SDELOSSANTOS1
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I am far from an expert and actually very new to OBGYN specialty.
I have a surgery that I am unsure of which CPT codes are appropriate and any advice would be appreciated.
Case:
Pre-procedure diagnosis:
1. Abnormal uterine bleeding
2. Dysmenorrhea
3. Uterine fibroids
4. Pelvic pain
Post-procedure diagnosis:
1. Abnormal uterine bleeding
2. Dysmenorrhea
3. Uterine fibroids
4. Pelvic pain
5. Peritoneal adhesions
Procedures performed:
1. Total Laparoscopic Hysterectomy
2. Laparoscopic myomectomy
3. Bilateral salpingectomy
4. Cystoscopy
Technique/Procedure:
Laparoscopic
Total laparoscopic Patient was taken to the operating room where she was prepped and draped in the usual sterile in
a dorsal lithotomy fashion. A Foley catheter was placed through the urethral meatus. A RUMI uterine manipulator
was secured in place. Ancef and Flagyl were given prior to the start of the procedure. Attention was then turned to
the abdomen.
The umbilical incision was made with a scalpel, after the area was infiltrated with 0.25% Marcaine plain, and the trocar
with OptiView trocar was inserted directly. We encountered omental adhesions upon entry but were able to still obtain
Pneumoperitoneum with CO2 gas.
The inferior epigastric vessels were then identified along the anterior abdominal wall. In the patients right and left
lower quadrant and midline suprapubic 5 mm incisions were made and 5 mm trocars were place under direct
visualization. The pelvis was then visualized with the above noted findings.
The OptiView camera was placed in the right port. From the left side, the Harmonic device was placed and used to
take down the omental adhesions as they were obstructing the umbilical port and the pelvis. After careful dissection
with care not to injure the bowel or any other organs, the adhesions were taken down and there was adequate
visualization to continue with the procedure.
Beginning on the patients left side the utero-ovarian and round ligament were coagulated and transected with the
Harmonic scalpel. The anterior leaf of the broad ligament was dissected with the harmonic scalpel. The left fallopian
tube was incised lateral to the left ovary using the Harmonic scalpel. This was then extended to the previously
transected round ligament. The bladder flap was created with careful dissection of the scarred tissue and adhesions
along the Vescio uterine peritoneum to ensure no injury was done to the bladder. The uterine myoma was obstructing
the right side more, so we first coagulated and transected the round ligament first to give us more mobility. I then
proceeded to perform the salpingectomy from the uterine cornua until I was able to visualize the utero-ovarian
ligament (the remaining portion of the right salpingectomy was performed later in the procedure), which I then
coagulated and transected. The uterine artery was then skeletonized and the remaining portion of the bladder flap
was created. The uterine arteries were then cauterized with bipolar cautery. The uterus was amputated along the
metal cervical ring using the harmonic scalpel. The uterus and fallopian tubes were unable to be delivered through
the vagina. We attempted to bivalve the uterus from the vagina, however the bulkiness and size of the myoma was
still too much. We then returned to the abdomen, where we proceeded with a myomectomy. The Harmonic was used
to make an incision into the uterus and cut until we got to the capsule of the myoma. We continued to cut around and
free the capsule wall, while also using blunt traction and counter-traction to remove the myoma from the capsule.
Once we were successfully able to remove the myoma, I continued to bivalve the uterus laparoscopically. I was then
able to carefully morcellate the uterus through the vagina with the scalpel until I was able to completely remove it.
Once the uterus was removed, I carefully grasped the uterine myoma and morcellated it until able to be delivered
through the vagina.
Attention was then turned back to the abdomen where the right salpingectomy was completed, and the right fallopian.
tube was passed through the vagina.
The vaginal cuff was closed using a running suture of 0 V-lock 180. The pelvis was irrigated and viewed under low
pressure, found to be hemostatic. The ureters were inspected and found to have peristalsis bilaterally.
I then proceeded to perform the cystoscopy using the 30-degree camera. After the foley catheter was removed, the
camera was inserted into the bladder. There was a bubble found upon entry at the dome, and no suture perforations
were found after inspecting all angles of the bladder. There was jetting from the ureters bilaterally.
Trocars were removed under direct visualization. Pneumoperitoneum was released. Incisions were closed with 4.0
Monocryl and dermal glue.
Patient tolerated procedure well. Sponge, lap and needle counts were correct x 2. Patient was taken to the recovery
room in stable condition.
I have a surgery that I am unsure of which CPT codes are appropriate and any advice would be appreciated.
Case:
Pre-procedure diagnosis:
1. Abnormal uterine bleeding
2. Dysmenorrhea
3. Uterine fibroids
4. Pelvic pain
Post-procedure diagnosis:
1. Abnormal uterine bleeding
2. Dysmenorrhea
3. Uterine fibroids
4. Pelvic pain
5. Peritoneal adhesions
Procedures performed:
1. Total Laparoscopic Hysterectomy
2. Laparoscopic myomectomy
3. Bilateral salpingectomy
4. Cystoscopy
Technique/Procedure:
Laparoscopic
Total laparoscopic Patient was taken to the operating room where she was prepped and draped in the usual sterile in
a dorsal lithotomy fashion. A Foley catheter was placed through the urethral meatus. A RUMI uterine manipulator
was secured in place. Ancef and Flagyl were given prior to the start of the procedure. Attention was then turned to
the abdomen.
The umbilical incision was made with a scalpel, after the area was infiltrated with 0.25% Marcaine plain, and the trocar
with OptiView trocar was inserted directly. We encountered omental adhesions upon entry but were able to still obtain
Pneumoperitoneum with CO2 gas.
The inferior epigastric vessels were then identified along the anterior abdominal wall. In the patients right and left
lower quadrant and midline suprapubic 5 mm incisions were made and 5 mm trocars were place under direct
visualization. The pelvis was then visualized with the above noted findings.
The OptiView camera was placed in the right port. From the left side, the Harmonic device was placed and used to
take down the omental adhesions as they were obstructing the umbilical port and the pelvis. After careful dissection
with care not to injure the bowel or any other organs, the adhesions were taken down and there was adequate
visualization to continue with the procedure.
Beginning on the patients left side the utero-ovarian and round ligament were coagulated and transected with the
Harmonic scalpel. The anterior leaf of the broad ligament was dissected with the harmonic scalpel. The left fallopian
tube was incised lateral to the left ovary using the Harmonic scalpel. This was then extended to the previously
transected round ligament. The bladder flap was created with careful dissection of the scarred tissue and adhesions
along the Vescio uterine peritoneum to ensure no injury was done to the bladder. The uterine myoma was obstructing
the right side more, so we first coagulated and transected the round ligament first to give us more mobility. I then
proceeded to perform the salpingectomy from the uterine cornua until I was able to visualize the utero-ovarian
ligament (the remaining portion of the right salpingectomy was performed later in the procedure), which I then
coagulated and transected. The uterine artery was then skeletonized and the remaining portion of the bladder flap
was created. The uterine arteries were then cauterized with bipolar cautery. The uterus was amputated along the
metal cervical ring using the harmonic scalpel. The uterus and fallopian tubes were unable to be delivered through
the vagina. We attempted to bivalve the uterus from the vagina, however the bulkiness and size of the myoma was
still too much. We then returned to the abdomen, where we proceeded with a myomectomy. The Harmonic was used
to make an incision into the uterus and cut until we got to the capsule of the myoma. We continued to cut around and
free the capsule wall, while also using blunt traction and counter-traction to remove the myoma from the capsule.
Once we were successfully able to remove the myoma, I continued to bivalve the uterus laparoscopically. I was then
able to carefully morcellate the uterus through the vagina with the scalpel until I was able to completely remove it.
Once the uterus was removed, I carefully grasped the uterine myoma and morcellated it until able to be delivered
through the vagina.
Attention was then turned back to the abdomen where the right salpingectomy was completed, and the right fallopian.
tube was passed through the vagina.
The vaginal cuff was closed using a running suture of 0 V-lock 180. The pelvis was irrigated and viewed under low
pressure, found to be hemostatic. The ureters were inspected and found to have peristalsis bilaterally.
I then proceeded to perform the cystoscopy using the 30-degree camera. After the foley catheter was removed, the
camera was inserted into the bladder. There was a bubble found upon entry at the dome, and no suture perforations
were found after inspecting all angles of the bladder. There was jetting from the ureters bilaterally.
Trocars were removed under direct visualization. Pneumoperitoneum was released. Incisions were closed with 4.0
Monocryl and dermal glue.
Patient tolerated procedure well. Sponge, lap and needle counts were correct x 2. Patient was taken to the recovery
room in stable condition.