# Laparoscopic procedure completed then converted to open for another procedure



## hevan004 (Apr 17, 2014)

One of my doctors did a laparoscopic pelvic lymphadenectomy and completed it. After he did it he found out that he transected a ureter so he had to convert it to an open procedure so that a doctor could do a consult. After the consult he did an open TAH BSO. 

I believe that the doctor should be able to bill for the laparoscopic procedure since he completed it. Then bill for the open TAH BSO. 

I want to see what others think of this. 


Here is the op note:



DESCRIPTION OF PROCEDURE: After induction of general anesthesia, the patient was
prepped and draped in the usual sterile fashion and placed in the dorsal
lithotomy position.  The cervix was visualized and grasped with a tenaculum.  0
Prolene sutures were placed at 12 o'clock and 6 o'clock for retraction.  The
endocervical canal was dilated and the uterus sounded to 9 cm.  A cervical cap
size 3 cm was fitted to the cervix.    The RUMI intrauterine manipulator was
fitted to the cervical cap and placed into the uterus ensuring a good fit of the
cap over the cervix.  The RUMI manipulator was attached to the uterine
positioning system.  The vaginal balloon was then insufflated with normal saline
to ensure a good fit into the vagina.  It was very difficult to put the uterine
manipulator due to very narrow introitus.  Even with the smallest cervical
cover, we had difficulty to pass the introitus and it eventually had to be done
in a quite forceful manner.

After changing gowns and gloves, attention was then turned to the abdomen.  An
incision 4 cm superior to and 2 cm right of the umbilicus was made with a knife
and extended through the underlying tissue with electrocautery.   The incision
was extended approximately 8 cm length on the fascia.  The wound protector was
placed.  The omentum was exteriorized and evaluated.  There was no evidence of
metastatic disease.  Infragastric omentectomy was performed with LigaSure.
Subsequently, small bowel was exteriorized and run.  There was no evidence of
tumor implants.  During the omentectomy, there was a questionable area of
serosal defect in the transverse colon.  This area was reapproximated with 3-0
Vicryl sutures.  The fascia was closed with #1 PDS sutures, 1 starting
superiorly, the other inferiorly.  At the superior aspect, the closure of the
fascia started at approximately 1 cm below the apex to allow for placement of
Hasson type of trocar at the apex.

The fascia was grasped with Kocher clamps, cut and 0 Vicryl sutures were placed
bilaterally for future closure. The peritoneum was cut between straight clamps
and blunt trocar was inserted under direct visualization.   The abdomen was then
insufflated with CO2 gas to a pressure of 15 mmHg.  Two 8 mm trocars were then
inserted approximately 10 cm lateral and slightly inferior to the superior
umbilical port under direct visualization.  A 12 mm bladeless port was then
placed superior and the left of the midline port while under direct
visualization.  Washings of warm normal saline were collected.  The DaVinci
robot was then docked without incident and all aspects were working well.

Bilateral pelvic lymphadenectomies were performed using blunt dissection and
cautery.  The superior borders was (?) the bifurcation of the common iliac,
inferior border was the deep circumflex vein, lateral border was the psoas
muscle, medial border was the umbilical artery and the posterior border was the
obturator nerve.  The ureters were under direct visualization at all times
without injury and the genitofemoral nerves were spared bilaterally.

Bilateral para-aortic lymphadenectomies were then performed using blunt
dissection and cautery.  The inferior border was the bifurcation of the aorta
and the superior border was the inferior mesenteric artery.  During the
dissection of left paraaortic lymph nodes, fibrotic and inflamed tissue was
encountered.  When separating the mesentery from the lymphatic, 2 mm wide
structure was noted running towards the pelvis.  This structure was palpated and
no peristalsis was elicited.  Also, during the dissection, some of the quite
brisk bleeding occurred, suggestive of the vascular nature of this structure.
Also, there was another structure arising in the mesentery that had the
appearance of the ureter.  Unfortunately, due to fibrosis in the mesentery,
despite a couple of attempts, I could not dissect the mesenteric structure well.
 It appeared that the 2 mm structure was not crossing over the external iliac
vessels.  The decision was to transect it.  The transection was performed with
electrocautery.

During the dissection of the left pelvic lymph nodes, the left ureter was
identified.  The ureter appeared to be transected.  The conclusion was that the
2 mm structure that was thought to be a vessel during the left paraaortic
lymphadenectomy in fact was the ureter.  Tips of the ureter were marked with a
3-0 Vicryl suture proximally and distally.  There appeared to be a distance
approximately 3 to 4 cm between those.  The area of transection was 3 cm above
the level of the common iliac artery at the level of crossing of the ureter.
This transection was approximately at the level of the bifurcation of the aorta.
 Consultation from Dr. from Urology was obtained.  The robot was undocked
and the case was converted to exploratory laparotomy.  The area was exposed and
the ureters were identified.  When I was showing the ureter marked with suture
to Dr. , he voiced multiple times his concerned that maybe that was not the
ureter since it was so small.  I responded to Dr. that it was my concern at
the initial portion of the case, that the structure did not resemble the ureter,
also, because of its very small size.  Furthermore, Dr.recommended that it
was probably the smallest ureter that he has ever seen.  We attached the self
retaining retractor to the bed and exposed the area of the ureter.  Dr. trimmed the coagulated edges of the ureter and performed end to end anastomosis
with 4-0 Monocryl sutures.  Also, 4 French size double pigtail stent was placed.
 The anastomosis was performed over the stent.  I assisted Dr.with this
step of the procedure.  Please refer to Dr.note for more details.

Attention was turned to the uterus. The bladder flap was created with
electrocautery and blunt dissection.  It was noted that the uterine manipulator
was perforating the vagina and the posterior cul-de-sac.  The uterine
manipulator was withdrawn.  The muscle (?) bladder flap was created.  Attention
was turned to the uterus and the hysterectomy was performed in the traditional
fashion.  The vagina was entered and cervix and uterus were resected.  The
entire cervix was removed.  The vagina was closed with interrupted 2-0 Vicryl
sutures incorporating the area of the posterior cul-de-sac perforation.  Upon
completion of this part of the procedure, red rubber catheter was placed into
the rectum and air was injected.  There was no evidence of fluid bubbling on the
abdominal side.  The abdomen was copiously irrigated.  The bowel was run and no
evidence of tumor found.  In the right upper quadrant at the hepatic flexure of
the colon, a small nodule was found.  Upon further examination, it appeared that
the patient had a diverticula blocked with fecaliths.

FloSeal was applied to the right pelvic lymph nodes.  This fascia was closed
with #1 PDS suture, 1 starting superiorly, the other inferiorly.  Those sutures
were tied in the middle.  The subcutaneous tissue was copiously irrigated and
closed with staples.  A flat JP drain was placed in the pelvic area and sutured
to the skin with silk sutures.  The trocar sites were closed at the fascial
level with 0 Vicryl suture and 4-0 Monocryl at the skin

The surgery was significantly more difficult due to patient's obesity.  Also,
due to unusual subtype of the endometrial cancer (serous and clear cell
component), the surgery required hand assisted portion for peritoneum
assessment.  Also, patient had significant fibrosis in the lymph node area.  The
fibrosis was especially prominent in the left paraaortic region and right pelvic
region.

All sponge, needle and instrument counts were correct at the end of the case
times two.  The patient tolerated the procedure well and was taken to the
recovery room in stable condition.  

FINDINGS:  Normal upper abdomen including liver, stomach, omentum, bilateral
diaphragms and spleen.  Normal small and large bowel.  8 week size uterus with
normal tubes and ovaries.  Fimbria fallopian tube with 2 to 3 mm cyst, more
likely benign.  No evidence of extrauterine tumor.  Fibrosis in the left
paraaortic and right pelvic region.  The left ureter was 2 mm size in diameter,
as per Dr. , the smallest he has ever seen.  During the identification of
the ureter, the ureter did not show any peristalsis.  Incidental transection of
the left ureter followed by reanastomosis over 4 French size double pigtail
stent by Dr. .  Right external iliac vein with very extensive lymphatic
fibrosis around it.  I was not able to coincidentally note the lumen of the
right external iliac vein.  There is a possibility that this vein was
obliterated.  The patient with extensive atherosclerosis.  Bulging
atherosclerotic plaque approximately 3 cm above the bifurcation of the aorta.
Also, palpable plaque in the common iliac arteries.  Fecaliths in the
diverticula and the liver reflection of the colon.


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## Anastasia (Apr 24, 2014)

According to CCI, these are sequential procedures and generally the more invasive procedure is only billed. Bill the TAH with a 22 modifier and use dx code V64.41 (closed converted to open procedure) and send the operative report.


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