Hello all! Help needed please and thank you!!
Surgeon completed treatment of ectopic laparoscopically, then converted to open for evacuation of hemoperitoneum, unable to be performed laparoscopically. I know that all laparoscopies converted to open get coded as open when the completion of the procedure is performed through the open approach, however, in this case, the full procedure for the treatment of ectopic was performed laparoscopically. So, it's throwing me off. Am I thinking too much into this? I should still code as 59120, right? What are everybody's thoughts. Also, general surgery came in and performed exploratory laparoscopy. Why am I so confused? lol. Thank you so much!!
OB Details: Normal appearing external female genital. Foley was introduced into the bladder
and 50cc of yellow-colored urine were noted. Humi manipulator placed. Veno dynes in place
prior to start of anesthesia. 5mm incision made in umbilicus. 5mm port introduced into the
umbilicus. Abdomen was insufflated with gas to 15mmHg. Survey of the abdominal cavity
revealed hemoperitoneum and right-side ectopic pregnancy. 5mm incision made in LLQ and
RLQ and 5mm trocar was introduced into port sites under direct visualization. Using suction
irrigation system, evacuation of hemoperitoneum was attempted. Large clots noted throughout
the abdominal cavity. Right tube grasped and ligated and cut with Maryland ligasure. Umbilical
port switched to 12mm, and Endo bag used to remove specimen. Tissue sent to pathology.
Attention paid to abdominal cavity where copious amounts of blood /clots were noted, poor
visualization with laparoscopy. Decision was made to perform exploratory laparotomy.
Pfannenstiel skin incision was made with a scalpel. The incision was carried down to the fascia
with a Bovie. The fascia was incised and extended laterally. The inferior aspect of the fascia
was grasped with Kocher clamps. Underlying rectus muscle and pyramidalis were dissected off
with Mayo scissors. In similar fashion, the superior aspect of the fascia was elevated with
Kocher and the rectus muscle was dissected off. Hemostasis was achieved with Bovie. Rectus
muscles were separated in the midline down to the level of the pubic symphysis. Preperitoneal
fatty tissue was bluntly dissected to expose the peritoneum. The peritoneum was found to be
free of adherent bowel and entered bluntly. Hemoperitoneum noticed. Evacuation of
hemoperitoneum done. Right ovary inspected and mesosalpinx as well, good hemostasis seen.
Rectus muscle reapproximated with 2-0 chromic in interrupted fashion x2. Fascia closed with
1-0 vicryl in running fashion. Subcutaneous tissue closed in interrupted fashion x3. Skin was
closed with 4-0 Monocryl and skin glue. Attention paid to umbilical port and copious amount of
blood noted thru the umbilical port. Decision was made to reenter with laparoscope and perform
and abdominal survey. Surgery team called for assistance. Surgery team retrieved large clots
from RUQ in supra-hepatic recess and in pelvis in the cu l-de-sac. Persistent oozing from
umbilical port site, controlled with cautery and fascial approximation with M-close in figure of 8
manner. 19fr Blake Drain placed. Gas was allowed to escape. All instruments were removed
from the abdomen. Incisions closed with 4-0 Monocryl and skin glue. Excellent hemostasis
achieved. Foley catheter and Humi manipulator removed. Counts were correct x2. EBL 1000cc.
UO: 250cc
Gen Details: The patient was undergoing a laparoscopic converted into open right
sided salpingectomy, right salpingectomy was successfully done, and specimen was out at the
time of my presence. Patient was still under the general anesthesia and intubated, with
pneumoperitoneum through the 5mm umbilical trocar. A total of 3 port sites entry noticed, 12mm
skin incision and previously 12mm port at the umbilicus, that was converted with 5mm port with
towel clamps on the skin, and 5mm skin incisions each at the bilateral lower abdomen. Slow
hemorrhage noticed at the 5mm umbilical port that was obscuring view from the camera. Right
lower quadrant 5mm trocar was re-inserted through the pre-existing 5mm skin incision with an
OptiView trocar. another 5mm trocar was re-inserted through the pre-existing 5mm skin incision
to the left lower quadrant with an OptiView trocar.
Upon the intraperitoneal entry, there was no frank bowel injury or bowel contents spillage
noticed. Abdomen was examined starting from the left lower abdomen, small amount of
hematoma was noticed thus evacuated with suction irrigator. No underlying active bleeding
noticed. Left upper quadrant was examined next, no active bleeding or hematoma noticed.
Right upper quadrant was examined next, perihepatic hematoma and sanguinous flu id noticed
thus, all evacuated. More hematoma noticed at the Morrison's pouch thus suctioned out. No
active hemorrhage noticed after the suction. Next, right lower quadrant was examined and
noticed to have small amount of sanguinous fluid, that was suctioned out. Right salpingectomy
site was examined, cauterized area was clean dry and intact, no active hemorrhage noticed.
Lastly pelvis was examined. large hematoma with sanguinous flu id noticed at the cul-de-sac,
thus evacuated. Pelvic wall was carefully examined after the hematoma evacuation, no frank
pelvic wall laceration noticed, no source of bleeding was identified. Decision was made to
examine the port entry sites. Bilateral lower abdominal port site was clean dry and intact without
active signs of bleeding. Umbilical port entry site has two peritoneal defects, 5mm and 12mm,
and 12mm defect showed exposed rectus muscle that is oozing sanguinous flu id from the raw
surface. Decision was made to cauterize the muscle surface with Maryland grasper on a
electrosurgery. Once achieving satisfactory hemostasis, M close was used to close
periumbilical 5mm port with 0-vicryl suture. 12mm defect was left open due to inaccessibility to
the port with the M close through the umbilical skin open in g. 19 French Blake drain was left in
the cul-de-sac.
At this time of satisfactory hemostasis, decision was made to have gynecology team proceed
with their procedure and closure.
Surgeon completed treatment of ectopic laparoscopically, then converted to open for evacuation of hemoperitoneum, unable to be performed laparoscopically. I know that all laparoscopies converted to open get coded as open when the completion of the procedure is performed through the open approach, however, in this case, the full procedure for the treatment of ectopic was performed laparoscopically. So, it's throwing me off. Am I thinking too much into this? I should still code as 59120, right? What are everybody's thoughts. Also, general surgery came in and performed exploratory laparoscopy. Why am I so confused? lol. Thank you so much!!
OB Details: Normal appearing external female genital. Foley was introduced into the bladder
and 50cc of yellow-colored urine were noted. Humi manipulator placed. Veno dynes in place
prior to start of anesthesia. 5mm incision made in umbilicus. 5mm port introduced into the
umbilicus. Abdomen was insufflated with gas to 15mmHg. Survey of the abdominal cavity
revealed hemoperitoneum and right-side ectopic pregnancy. 5mm incision made in LLQ and
RLQ and 5mm trocar was introduced into port sites under direct visualization. Using suction
irrigation system, evacuation of hemoperitoneum was attempted. Large clots noted throughout
the abdominal cavity. Right tube grasped and ligated and cut with Maryland ligasure. Umbilical
port switched to 12mm, and Endo bag used to remove specimen. Tissue sent to pathology.
Attention paid to abdominal cavity where copious amounts of blood /clots were noted, poor
visualization with laparoscopy. Decision was made to perform exploratory laparotomy.
Pfannenstiel skin incision was made with a scalpel. The incision was carried down to the fascia
with a Bovie. The fascia was incised and extended laterally. The inferior aspect of the fascia
was grasped with Kocher clamps. Underlying rectus muscle and pyramidalis were dissected off
with Mayo scissors. In similar fashion, the superior aspect of the fascia was elevated with
Kocher and the rectus muscle was dissected off. Hemostasis was achieved with Bovie. Rectus
muscles were separated in the midline down to the level of the pubic symphysis. Preperitoneal
fatty tissue was bluntly dissected to expose the peritoneum. The peritoneum was found to be
free of adherent bowel and entered bluntly. Hemoperitoneum noticed. Evacuation of
hemoperitoneum done. Right ovary inspected and mesosalpinx as well, good hemostasis seen.
Rectus muscle reapproximated with 2-0 chromic in interrupted fashion x2. Fascia closed with
1-0 vicryl in running fashion. Subcutaneous tissue closed in interrupted fashion x3. Skin was
closed with 4-0 Monocryl and skin glue. Attention paid to umbilical port and copious amount of
blood noted thru the umbilical port. Decision was made to reenter with laparoscope and perform
and abdominal survey. Surgery team called for assistance. Surgery team retrieved large clots
from RUQ in supra-hepatic recess and in pelvis in the cu l-de-sac. Persistent oozing from
umbilical port site, controlled with cautery and fascial approximation with M-close in figure of 8
manner. 19fr Blake Drain placed. Gas was allowed to escape. All instruments were removed
from the abdomen. Incisions closed with 4-0 Monocryl and skin glue. Excellent hemostasis
achieved. Foley catheter and Humi manipulator removed. Counts were correct x2. EBL 1000cc.
UO: 250cc
Gen Details: The patient was undergoing a laparoscopic converted into open right
sided salpingectomy, right salpingectomy was successfully done, and specimen was out at the
time of my presence. Patient was still under the general anesthesia and intubated, with
pneumoperitoneum through the 5mm umbilical trocar. A total of 3 port sites entry noticed, 12mm
skin incision and previously 12mm port at the umbilicus, that was converted with 5mm port with
towel clamps on the skin, and 5mm skin incisions each at the bilateral lower abdomen. Slow
hemorrhage noticed at the 5mm umbilical port that was obscuring view from the camera. Right
lower quadrant 5mm trocar was re-inserted through the pre-existing 5mm skin incision with an
OptiView trocar. another 5mm trocar was re-inserted through the pre-existing 5mm skin incision
to the left lower quadrant with an OptiView trocar.
Upon the intraperitoneal entry, there was no frank bowel injury or bowel contents spillage
noticed. Abdomen was examined starting from the left lower abdomen, small amount of
hematoma was noticed thus evacuated with suction irrigator. No underlying active bleeding
noticed. Left upper quadrant was examined next, no active bleeding or hematoma noticed.
Right upper quadrant was examined next, perihepatic hematoma and sanguinous flu id noticed
thus, all evacuated. More hematoma noticed at the Morrison's pouch thus suctioned out. No
active hemorrhage noticed after the suction. Next, right lower quadrant was examined and
noticed to have small amount of sanguinous fluid, that was suctioned out. Right salpingectomy
site was examined, cauterized area was clean dry and intact, no active hemorrhage noticed.
Lastly pelvis was examined. large hematoma with sanguinous flu id noticed at the cul-de-sac,
thus evacuated. Pelvic wall was carefully examined after the hematoma evacuation, no frank
pelvic wall laceration noticed, no source of bleeding was identified. Decision was made to
examine the port entry sites. Bilateral lower abdominal port site was clean dry and intact without
active signs of bleeding. Umbilical port entry site has two peritoneal defects, 5mm and 12mm,
and 12mm defect showed exposed rectus muscle that is oozing sanguinous flu id from the raw
surface. Decision was made to cauterize the muscle surface with Maryland grasper on a
electrosurgery. Once achieving satisfactory hemostasis, M close was used to close
periumbilical 5mm port with 0-vicryl suture. 12mm defect was left open due to inaccessibility to
the port with the M close through the umbilical skin open in g. 19 French Blake drain was left in
the cul-de-sac.
At this time of satisfactory hemostasis, decision was made to have gynecology team proceed
with their procedure and closure.
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