# Surgery Coding help



## chrisandtris (Jan 8, 2013)

I am needing help coding the following GYN operation For Dr. S.

DATE OF OPERATION
01/03/13

PREOPERATIVE DIAGNOSES
1.   Pelvic pain.
2.   Tuboovarian abscess, right.
3.   Intrauterine device, ParaGard.
4.   Leukocytosis.
5.   Nausea/diarrhea.

POSTOPERATIVE DIAGNOSES
1.   Pelvic pain secondary to right tuboovarian abscess with loculated abscess involving the cul-de-sac and pararectal space.
2.   Small bowel adhesions involving the cul-de-sac abscess and right adnexal structures, status post adhesiolysis.
3.   Sigmoid adhesions to the left adnexa and bladder reflection anteriorly with secondary inflammatory changes.

NAME OF OPERATION
1.   Operative laparoscopy -- possible right salpingo-oophorectomy, failed secondary to multiple intestinal/omental/pelvic adhesive disease with midline pelvic mass.
2.   Exploratory laparotomy with right salpingo-oophorectomy and dissection of intrapelvic/cul-de-sac abscess.
3.  Extensive small bowel/pelvic abscess adhesiolysis. 
4.  Sigmoidal adhesiolysis -- Dr. P.  Abdominal exploration -- Dr. P.
5.   Removal of intrauterine device.

SURGEON
Dr. S MD
ESTIMATED BLOOD LOSS: 400 mL.
COMPLICATIONS: None.
INTRAOPERATIVE CONSULTATION:  
1.   General Surgery, Dr. X, for colonic adhesiolysis and exposure of the gynecological structures.
2.   Urology, Dr. D for lighted stent placement intraoperatively.

ANESTHESIA
Amy Shatto, CRNA

INDICATIONS 
This is a 22-year-old gravida 2, para 1, ectopic 1, white female who is a long-standing patient of Dr. Martin Schwartz, who was admitted through the Emergency Room on December 30, 2012 with complaints of a palpable mass on the posterior back and with midline low back pain.  The patient was initially evaluated.  General Surgical consultation with Dr. Shat was obtained and CT scan and ultrasound of the abdomen and pelvis was performed.  A lipoma was noted clinically and a CT scan on ultrasound confirmed an approximately 10 x 12 cm probable right tubal abscess with evidence of a complex fluid collection involving this region.  The patient had an IUD, which appeared to be in the normal intrauterine place.  Cervical cultures were obtained and the patient was initially started on IV Levaquin and Flagyl.  The patient had initial white count of 36,000, which subsequently defervesced to 25,000; however, the patient clinically did not improve with continued nausea, vomiting and loss of appetite.  After transition of care on January 1, 2013 the patient was followed with persistence of symptoms and the decision to proceed to the Operating Room for laparoscopic assessment, possible right salpingo-oophorectomy versus open laparotomy was discussed.  The risks, benefits and limitations of the procedure were discussed with the patient and family.  Informed consent was obtained.

DESCRIPTION OF OPERATION
After informed consent the patient was taken to the Operating Room and placed in the supine position.  She was anesthetized via general endotracheal anesthesia, placed in the dorsal lithotomy position with TED hose and SCDs.  She was placed in Allen stirrups, sterilely prepped and draped in the usual manner with a Foley catheter being placed on the operative field.  

A weighted speculum was initially placed in the vaginal vault and the IUD string was grasped and the intrauterine device was removed.  A Hulka uterine elevator was then introduced for uterine manipulation.  The weighted speculum was removed.  

The intraumbilical incision was made to accommodate a 5 mm, non-bladed port utilizing direct visual entry laparoscopy.  The port was placed in the peritoneal cavity and 3 liters of CO2 were then infused.  Trendelenburg positioning was accomplished.   Inspection immediately noted marked omental attachment to the anterior bladder flap reflection with the sigmoid colon appearing to be looped upon itself and densely attached to the left lower adnexal region.  The omentum was unable to be  mobilized after a 5 mm port was placed suprapubically with confirmation of the large pelvic mass filling the pelvis.  At this time the decision was made to abort the laparoscopic procedure and proceed to an open laparotomy.  The family was informed.

A Pfannenstiel incision was then made extended onto the  level of the fascia.  The fascia was incised and extended laterally with Mayo scissors.  The fascia was bluntly and sharply dissected from rectus muscles, the muscles were split vertically in the midline, the peritoneum was grasped and entered.  Upon entry the omental adhesions to the pelvic sidewalls and bladder flap inferiorly were initially sharply dissected with an eventual plane not being able to be identified in the midline.  The LigaSure device was introduced and the omental attachment was then sealed and transected allowing mobilization and visualization of the markedly distorted uterus, right tube and ovary, along with pelvic sidewall structures.  The marked induration and phlegmon involving the small bowel whose mesentery was attached and formed part of the abscess region loculated in the cul-de-sac portion.  Initial steps to separate the small bowel from the abscess structure was accomplished and the small bowel was initially just pushed out of the abdomen under laparotomy sponges with visualization with the Turner-Warwick retractor being accomplished.  At this time identification of specifically the right tube and ovary was unrecognizable with a question of a small loop of small bowel being adherent.  The sigmoid itself was attached and folded upon itself and adhesed fairly densely without an appropriate plane being identified.  After approximately an hour of dissection, with further visualization and mobilization of the abscess in the right pararectal space being accomplished, the decision was made to proceed to a General Surgical consultation for removal of the sigmoid and access to the left pararectal gutter for visualization and confirmation that this was a tuboovarian abscess process.  Dr. P arrived, and please see his operative dictation for his portion of the procedure.  Once his surgical intervention was accomplished the sigmoid colon was elevated out of the pelvis, the small bowel had been run and explored without evidence of any injury or other abnormalities, certainly supportive of the massive edema and phlegmon formation.  With visualization and confirmation of an intact uterus, and a fairly normal appearing left fallopian tube and ovary, at this time prior to dissection into the large infectious mass was begun, intraoperative consultation with Urology was requested.  Subsequently, bilateral ureteral stents were placed, the family again was informed that pending the ability of dissection, and the degree of infectious spread and induration, the the patient may need to undergo a hysterectomy intraoperatively.  Once the ureteral stents were placed the uteroovarian ligament was isolated and dissection medially to laterally was then performed with Metzenbaums and pickups.  Curved Heaney clamps were placed.  These, however, due to the state of the tissue, were actually non-effective in adequate tissue separation and pedicle formation for ligature.  Interrupted figure-of-eight sutures were utilized for some hemostasis, as dissection of the abscess was accomplished.  The round ligament was sutured, transected on the patient's right side and split, allowing undermining between the broad ligament and inferiorly and posteriorly to the abscess mass to allow mobilization subsequently of the right tube away from the right pelvic sidewall.  Once this was accomplished the region of the infundibulopelvic ligament was isolated well superior to the lighted stent and curved Heaney clamps were placed.  The tissue specimen was then subsequently removed and submitted for pending pathology.  The separate loculated abscess area of the cul-de-sac was then debrided with tissue being extracted and final figure-of-eight sutures placed along the region of the broad ligament with marked tissue induration for hemostasis.  Pressure utilizing a moistened laparotomy sponge was applied as well.  At this time further inspection revealed no evidence of continued oozing or active bleeding.  The decision was made to stop conservatively at this time and place a Blake 19-drain in the cul-de-sac for postoperative management. 

Once the drain was placed the contents were irrigated copiously with 2.5 liters of fluid and removal of all laparotomy sponges and retractors were accomplished.  The omentum was then brought inferiorly into the lower pelvis with repositioning of structures as appropriate.  The fascia was then closed with 1-PDS from the right apices to the midline and a double stranded 1-PDS from left apices to the midline.  The subcutaneous tissue was irrigated, three interrupted sutures of 3-0 Vicryl ligatures were placed and the skin edges were then closed with staples.  The umbilical incision was previously closed with a 4-0 Vicryl suture.   The drain itself was secured with an 0-nylon ligature.  The Hulka uterine elevator had previously been removed at the moment the decision was made to proceed to an exploratory laparotomy.  At this time at the conclusion of the procedure the ureteral stents were removed and an indwelling Foley catheter placed.

The family was updated throughout the procedure as to findings and intraoperative events, which were relayed via Operating Room personnel.  Sponge, needle and instrument counts were correct times two.  The patient tolerated the procedure well and  transferred to Recovery Room in stable condition.

Thank you! Any help would be appreciated.


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