Rectovaginal fistula plus a rectovesical fistula

debellis59

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Kennewick, WA
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I need some help coding this procedure. I looked and looked, but I don't see a laparoscopic code for this. Does anyone have any suggestions?

The note states:
PROCEDURE IN DETAIL: Risks, benefits, indications, alternatives of the procedure reviewed with the patient. Informed consent was obtained. Patient was taken to the OR with IV running, placed in dorsal supine position, given general anesthesia. After this was obtained, she was then placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion. Foley catheter was then placed. A bivalve speculum was then placed in vagina. Visualization of the posterior and anterior vaginal wall. There were no fistula areas there. It was at the vaginal cuff. Attention was then turned to the abdomen where an 8 mm infraumbilical incision was preinjected with lidocaine, made with an 11-blade scalpel. The abdominal wall was elevated and approximately 2 L of CO2 were used to obtain a pneumoperitoneum. The 8.5 mm trocar was then advanced and intraabdominal placement verified with a scope. A right and a left quadrant port was placed 10 cm lateral and 15 degrees superior to the umbilicus and then an 8 mm right lower quadrant port was placed through the assistant port that was the AirSeal. This was placed under direct visualization. The robot was then docked at 45 degrees from the left side of the body. Monopolar scissors were placed through arm #1 and bipolar fenestrated graspers through arm #2. At this point, I scrubbed out of the case and console time started. At this point, the bowel was densely adherent to the lateral side wall and all the way down to the vaginal cuff on the right side wall. This was dissected free using sharp and blunt dissection with the monopolar scissors. Once the bowel was freed up and it was densely adherent to the bladder, to the vaginal cuff, and down posteriorly to the rectovaginal space. It was cut free. The areas at this point that were seen was one connection to the bladder dome. The bladder was then dissected off of the vaginal cuff and the rectum dissected posteriorly a little bit. The fistula tracts were then visualized and cut and removed. The bladder was then dissected free of the vaginal wall. At this point, the monopolar scissors were removed. The omega needle driver was then placed and then using a 3-0 Vicryl, the fistula openings to the vaginal cuff were then closed in 3 layers. Excellent hemostasis was obtained and copious irrigation performed. At this point, we called Dr. M of urology to come in and evaluate so he came in and took a look. His portion of the surgery will be dictated separately. Due to the connection to the bladder, it was decided to leave the Foley catheter and send her home with 3 weeks of a Foley catheter and then removal with cystogram at the end. At this point, the end of my case was performed. All needles were removed and then Dr. R began his portion of the case and that will be dictated later. No complications were observed. Both ureters were visualized peristalsing in the pelvis at the end of the case.
 
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