Korbc
Expert
hey guys,
i know there's debate about this some people say code to just how the specimens and organs were removed vs cpt saying convert to open. This instance this was done both. originally doing a 58571 removed tubes and ovaries laproscopically converts to supracervical hyt. then removes uterus at the end via mini laparotomy. Since she removed the uterus "open" then i assume i should code to that even though the other organs are done laparoscopic or do i need to split this up and code to what was done laparoscopic and code for the open removal of uterus only. below is the "meat" of the procedure
The procedure was begun with extensive lysis of adhesions within the adnexa and the cul de sac. The cystic and filmy adhesions were taken down in layers using primarily blunt dissection until the L ovary was identified. The L pelvic triangle was identified. The retroperitoneal structures were identified and dissected laterally. The ureter was seen through the peritoneum at the entry of the IP to the pelvis. A window was made between the IP and the visualized ureter. The IP vessels were then coagulated and divided. The broad ligament incision was carried toward the uterine vessels on the left. The L round ligament was coagulated and cut. The bladder flap was developed.
Posterior dissection could not be performed at all. The L uterine vessels were coagulated but not cut. Attention then turned back to the R side. The R round ligament was coagulated and cut and the bladder flap completed. The R uterine vessels were identified and coagulated but not cut. There was an area centrally where the rectum was adherent but a plane was visible. This was developed in layers using sharp and blunt dissection. The rectum appeared to drop centrally to the level of the koh ring but the remaining adhesions laterally on both sides were so dense that a plane was not recognizable at all.
At this point Dr Ayers assistance was requested for appendectomy and assessment of the remaining rectal cul de sac adhesions. Please see her separate dictation for this portion of the case.
The case was handed back over after appendectomy and removal of the appendix from the field. Decision had been made to proceed with a supracervical hysterectomy, as there was no visible plane between the rectum and posterior cervix/vagina, and there were clear rectal adhesions to the level of the koh ring everywhere except centrally.
The uterus was amputated at the level of the internal os using monopolar scissors. The cervical stump was cauterized until hemostatic. The pelvis was copiously irrigated and suctioned. Surgicel powder was placed throughout the pelvis, after which hemostasis appeared excellent.
The uterus was brought back into the pelvis and the robot was undocked. The patient was taken out of trendelenburg position. The 12mm robotic port (had been placed for appendectomy portion) was closed with the carter thompson device and 0-vicryl suture. All trochars were then removed.
A 8cm pfannenstiel mini laparotomy was made with the scalpel and carried down to the fascia with the bovie. The fascial incision was made with the Bovie and extended transversely with Mayo scissors. The inferior edge of the fascia was elevated from the underlying rectus muscles using Kocher clamps x 2 and dissected off the rectus muscles with Mayo scissors. The same was performed superiorly. The peritoneum was entered bluntly. The uterus was grasped and pulled out through the incision and passed off the field. The fascia was then reapproximated with running sutures of 0 Vicryl. The subcutaneous tissue was irrigated and hemostasis was observed. The subcutaneous layer was reapproximated with interrupted 3-0 Vicryl sutures. The skin was then reapproximated with 4-0 Monocryl in a running subcuticular fashion. Steri strips and dressing were applied. The laparoscopic ports were closed with interrupted stitches of 4-0 monocryl and bandaids placed.
i know there's debate about this some people say code to just how the specimens and organs were removed vs cpt saying convert to open. This instance this was done both. originally doing a 58571 removed tubes and ovaries laproscopically converts to supracervical hyt. then removes uterus at the end via mini laparotomy. Since she removed the uterus "open" then i assume i should code to that even though the other organs are done laparoscopic or do i need to split this up and code to what was done laparoscopic and code for the open removal of uterus only. below is the "meat" of the procedure
The procedure was begun with extensive lysis of adhesions within the adnexa and the cul de sac. The cystic and filmy adhesions were taken down in layers using primarily blunt dissection until the L ovary was identified. The L pelvic triangle was identified. The retroperitoneal structures were identified and dissected laterally. The ureter was seen through the peritoneum at the entry of the IP to the pelvis. A window was made between the IP and the visualized ureter. The IP vessels were then coagulated and divided. The broad ligament incision was carried toward the uterine vessels on the left. The L round ligament was coagulated and cut. The bladder flap was developed.
Posterior dissection could not be performed at all. The L uterine vessels were coagulated but not cut. Attention then turned back to the R side. The R round ligament was coagulated and cut and the bladder flap completed. The R uterine vessels were identified and coagulated but not cut. There was an area centrally where the rectum was adherent but a plane was visible. This was developed in layers using sharp and blunt dissection. The rectum appeared to drop centrally to the level of the koh ring but the remaining adhesions laterally on both sides were so dense that a plane was not recognizable at all.
At this point Dr Ayers assistance was requested for appendectomy and assessment of the remaining rectal cul de sac adhesions. Please see her separate dictation for this portion of the case.
The case was handed back over after appendectomy and removal of the appendix from the field. Decision had been made to proceed with a supracervical hysterectomy, as there was no visible plane between the rectum and posterior cervix/vagina, and there were clear rectal adhesions to the level of the koh ring everywhere except centrally.
The uterus was amputated at the level of the internal os using monopolar scissors. The cervical stump was cauterized until hemostatic. The pelvis was copiously irrigated and suctioned. Surgicel powder was placed throughout the pelvis, after which hemostasis appeared excellent.
The uterus was brought back into the pelvis and the robot was undocked. The patient was taken out of trendelenburg position. The 12mm robotic port (had been placed for appendectomy portion) was closed with the carter thompson device and 0-vicryl suture. All trochars were then removed.
A 8cm pfannenstiel mini laparotomy was made with the scalpel and carried down to the fascia with the bovie. The fascial incision was made with the Bovie and extended transversely with Mayo scissors. The inferior edge of the fascia was elevated from the underlying rectus muscles using Kocher clamps x 2 and dissected off the rectus muscles with Mayo scissors. The same was performed superiorly. The peritoneum was entered bluntly. The uterus was grasped and pulled out through the incision and passed off the field. The fascia was then reapproximated with running sutures of 0 Vicryl. The subcutaneous tissue was irrigated and hemostasis was observed. The subcutaneous layer was reapproximated with interrupted 3-0 Vicryl sutures. The skin was then reapproximated with 4-0 Monocryl in a running subcuticular fashion. Steri strips and dressing were applied. The laparoscopic ports were closed with interrupted stitches of 4-0 monocryl and bandaids placed.
