emagel@aqreva.com
Networker
Can anyone recommend a code for the below procedure. At this point I am leaning towards unlisted.The patient was taken to the operating rom and underwent general anesthesia and was repositioned in the dorsal lithotomy position on the operating table. The vagina and perineum were them sterilely prepped and draped in the usual sterile fashion. The patient had voided prior to presenting to the operating room. After she was prepped and draped, examination under anesthesia was them performed, which revealed a distal, approximately half moon shaped stricture encompassing and adhering down the posterior vaginal mucosa extending up onto the lateral vagina sidewalls and upside down or sideways type C configuration, dramatically decreasing the vaginal caliber approximately 3cm proximal from the introitus. She also was found with exam under anesthesia to have an extremely, abnormally deviated cervix that was actually stuck anteriorly behind the pubic bone, markedly deviating once again the lower uterine segment of the cervix. Unfortunately, this is something that we were not able to address with any sort of vaginal procedure, but was noted and possibly is a component of some of the pain she has with intercourse and tampon insertion. With the finding of the vaginal stricture once again about 3cm proximal from the vaginal introitus, we were able to identify the area where there was adherence beneath the posterior vaginal mucosa and underlying perirectal fascia. This area was able to be identified by placing an Allis clamp here and the redundant posterior vaginal mucosa was then able to be elevated also at the introitus with Allis clamps. A small triangular incision was made in the perineal body and we were able then to use vasopressin and saline to develop a plane beneath the overlying vaginal mucosa and underlying perirectal fascia. We were then able to dissect the posterior vaginal mucosa off the underlying perirectal fascia at which time the ridge of scarring was noted at the posterior stricture area. This area was carefully freed up and was found to have bowel entrapped in this area as well, so careful dissection was required to avoid any sort of bowel injury and to free up the perirectal fascia and the strictured area to increase the vaginal caliber. This was once again done carefully. The vaginal mucosa was freed off of this strictured area and then in a tension free manner was sutured with several interrupted sutures to the distal perirectal fascia increasing the vaginal caliber. Several deep sutures were then used to reapproximate the transverse peritoneal musculature and several interrupted sutures were then used to reapproximate the skin at the introitus. Vaginal cream was placed intravaginally to speed the healing process.
Any help would be greatly appreciated !