catharine
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I seriously need a little help with this one. I'm tossing around a lot of unspecified codes and some comparative that don't quite fit. any help would be great.
PROCEDURES:
1. Cystoscopy.
2. Right retrograde pyelogram.
3. Right diagnostic ureteroscopy and placement of indwelling stent.
4. Laparoscopic lysis of adhesions.
5. Extensive distal ureterectomy excision of fistula tract and closure of vaginal fistula.
6. Right ureteral reimplantation with psoas hitch maneuver and retropubic suspension.
ANESTHESIA:
general endotracheal.
OPERATIVE FINDINGS:
The patient had a distal ureterovaginal fistula on the right side causing incontinence.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought to the operating room. After the induction of general endotracheal anesthesia, an orogastric tube was placed. SCDs have been placed preoperatively. She was placed in the dorsal lithotomy position with all pressure points meticulously padded. Her abdomen and perineum were prepped and draped in a standard sterile fashion. Her arms were kept with shoulder pads, arm shields, TEDs and SCDs were placed preoperatively. Perineum and abdomen prepped and draped in a standard sterile fashion. We used a well-lubricated 21-French rigid cystoscope for cystoscopy, which confirmed a normal caliber urethra. She had some hypermobility of the urethra that was detected. No true vesicovaginal fistula was seen. I then intubated the right ureteral orifice with a 0.035 inch Glidewire and the wire actually came out the vaginal lining. We performed a diagnostic ureteroscopy, could see the fistula tract, seen at the 1-2 cm above the ureterovesical junction. Retrograde pyelogram and contrast could see methylene blue coming out the vaginal mucosa as well. I left an open-ended catheter just above the fistula tract as a stent and then placed an 18-French Foley catheter.
We then obtained pneumoperitoneum via the left upper quadrant at Palmer's point, aspirated back and performed a drop test and insufflated the abdomen to 15 mmHg pressure. First trocar was placed at the level of umbilicus. Three robotic trocars were placed, 8 mm ports. An assistant port was placed in the right lower quadrant. The patient was then placed in the Trendelenburg position and the robot was docked in a standard sterile fashion. We first turned our attention to performing extensive lysis of adhesions. There was an extensive amount of adhesions that were detected along the sigmoid colon, ascending white line of Toldt, with the colon and the appendix all in the pelvis. Once we incised along all the adhesions along the anterior abdominal wall as well as the ascending white line of Toldt, we were able to move the colon up medially and mobilized the sigmoid laterally as well. This helped to expose the external iliac vasculature. Identified the ureter going overlying the iliac vessels and followed it down to the level of an inflammatory rind-like reaction in the pelvis. We were able to retract the ovaries laterally as we were able to identify this rind-like reaction. Once this was done, we completely mobilized the ureter off this rind-like reaction and could see the fistula tract going into the vaginal mucosa as the ureter went into the portion of the bladder. At this point, we excised the fistula tract as well as the ureter oversewed the vaginal mucosa, with 3-0 Vicryl sutures. We then mobilized the ureter up all the level of the bifurcation.
We then dropped the bladder down by incising along the lateral umbilical folds. Once this was done, we mobilized the bladder away from the right and the left side to perform a hitch maneuver. The ureter was then cut and spatulated widely in the distal portion of the ureter was sent for analysis with the fistula tract.
We then filled the bladder to 200 mL of water and then I made an incision in the most dependent portion on the right side of the bladder. We then began our anastomosis with interrupted and running 3-0 Vicryl sutures. After the anastomosis was done, we placed a 0.035 inch Glidewire up into the ureter and passed a 6-French x 24 cm double-J stent. The stent was then placed into the bladder. We completed our anastomosis. We then oversewed the bladder mucosa muscularis overlying the ureter to perform a second layer of our anastomosis. We performed a hitch maneuver of the lateral aspect of the bladder onto the psoas tendon. Care was taken not to injure the genitofemoral nerve. Once the hitch maneuver was performed, we then resuspended the portion of the bladder neck up against the pubic symphysis to help with postoperative incontinence.
A final JP drain was placed above the anastomosis. We placed some to seal overlying the rind-like reaction in the pelvis to offer better hemostasis. At this point in the procedure, we placed interrupted #1 Vicryl sutures along the 12 mm ports to close the port fascia and then all the ports were removed under direct visualization. The robot was de-docked.
The fascia was closed with #1 Vicryl sutures as mentioned above.
The skin was closed with a 4-0 Monocryl subcuticular suture. The drain was secured in place. All sponge and needle counts were reported correct x2. There were no operative complications. Estimated blood loss for procedure was less than 20 mL. The patient tolerated the procedure well and was taken to recovery in stable condition.
I was heading to 50947 and 51999 with a comparison of 50760. But am not so sure.
PROCEDURES:
1. Cystoscopy.
2. Right retrograde pyelogram.
3. Right diagnostic ureteroscopy and placement of indwelling stent.
4. Laparoscopic lysis of adhesions.
5. Extensive distal ureterectomy excision of fistula tract and closure of vaginal fistula.
6. Right ureteral reimplantation with psoas hitch maneuver and retropubic suspension.
ANESTHESIA:
general endotracheal.
OPERATIVE FINDINGS:
The patient had a distal ureterovaginal fistula on the right side causing incontinence.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought to the operating room. After the induction of general endotracheal anesthesia, an orogastric tube was placed. SCDs have been placed preoperatively. She was placed in the dorsal lithotomy position with all pressure points meticulously padded. Her abdomen and perineum were prepped and draped in a standard sterile fashion. Her arms were kept with shoulder pads, arm shields, TEDs and SCDs were placed preoperatively. Perineum and abdomen prepped and draped in a standard sterile fashion. We used a well-lubricated 21-French rigid cystoscope for cystoscopy, which confirmed a normal caliber urethra. She had some hypermobility of the urethra that was detected. No true vesicovaginal fistula was seen. I then intubated the right ureteral orifice with a 0.035 inch Glidewire and the wire actually came out the vaginal lining. We performed a diagnostic ureteroscopy, could see the fistula tract, seen at the 1-2 cm above the ureterovesical junction. Retrograde pyelogram and contrast could see methylene blue coming out the vaginal mucosa as well. I left an open-ended catheter just above the fistula tract as a stent and then placed an 18-French Foley catheter.
We then obtained pneumoperitoneum via the left upper quadrant at Palmer's point, aspirated back and performed a drop test and insufflated the abdomen to 15 mmHg pressure. First trocar was placed at the level of umbilicus. Three robotic trocars were placed, 8 mm ports. An assistant port was placed in the right lower quadrant. The patient was then placed in the Trendelenburg position and the robot was docked in a standard sterile fashion. We first turned our attention to performing extensive lysis of adhesions. There was an extensive amount of adhesions that were detected along the sigmoid colon, ascending white line of Toldt, with the colon and the appendix all in the pelvis. Once we incised along all the adhesions along the anterior abdominal wall as well as the ascending white line of Toldt, we were able to move the colon up medially and mobilized the sigmoid laterally as well. This helped to expose the external iliac vasculature. Identified the ureter going overlying the iliac vessels and followed it down to the level of an inflammatory rind-like reaction in the pelvis. We were able to retract the ovaries laterally as we were able to identify this rind-like reaction. Once this was done, we completely mobilized the ureter off this rind-like reaction and could see the fistula tract going into the vaginal mucosa as the ureter went into the portion of the bladder. At this point, we excised the fistula tract as well as the ureter oversewed the vaginal mucosa, with 3-0 Vicryl sutures. We then mobilized the ureter up all the level of the bifurcation.
We then dropped the bladder down by incising along the lateral umbilical folds. Once this was done, we mobilized the bladder away from the right and the left side to perform a hitch maneuver. The ureter was then cut and spatulated widely in the distal portion of the ureter was sent for analysis with the fistula tract.
We then filled the bladder to 200 mL of water and then I made an incision in the most dependent portion on the right side of the bladder. We then began our anastomosis with interrupted and running 3-0 Vicryl sutures. After the anastomosis was done, we placed a 0.035 inch Glidewire up into the ureter and passed a 6-French x 24 cm double-J stent. The stent was then placed into the bladder. We completed our anastomosis. We then oversewed the bladder mucosa muscularis overlying the ureter to perform a second layer of our anastomosis. We performed a hitch maneuver of the lateral aspect of the bladder onto the psoas tendon. Care was taken not to injure the genitofemoral nerve. Once the hitch maneuver was performed, we then resuspended the portion of the bladder neck up against the pubic symphysis to help with postoperative incontinence.
A final JP drain was placed above the anastomosis. We placed some to seal overlying the rind-like reaction in the pelvis to offer better hemostasis. At this point in the procedure, we placed interrupted #1 Vicryl sutures along the 12 mm ports to close the port fascia and then all the ports were removed under direct visualization. The robot was de-docked.
The fascia was closed with #1 Vicryl sutures as mentioned above.
The skin was closed with a 4-0 Monocryl subcuticular suture. The drain was secured in place. All sponge and needle counts were reported correct x2. There were no operative complications. Estimated blood loss for procedure was less than 20 mL. The patient tolerated the procedure well and was taken to recovery in stable condition.
I was heading to 50947 and 51999 with a comparison of 50760. But am not so sure.