lcathey@smsc.org
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I think I can only code the 58150 in this, but would like to have others opinion. Also, i'm wondering if I should bill the Cysto. Thanks for the help!
Date and Name of Procedure: 6/6/2016 Procedure(s):
DIAGNOSTIC LAPAROSCOPY, EXPLORATORY LAPAROTOMY, TAH, LSO, PARTIAL RIGHT SALPINGECTOMY,CYSTOSCOPY
Preop DX: Dysfunctional uterine bleeding [N93.8]; ABNORMAL UTERINE BLEEDING (MENORRHAGIA), LEFT ADNEXAL MASS
Postop DX: Dysfunctional uterine bleeding [N93.8]; ABNORMAL UTERINE BLEEDING (MENORRHAGIA), LEFT ADNEXAL MASS
Surgical Findings: Dense omental adhesions to anterior abdominal wall which incorporated what appeared to be small bowel adhesions; approximately 12cm left ovarian cyst and elongated left fallopian tube, uterus lightly enlarged at about 10-12 weeks, normal appearing right fallopian tube, right ovary with small follicular cyst but otherwise normal in appearance, bilateral efflux of urine at ureteral orifices on cystoscopy
Type of Anesthesia: General
Specimen Removed: yes : left fallopian tube and ovary, uterus, cervix, proximal part of right fallopian tube
Estimated Blood Loss: 500 ml
Complications: Decision was made to convert to laparotomy secondary to amount of anterior abdominal wall adhesions making visualization difficult via the laparoscope; but otherwise there were no complications.
Procedure in detail:
Patient taken to the OR with IVF running. She underwent induction of general anesthesia without difficulty. She was placed in dorsal lithotomy position using Allen stirrups and was prepped and draped in the normal sterile fashion. A foley cathter was placed. The cervix was visualized with a speculum and the anterior lip of the cervix grasped with a tenaculum. The uterus sounded to 10cm. The cervix was serially dilated until the uterine manipulator could be placed with ease. The RUMI-2 uterine manipulator was assembled and placed into the uterus; the cervical balloon was insufflated and the cervical ring was palpated around the cervix and noted to be free from excessive vaginal tissue. Attention was then turned to the abdomen.
A 12mm infraumbilical skin incision was made with the scalpel. The subcutaneous tissue was separated bluntly until the fascia was visualized. The fascia was grasped with two kochers and elevated. The fascia was incised with the scalpel. Stay sutures were placed along the fascial edges with 0-vicryl. The peritoneum was noted to be scarred. The peritoneum was grasped with two hemostats at areas that appeared thin; the peritoneum was incised with the scalpel. A Hassan trochar was placed into the incision, and pneumoperitoneum was created to a pressure of 15mmHg. Dense omental adhesions were noted to the anterior abdominal wall. Manipulation of the camera showed concern for small bowel adhesions laterally to the anterior abdominal. We were able to advance the camera posteriorly to visualize the superior aspect of the left adnexal mass, but the uterus could not be visualized. Due to limited visualization, we felt that we could not safely proceed with surgery laparoscopically. We proceeded with laparotomy.
A pfannenstiel skin incision was made with the scalpel and carried down to the underlying layer of fascia with the scalpel. The fascia was incised in the midline and extended laterally with the Mayo scissors. The superior edge of the fascia was grasped with two Kocher clamps, elevated, and the underlying rectus muscles dissected off with the Mayo scissors. In a similar fashion, the inferior border of the fascia was grasped with two Kocher clamps, elevated, and the underlying rectus muscles dissected off with the Mayo scissors. The rectus muscles were separed bluntly at the midline. The peritoneum was elevated with two hemostats and entered with the Metzenbaum scissors. The peritoneal incision was extended inferiorly and superiorly using the Bovie with good visualization of the bladder. The abdomen was explored with findings as above. Inspection of the area at the umbilicus at our previous trochar site was noted to be only with dense omental adhesions. An Alexis O-ring retractor was placed in the abdomen, and the intestines were packed away with moist laps. The left ureter was palpated and noted to be inferior to the infundibulopelvic (IP) ligament. My fingers were placed under the IP ligament, and a small window was made through the peritoneum with the Bovie. The left IP ligament was ligated and transected with the Ligasure. The left uteroovarian ligament was transected with the Ligasure and the left ovary and fallopian tube were removed from the abdomen. Both structures were sent to frozen pathology. Frozen pathology returned as a benign ovarian teratoma.
We proceeded with hysterectomy.
The left round ligament grasped, suture ligated with 1-vicryl and transected with the Bovie. The anterior leaf of the left broad ligament was transected with the Bovie to the midline of the vesicouterine peritoneum. In a similar fashion the posterior leaf of the broad was transected with the Bovie. Skeletonization of the left uterine artery occurred with the Ligasure and the Bovie as needed. Attention was then turned to the right side. In a similar fashion the right round ligament was ligated with 1-vicryl and transected with the Bovie. The anterior leaf of the right broad was transected with the Bovie to meet the left's prior transection. The vesicouterine peritoneum was dissected away from the lower part of uterus and cervix. The right ureter was palpated and noted to be well inferior to the right IP ligament. The right uteroovarian ligament was transected with the Ligasure. The patient was with previous postpartum BTL, and so the proximal half of the right fallopian tube was removed with the uterus. The right posterior aspect of the broad was transected with the Bovie, and skeletonization of the right uterine occurred with the hand-held Ligasure. The uterine arteries were ligated with the Ligasure bilaterally at the junction of uterine body and the cervix. The right uterine artery was tortuous and noted to be with acute bleed after transection. This accounted for the majority of EBL. The bleeding vessel was first grasped with a curved Heaney clamp. Later a right angle clamp was placed and the pedicle suture ligated with 1-vicryl. With placing Balentine clamps within our previous pedicles, we continued to down the cervix, transecting with Mayo scissors and suture ligating with 1-vicryl. The Rumi uterine manipulator was removed from the uterus. The cardinal ligaments were transected bilaterally with Mayo scissors and suture ligated with 1-vicryl. In a similar manner the uterosacral ligaments were transected and suture ligated with 1-vicryl. Two Heaney clamps were placed under the cervix and the cervical-vaginal junction was ligated with the Jorgenson scissors. The cervix and uterus were removed in bulk and passed off the table. The vaginal cuff was closed in a running locked fashion using 1-vicryl. The pelvis was suctioned irrigated and hemostasis observed. The ureters were not visualized at the end of the procedure so we proceeded with cystoscopy. The foley catheter was removed. A 30 degree cystoscope was placed into the bladder. The bladder was distended with normal saline. No defects were noted in the vaginal mucosa. The ureters were visualized bilaterally and noted to be with efflux. The cystoscope was removed and the foley catheter replaced. All lap sponges were removed from the abdomen; the Alexis retractor was removed. The fascia was closed in a running fashion with 1-PDS. The subcutaneous tissue was irrigated and noted to be hemostatic The subcutaneous tissue was approximated with 2-0 plain gut. The skin was closed with staples. Patient tolerated the procedure well. She was extubated and taken to PACU in stable condition.
Date and Name of Procedure: 6/6/2016 Procedure(s):
DIAGNOSTIC LAPAROSCOPY, EXPLORATORY LAPAROTOMY, TAH, LSO, PARTIAL RIGHT SALPINGECTOMY,CYSTOSCOPY
Preop DX: Dysfunctional uterine bleeding [N93.8]; ABNORMAL UTERINE BLEEDING (MENORRHAGIA), LEFT ADNEXAL MASS
Postop DX: Dysfunctional uterine bleeding [N93.8]; ABNORMAL UTERINE BLEEDING (MENORRHAGIA), LEFT ADNEXAL MASS
Surgical Findings: Dense omental adhesions to anterior abdominal wall which incorporated what appeared to be small bowel adhesions; approximately 12cm left ovarian cyst and elongated left fallopian tube, uterus lightly enlarged at about 10-12 weeks, normal appearing right fallopian tube, right ovary with small follicular cyst but otherwise normal in appearance, bilateral efflux of urine at ureteral orifices on cystoscopy
Type of Anesthesia: General
Specimen Removed: yes : left fallopian tube and ovary, uterus, cervix, proximal part of right fallopian tube
Estimated Blood Loss: 500 ml
Complications: Decision was made to convert to laparotomy secondary to amount of anterior abdominal wall adhesions making visualization difficult via the laparoscope; but otherwise there were no complications.
Procedure in detail:
Patient taken to the OR with IVF running. She underwent induction of general anesthesia without difficulty. She was placed in dorsal lithotomy position using Allen stirrups and was prepped and draped in the normal sterile fashion. A foley cathter was placed. The cervix was visualized with a speculum and the anterior lip of the cervix grasped with a tenaculum. The uterus sounded to 10cm. The cervix was serially dilated until the uterine manipulator could be placed with ease. The RUMI-2 uterine manipulator was assembled and placed into the uterus; the cervical balloon was insufflated and the cervical ring was palpated around the cervix and noted to be free from excessive vaginal tissue. Attention was then turned to the abdomen.
A 12mm infraumbilical skin incision was made with the scalpel. The subcutaneous tissue was separated bluntly until the fascia was visualized. The fascia was grasped with two kochers and elevated. The fascia was incised with the scalpel. Stay sutures were placed along the fascial edges with 0-vicryl. The peritoneum was noted to be scarred. The peritoneum was grasped with two hemostats at areas that appeared thin; the peritoneum was incised with the scalpel. A Hassan trochar was placed into the incision, and pneumoperitoneum was created to a pressure of 15mmHg. Dense omental adhesions were noted to the anterior abdominal wall. Manipulation of the camera showed concern for small bowel adhesions laterally to the anterior abdominal. We were able to advance the camera posteriorly to visualize the superior aspect of the left adnexal mass, but the uterus could not be visualized. Due to limited visualization, we felt that we could not safely proceed with surgery laparoscopically. We proceeded with laparotomy.
A pfannenstiel skin incision was made with the scalpel and carried down to the underlying layer of fascia with the scalpel. The fascia was incised in the midline and extended laterally with the Mayo scissors. The superior edge of the fascia was grasped with two Kocher clamps, elevated, and the underlying rectus muscles dissected off with the Mayo scissors. In a similar fashion, the inferior border of the fascia was grasped with two Kocher clamps, elevated, and the underlying rectus muscles dissected off with the Mayo scissors. The rectus muscles were separed bluntly at the midline. The peritoneum was elevated with two hemostats and entered with the Metzenbaum scissors. The peritoneal incision was extended inferiorly and superiorly using the Bovie with good visualization of the bladder. The abdomen was explored with findings as above. Inspection of the area at the umbilicus at our previous trochar site was noted to be only with dense omental adhesions. An Alexis O-ring retractor was placed in the abdomen, and the intestines were packed away with moist laps. The left ureter was palpated and noted to be inferior to the infundibulopelvic (IP) ligament. My fingers were placed under the IP ligament, and a small window was made through the peritoneum with the Bovie. The left IP ligament was ligated and transected with the Ligasure. The left uteroovarian ligament was transected with the Ligasure and the left ovary and fallopian tube were removed from the abdomen. Both structures were sent to frozen pathology. Frozen pathology returned as a benign ovarian teratoma.
We proceeded with hysterectomy.
The left round ligament grasped, suture ligated with 1-vicryl and transected with the Bovie. The anterior leaf of the left broad ligament was transected with the Bovie to the midline of the vesicouterine peritoneum. In a similar fashion the posterior leaf of the broad was transected with the Bovie. Skeletonization of the left uterine artery occurred with the Ligasure and the Bovie as needed. Attention was then turned to the right side. In a similar fashion the right round ligament was ligated with 1-vicryl and transected with the Bovie. The anterior leaf of the right broad was transected with the Bovie to meet the left's prior transection. The vesicouterine peritoneum was dissected away from the lower part of uterus and cervix. The right ureter was palpated and noted to be well inferior to the right IP ligament. The right uteroovarian ligament was transected with the Ligasure. The patient was with previous postpartum BTL, and so the proximal half of the right fallopian tube was removed with the uterus. The right posterior aspect of the broad was transected with the Bovie, and skeletonization of the right uterine occurred with the hand-held Ligasure. The uterine arteries were ligated with the Ligasure bilaterally at the junction of uterine body and the cervix. The right uterine artery was tortuous and noted to be with acute bleed after transection. This accounted for the majority of EBL. The bleeding vessel was first grasped with a curved Heaney clamp. Later a right angle clamp was placed and the pedicle suture ligated with 1-vicryl. With placing Balentine clamps within our previous pedicles, we continued to down the cervix, transecting with Mayo scissors and suture ligating with 1-vicryl. The Rumi uterine manipulator was removed from the uterus. The cardinal ligaments were transected bilaterally with Mayo scissors and suture ligated with 1-vicryl. In a similar manner the uterosacral ligaments were transected and suture ligated with 1-vicryl. Two Heaney clamps were placed under the cervix and the cervical-vaginal junction was ligated with the Jorgenson scissors. The cervix and uterus were removed in bulk and passed off the table. The vaginal cuff was closed in a running locked fashion using 1-vicryl. The pelvis was suctioned irrigated and hemostasis observed. The ureters were not visualized at the end of the procedure so we proceeded with cystoscopy. The foley catheter was removed. A 30 degree cystoscope was placed into the bladder. The bladder was distended with normal saline. No defects were noted in the vaginal mucosa. The ureters were visualized bilaterally and noted to be with efflux. The cystoscope was removed and the foley catheter replaced. All lap sponges were removed from the abdomen; the Alexis retractor was removed. The fascia was closed in a running fashion with 1-PDS. The subcutaneous tissue was irrigated and noted to be hemostatic The subcutaneous tissue was approximated with 2-0 plain gut. The skin was closed with staples. Patient tolerated the procedure well. She was extubated and taken to PACU in stable condition.