# GyneOnc coding Help - bladder defect



## maybabysgirl (May 14, 2013)

1. An 18 weeks size uterus/pelvic mass.
2. Enlarging symptomatic uterine fibroids.
3. Myotonic dystrophy.
4. Obesity. 

PROCEDURE PERFORMED:
1. Exploratory laparotomy, total abdominal hysterectomy.
2. Lysis of adhesions.
3. Repair of sigmoid serosal defect.
4. Bilateral ureterolysis.


FINDINGS: At the time surgery, the patient had a very abnormal shaped 18-week
size OF fibroid uterus with a large submucosal fibroid in the mid portion of the
uterus filling the pelvis to the pelvic sidewalls. There were adhesions between
the sigmoid colon and the posterior surface of the uterus and the left adnexa.
There were dense adhesions between the anterior bladder peritoneum and bladder
pillars and the anterior surface of the uterus and the fibroid. Frozen section
demonstrated, no evidence of sarcoma. The upper abdomen was normal on
examination. Increased surgical time and effort due to the large size of the uterus, the fibroids, and limited visualization due to these structures. Also increased surgical time due to patients history of myotonic dystrophy (anesthesia and surgically related). 

COMPLICATIONS: None. 

DESCRIPTION OF PROCEDURE: After receiving proper consent, the patient was taken
to the operating room, prepared and draped in normal sterile fashion in the
dorsal supine position. A vaginal perineal preparation performed. A Foley
catheter was placed. A midline skin incision was made and carried from the
symphysis pubis to approximately 5-6 cm above the umbilicus. This was carried
down to the rectus fascia. The rectus fascia was divided. The peritoneum was
then identified, tented up, entered sharply into the peritoneal incision
extended superiorly inferiorly good visualization of underlying structures. At
this point in time, the abdomen and pelvis surveyed with above-noted findings.
Due to the extensive size of the uterus, filling the pelvis and distorting the
pelvic anatomy and anticipating a difficult procedure I contacted one of my
partners, Dr. Chapman-Davis as well as asked for the patient be type and cross
for 2 units of packed red blood cells. At this point in time, the
retroperitoneal space was entered and developed by ligating and dividing the
round ligaments on both sides, and allowing for identification of the ureters on
the right and left side. As the patient desired to preserve the ovaries the
utero-ovarian vascular pedicles were then divided preserving the right and left
fallopian tube and ovary. The ovary tubes were mobilized out of the pelvis for
allowing for further identification of the ureters. Thus at this point in time,
the anterior leaf of the broad ligament was divided and this was complicated by
the dense adhesions between the uterus between the bladder and the anterior
surface of the uterus. It was noted that there was a small defect on the
muscularis of the bladder did not appear to be a incidental cystotomy. At this
point in time, Dr. Chapman-Davis had presented to the operating room and
assisted in the procedure. At this point in time, a decision was made to inject
the large fibroid with dilute Pitressin to decrease the blood loss associated
with the surgery. Once this had been completed, 60 mL of dilute Pitressin was
injected directly into the uterus. Zeppelin clamps were then placed, right
under the uterine fundus adjacent to the large fibroid that was pushing up on
the uterine fundus. This allowed for isolation and ligation and division of the
uterine arteries at this level of the mass. At this point in time, the capsule
of the fibroid was identified and it was noted that this submucosal fibroid had
been down the entire wall of the uterus circumferentially from the fundus to the
cervix. With this identified, we were then able to skeletonized the uterine
arteries down the side of the uterus with a LigaSure bipolar cautery device,
which allowed for unroofing and subsequently allowed for enucleation and removal
of the submucosal fibroid. This was done in several steps with minimal to no
blood loss. Due to the application of the Pitressin solution as well as the
dissection and division of the walls of the uterus with the LigaSure Impact
device. Once the fibroid had been excised, the pelvic anatomy became more
apparent and clear. The ureters were then once again re-identified and a bilateral ureterolysis was performed due to the close proximity of the ureters to the bladder and the remaining uterine arteries. This was performed without complication. At this point in time, additional bites along the uterine vessels were then taken down the level of the
uterosacral ligaments on both sides. Using a combination of LigaSure bipolar
cautery as well as, #1 Zeppelin clamps with each pedicle suture ligatures of 0
Vicryl. Once we reached the level of the uterosacral ligaments, they were
clamp, cut and divided with a suture ligatures of 0 Vicryl. The cervix, which
had been previously dilated from the prolapsing myoma was then identified and
was grasped and then a circumferential incision was made in the vagina that
allowed for removal of the remaining uterus of the cervix. The vaginal cuff was
then reapproximated with a 0 Vicryl suture in a interrupted figure-of-eight
fashion. At this point in time, the defect and the bladder mucosa muscularis
was identified and the bladder was back filled with 200 mL of saline, there
appeared to be no leakage from the bladder, however, a thinned out area was
identified and then the muscularis and the peritoneum over this area was
reapproximated with 2 different suture layers of 2-0 Vicryl. Additional
hemostasis was then achieved along the anterior vaginal wall. At this point in
time, with the hysterectomy complete, the sigmoid colon was inspected and there
was noted to be a serosal defect on the sigmoid colon. This was repaired in a
simple fashion with a 2-0 silk suture. Of note, during the initial dissection
for the hysterectomy, the ureters were freed from medial leaf of the broad
ligament down to the insertion of the cardinal ligaments. At this point in
time, they were traced down into the insertion of the bladder ensuring their
patency and continuity from the pelvis and the insertion of the bladder. The remainder
of the colonc and small bowel were inspected and no abnormalities were noted. 
At this point in time, sponge, lap andneedle counts were correct x2. 
All areas of vascular pedicles were inspected and were noted to be hemostatic and all areas of sharp dissection were inspectedand hemostasis was achieved with Bovie cautery or the application of FloSeal. At this point in time, the lap count was correct. The fascia was then closed with a 0 loop PDS running continuous fashion. Subcutaneous tissues irrigated and skin was closed with staples. The patient was then taken to the recovery
room in stable condition. 

I am looking for the CPT for the bladder defect, any help will be greatly appreciated. 

Thanks


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## maybabysgirl (May 23, 2013)

*what am I missing ....*



maybabysgirl said:


> 1. An 18 weeks size uterus/pelvic mass.
> 2. Enlarging symptomatic uterine fibroids.
> 3. Myotonic dystrophy.
> 4. Obesity.
> ...



 84 reviews and not 1 response.

I have placed several request for help, NO response. What am I missing? I thought we were all here to help one another. I thought that's why we are all members of AAPC. Do we not assist each other?????  Thanks for all your help ....


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