# Robotic assisted hysterectomy help



## katelliott80 (Oct 23, 2009)

My OBGYN does started doing this procedure via the Di Vinci robot. It has elements of a Laparascopic abdominal hysterectomy but the uterus is removed vaginally. So because most of the work is done abdominally I cant bill a vaginally hysterectomy (58550) nor does this fit the description of a Lap total hysterectomy because uterus is removed vaginally in this case?? Anyone bill for these? Is it an unlisted code? Please help!  Thanks~Katie

Surgical Procedure(s):  Robotic-assisted hysterectom and Lysis of adhesions

Anesthesia:  General.   
Estimated Blood Loss:  50 ml
Replacements:  IV fluids.
She had 900 ml of urine output
Complications:  None.
Findings:  She has a parous uterus, normal ovaries and previous tubal ligation.  Cul-de-sac was clear.  Anterior bladder flap was clear.  No signs of endometriosis and no other pelvic adhesions.  All counts correct.  Foley catheter to bedside drain had 900 ml of urine and this was removed at the end of the procedure.  Uterus was sent to pathology.   

Operative Technique:  After identification of the patient and assurance the operative permission had been granted, the patient was taken to the operating room where general anesthesia was administered.  She was placed in low Allen stirrups.  She was prepped and draped in the usual sterile fashion for a laparoscopic procedure.  A time out procedure identifying the patient and the procedure was performed.  An examination under anesthesia revealed a slightly anteverted uterus, parous uterus.  No adnexal masses and the cul-de-sac appeared to be free.  The weighted speculum was placed and the anterior vaginal wall was retracted with a right angle retractor.  The cervix was grasped with a tenaculum.  A figure-of-eight suture of 0-Vicryl was placed on the cervix and threaded through the VK uterine manipulator.  The uterine manipulator stem was placed into the uterus.  The bulb was inflated to 10 ml of air.  The cervical cup was placed against the cervix and this was tied down.  The blue cup was then placed against the cervical cup to maintain our pneumoperitoneum and this was anchored.  The weighted speculum was removed.  Strings had been cut.  The surgeon's second pair of gloves were removed.  Attention was then placed to the abdomen.  A small 1.5 cm skin incision was made superior to the umbilicus.  A Veress needle was placed.  Negative saline test was performed and the insufflation was performed using 3.5 liters of CO2 gas.  The Veress needle was removed and the 12 mm trocar was placed in the umbilical superior incision.  The area was then marked for the assistant port and the 2 robotic ports.  These were 8 mm ports for the robotic ports, there were 3 robotic ports. These were placed, 2 on the right and 1 on the left.  These were marked and placed under direct visualization.  A 12 mm assistant port was also placed using the 12 mm trocar.  This was done also under direct visualization.  The Di Vinci robot was then docked in a side-docking manner.  Once the robot was docked the instruments were handed down through the robotic arms and visualized in the pelvis.  At that point the surgeon moved to the console and took control of the robotic arms.  The left uteroovarian ligaments were cauterized using the PK bipolar instrument in 2 places and cut using monopolar between the 2 cauterization places.  This was done down to the level of the uterine artery, containing the uteroovarian ligament, the fallopian tube and the round ligament.  The same procedure was carried out on the right.  The bladder flap was then opened using a monopolar scissors and the bladder was retracted off the lower uterine segment and the vagina.  Uterine artery on the right was grasped with a PK and cauterized in 3 places.  A small amount of back bleeding occurred with this.  On the left, after skeletization of the uterine artery, the PK instrument        was again used and cauterized in 3 areas.  The left uterine artery was then cut using the monopolar scissors.  The cardinal ligament was grasped with the PK, cauterized in 2 places and cut.  The uterosacral ligament at the superior edge was clamped with a PK and cauterized, and cut using the monopolar scissors.  This was carried out on the right and the left.  After an adequate amount of bladder had been dissected away from the vaginal cuff, an incision was made posteriorly  using the monopolar scissors going around the right, across the anterior vagina and across the left fornix.  After the entire cervix had been excised, the cervix and uterus were pulled through the vagina and handed off as specimen.  A wet lap was placed in the vagina to hold the pneumoperitoneum.  The PK bipolar instrument and the monopolar scissors were removed and a large needle driver and suture cutter and a mega needle driver were placed.  Suture was handed through, a 0-Vicryl and a CT1 and figure-of-eight sutures on the angles was performed.  Adequate hemostasis was present.  The cul-de-sac had earlier been suctioned.  Interrupted figure-of-eight sutures of 0 Vicryl were used to close in the midline as well.  Four figure-of-eight sutures closed the entire vaginal cuff.  Adequate hemostasis was present. Pedicles were examined and adequate hemostasis was present.  At this time the robot was undocked, and the surgeons scrubbed and regowned.  Endoclose needle was placed at the 12 mm trocar site using 0-Vicryl and under direct visualization.  A small piece of the mesentery was hit and had a small amount of bleeding that stopped spontaneously.  This was irrigated and watched.  Both sites at the superior umbilicus and at the assistant port on the left lateral side were closed with 0-Vicryl in the fascia.  The 8 mm ports were removed under direct visualization and adequate hemostasis was present.  The skin was closed using 4-0 Vicryl in a subcuticular fashion and Dermabond was placed on the wound.  Foley catheter was removed. She was taken out of Trendelenburg.  The wet lap pad was removed from the vagina.  She went to the recovery room in good condition. She had an estimated blood loss of 50 ml.


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## dan528i (Oct 26, 2009)

THere was an article on the ROBOTIC SURGERIES in th eOctober issue of the Coding Edge. I glanced through it but wasnt paying much attention because my doctors dont use robotics.

Good luck hope it helps.


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## Lisa Bledsoe (Oct 26, 2009)

If I remember correctly, you are to use the laparoscopic code for the robotic procedure.  It is in the October Coding Edge...I don't have it at my desk since I work from home and out of the office...


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## Valerie813 (Oct 28, 2009)

You will use the LAP code for the procedure. looks like it was a LAVH (lap assisted vag hyst)  There is no LAP code for the Davinci robot- I use S2900 after the primary procedure code for reporting purposes.  You will probably not get any extra reimbursement for it, but I apply the code just to indicate the robot was used.


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