada system was not an option as her cervix was only 1cm dilated. Due to the difficulty controlling bleeding at the hysterotomy, compression sutures were not attempted. Therefore the decision was made to proceed with a hysterectomy. An additional dose of antiobiotics was given due to high blood loss. The massive transfusion protocol was initiated and she received 2u pRBCs and 2u FFP. There were dense adhesions from the abdominal wall to the right lower uterine segment which were taken down with the bovie and the Ligasure to expose the lower uterine segment and bladder. The round ligament on the right side was grasped and divided with the Ligasure. This was carried down anteromedially to the level of the lower uterine segment with the bovie. The fallopian tube and utero ovarian ligament were isolated from the uterine body, ligated and divided with the Ligasure. The broad ligament was ligated and divided using the Ligasure down to the level of the uterine arteries. This process was repeated on the contralateral side. We then skeletonized the uterine vessels on either side and carefully dissected the bladder flap anteriorly. Heaney clamps were then placed where the uterine arteries adjoined the uterus. These were clamped using a Heaney clamp, ligated and divided using #0 Vicryl suture. The cervix was palpated deep in the pelvis therefore the decision was made to perform a supracervical hysterectomy. Heaney clamps were placed across the lower uterine segment and the uterus was amputated using the bovie. The small amount of remaining lower uterine segment was closed horizontally with a series of figure of eight stitches of 0-vicryl. The posterior edge of the stump was noted to be bleeding therefore a running locked suture of 0-monocryl was placed with good hemostasis. Good hemostasis was noted at the cervical stump. Attention was then turned to removing the fallopian tubes. The right fallopian tube was elevated with Babcocks and the Ligasure was used to serially ligate and transect the underlying mesosalpinx. The same was performed on the left side. Both fallopian tubes were sent to pathology. The abdomen was copiously irrigated. Good hemostasis was noted at all the major pedicles. Surgicell was placed over the major pedicles and cervical stump. The peritoneum was closed with running 3-0 plain gut. The fascia and rectus muscles were examined and areas of oozing were controlled with electrocautery. There was bleeding noted to be coming from below the peritoneum, therefore the peritoneal closure was opened. There was bleeding noted on the right anterior abdominal wall where adhesiolysis was performed. Two figure of eight stitches of 0-Monocryl were placed to achieve hemostasis. The abdomen was inspected again and good hemostasis was noted. The fascia was reapproximated with running suture of 0-Monocryl. The subcutaneous tissue was irrigated and non-hemostatic areas were electro-cauterized. The subcutaneous tissue was greater than 2 cm in thickness, and was therefore closed with 2-0 plain gut. An abdominal xray was performed due to two surgeons and a complete count was not performed. Radiology confirmed no retained objects. The skin was reapproximated with 4-0 Monocryl. Mepelix dressing was applied over the incision.
Instrument, sponge, and needle counts were correct prior to the abdominal closure and at the conclusion of the case.
Thank You