# 58600 and 58720



## ASC CODER (Apr 28, 2010)

The patient was brought to the operating room, where after identification of the patient and planned procedure, general anesthesia was induced, and the abdomen prepped and draped in sterile fashion. Small incision was made just below the umbilicus and the Veress needle was introduced through the fascia. Insufflation however showed relatively high pressures, and the insufflation was halted and the Veress needle manipulated several times in an attempt to enter the peritoneal space. No satisfactory placement was achieved, so the 5 mm trocar was used to attempt visual insertion of the laparoscope into the peritoneum with gentle traction on the abdominal wall. This was also unsuccessful, probably due to the thickened preperitoneal fatty layer which was slightly insufflated by this time. Finally the incision was extended somewhat, and direct visual dissection through the fascia, the preperitoneal , and finally the peritoneum was successful in introducing the trocar without its introducer into the peritoneum. Insufflation and followed under direct vision with the laparoscope. On inspection, it was noted that some of the omental fat had some air insufflation, and also some of the air as dissected into the serosa of the cecum in the right lower quadrant. There is no evidence of bowel penetration or perforation, and no bleeding noted. Attention then turned to the pelvic structures, or normal size uterus was delivered. The right tube and ovary were normal. The left ovary was essentially replaced by a smooth walled cystic mass approximately 3 inches across, and mobile. It has the appearance of a benign ovarian cyst. The cyst was deflated with a suction needle, and using the LigaSure device, the lateral ligaments and the proximal tube were divided under direct vision. The tube left ovary and the deflated cystic mass were then removed from the field without difficulty through the lateral trocar site. The LigaSure device was then reintroduced and the right tube was cauterized and transected without difficulty. Representative photographs were taken, and the procedure was terminated. CO2 was allowed to passively escape the trochars were removed, and puncture sites closed with layers of absorbable suture. Band-Aid dressings are applied, and the patient awakened from her anesthetic having tolerated the procedure well. She was transferred to the recovery room in satisfactory condition. 

so it was laparscopic then open then lap again???? Can someone else give their opinion?? thanks


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## bonzaibex (Apr 28, 2010)

I don't think the op note quantifies an open procedure.  I'm basing my opinion on "..the excision was extended somewhat..." and "...followed under direct vision with the laparoscope..."  It sounds like the incision was extended to aide in trocar insertion, but the surgical procedures were accomplished with laparscopic assistance.  Plus the closing sounds like a normal laparoscopic closing and not the closing of an open procedure.  That's just my interpretation of the above note, though, for whatever it's worth.  Hope it helps.  

Rebecca Hardin, CPC


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