# Lap hysterectomy intended, accidental perforation of uterus cauterized



## maddalynni (Dec 7, 2017)

Below is an op note: Requesting any insight as to how I code for the PHYSICIAN, not hospital side.
H and P stated intention was for lap total hysterectomy with bilateral salping-oophorectomy, but below is what transpired.
PLEASE HELP!!

PREOPERATIVE DIAGNOSIS(ES):  
1.   Enlarging fibroid uterus, postmenopausal.
2.   Left ovarian cyst.

POSTOPERATIVE DIAGNOSIS(ES):  
1.   Enlarging fibroid uterus, postmenopausal.
2.   Left ovarian cyst. 
3.   Episode of asystole intraoperatively and termination of the procedure.  

OPERATION:  Laparoscopy, cautery of uterine perforation.

ANESTHETIC TECHNIQUE:  General.

TOTAL FLUID IN:  1500 mL crystalloid.

ESTIMATED BLOOD LOSS:  10 mL.

DRAINS:  None.

SPECIMENS TO PATHOLOGY:  None.

INDICATIONS:  Please refer to admission history and physical.

FINDINGS:  There was a fibroid uterus.  There was a perforation in the fundus 
from the VCare uterine manipulator centrally.  A left ovarian cyst was noted 
approximately 6 cm in diameter.  

COMPLICATIONS:  Episode of asystole.

OPERATIVE PROCEDURE:  Patient was taken to the operating room and adequate 
general anesthesia was administered without incident.  The patient was placed 
in the dorsal lithotomy position and was sterilely prepped and draped in the 
usual fashion.  The patient was given Ancef intravenously for antibiotic 
prophylaxis, 5000 units of heparin subcutaneously, and Venodyne boots were 
placed on her legs for DVT prophylaxis.  The patient was correctly identified 
and a surgical pause was carried out by the surgical team as per protocol. 

________________________________________________________________________________

First a VCare unit uterine manipulator was placed in the uterus and a Foley 
catheter was placed in the bladder.  A small umbilical incision was made and 
a 10 mm trocar and sleeve was inserted with the laparoscope within the optic 
sheath.  Once entry into the abdominal cavity was confirmed, the abdominal 
cavity was infused with CO2 gas.  At this point, shortly after full 
insufflation the patient was noted to have complete asystole for 
approximately 15-20 seconds.  Two chest compressions were undertaken and the 
cardiac activity resumed at approximately 50 beats per minute.  
Glycopyrrolate was also given by Anesthesia and the patient's heart rate was 
regular at approximately 50 beats per minute.  Blood pressure was normal.  
Please refer to Anesthesia documentation for these parameters.  The episode 
of asystole lasted for approximately 15-20 seconds.  At this point, it was 
decided to discontinue the procedure.  A fundal midline uterine perforation 
was noted from the VCare manipulator.  The manipulator was removed.  A small 
amount of bleeding was noted from this area in the uterine fundus.  A 2nd 5 
mm port was placed suprapubically after confirming that the patient's vital 
signs were stable and the perforated area in the uterus was cauterized using 
the tip of a laparoscopic grasper.  Irrigation was undertaken and no bleeding 
was noted.  At this point, all gas and instruments were removed from the 
abdominal cavity.  The procedure was discontinued.  The incision sites were 
infused with 0.5% Marcaine and they were closed using 0 Vicryl suture on the 
fascia and superficial 4-0 Vicryl suture and Steri-Strips.  All sponge and 
instrument counts were correct at the completion of the procedure.  The 
patient was extubated without incident and taken to the recovery room in 
stable condition.  EKG and blood work has been ordered and Cardiology 
consultation has been requested.


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## cgaston (Dec 7, 2017)

I would not bill for the repair. The surgeon caused it so he should not be paid for it.

I would bill 58571-53 (since there is no indication that the uterus is over 250g)

and whatever your primary diagnoses for the surgery (fibroids?) with Z53.09 (cancelled case) and I46.9 (cardiac arrest) since this was the reason the case was cancelled.


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## maddalynni (Dec 7, 2017)

Thank you, this was the route I was going to go, but do you think by leaving the uterus manipulator in when they were doing chest compressions, that this caused the perforation?? Is this totally the physician's fault??


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## CodingKing (Dec 7, 2017)

If the perforation wasn't there before the procedure, its repair it's incidental to the procedure and not separately reportable.


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