# ROBOTIC  LEFT OVARIAN CYSTECTOMY, EXCISION ENDOMETRIAL IMPLANTS Chromotubation



## mjsjeep (Oct 28, 2015)

Hoping someone can help. I am new to OB coding.

The doctor Is billing the same surgery twice.

58662
58662
58350
S2900

Are the codes appropriate?
Any info would be greatly appreciated.
Thanks!!

Pre-op Diagnosis:       1. Pelvic pain              2. Ovarian cysts
Post-op Diagnosis:     1, Pelvic pain              2. Left endometrioma             3. Excision of endometriotic implants
Procedure:                  1. Robotic left ovarian cystectomy
                                    2. Robotic excision of endometriotic implants
                                    3. Chromotubation

Indications: The patient is a 35 y.o. G0P0000 female with pelvic pain and ovarian cysts. 

Procedure:
After the appropriate informed consents were reviewed, the patient was taken to the OR where, after her identity was confirmed she was placed in the supine position on the operating table and general anesthesia was induced without difficulty.The patient was placed in the dorsal lithotomy position and her arms were tucked by her sides and were well padded. The SCDs were placed. The patient was then prepped and draped in the usual sterile fashion.

A foley catheter was placed, and the bladder drained. The cervix was visualized and the anterior lip of the cervix grasped with a single-toothed tenaculum. A uterine manipulator consisting of a Ruben's cannula and the tenaculum was assembled and seated against the cervix in the usual fashion.  All other instruments were removed from the vagina. Gloves were changed.
Attention was paid to the abdominal portion of the procedure. A midline skin incision located at the lower edge of the umbilicus was made with a scalpel after injection of 0.25% Marcaine with Epinephrine. The Veress needle was used to enter the peritoneal cavity and the abdomen was insufflated with CO-2 gas with a maximum pressure of 15cm H2O.The Veress needle was removed and replaced with an 8.5mm robotic trocar. Entry into the peritoneal cavity was confirmed with the laparoscope. Patient was placed in Trendelenburg position. Survey of the abdomen and pelvis was done and the findings noted. 
8 mm robotic trocars were placed, one each in the LLQ and RLQ, and one 8 mm Airseal trocar for the assistant in the RUQ. The robot was docked in a parallel fashion. Monopolar scissors were placed in the right trocar and the PK graspers in the left.

The fallopian tubes were inspected and found to be WNL. The left ovary was enlarged due to a cystic structure. The ovary itself was adhesed to the pelvic sidewall. There was scarring along the anterior cul de sac adjacent to the bladder. There was also scarring hear the lateral edge of the right fallopian tube to the sidewall, at the level of the cornua. There was also an endometriotic implant on the right uterosacral ligament.

Attention was first turned anteriorly to the anterior cul de sac. There were filmy adhesions that were lysed and an area or scarring/puckering on the right aspect was excised with the monopolar scissors. Hemostasis was obtained w/o difficulty. Additional filmy tissue was removed and sent as specimen.

In the posterior cul de sac, only the implant on the right uterosacral ligament was appreciated. The right ureter was identified and was well above the level of the endometriotic implant. Using the monopolar scissors, the puckered area was excised. Hemostasis was obtained with the monopolar coagulation.

Attention was then turned to the left ovary which was elevated and the adhesions to the sidewall lysed. The cyst was entered and fluid consistent with a chocolate cyst was extruded. The cyst cavity was exposed and the cyst wall was thickened and adherent. It was eventually removed with a combination of excision and peeling. Hemostasis of the remaining ovarian tissue was obtained with monopolar and bipolar energy.
The pelvis was copiously irrigated and hemostasis of all operative sites confirmed. A piece of interceed was placed around the left ovary for adhesion prevention.

The robot was then undocked and moved away from the patient. The pt was taken out of trendelenberg position.

The 8-mm trocars were removed serially while releasing the pneumoperitoneum. All trocars were removed under direct visualization. The skin was closed with 4-0 vicryl and Dermabond. The cervix was inspected with the bivalve speculum, and it was intact and hemostatic. All instruments were removed from the vagina. 
All laps, instruments and needles were accounted for x2. The patient was extubated in the operating room and was transferred to recovery in stable condition. 


EBL: 50 ml
IVF:   1350 ML
UOP:   300 ML


Complications: none immediately appreciated


Findings:
Scarring of anterior cul de sac and bladder and adjacent to lateral right tube
Endometriotic implant on right uterosacral ligament
Left endometrioma
Bilateral spill of methylene blue dye through tubes
Adhesions of left ovary to sidewall


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