# Exploratory laparotomy w/  uterine artery ligation



## Airam0912 (Sep 28, 2010)

Help w/ coding OP Report follows:

PREOPERATIVE DIAGNOSIS: A 28-year-old 3 days postop from cesarean section with anemia and active abdominal bleeding. 

POSTOPERATIVE DIAGNOSIS: A 28-year-old 3 days postop from cesarean section with anemia and active abdominal bleeding with lower uterine vessel cervical branch bleeding on the left. 

PROCEDURES: Exploratory laparotomy, uterine artery ligation x2 on the left, suturing of cervical branch of the uterine artery on the left. 

COMPLICATIONS: None. 

URINE OUTPUT: 275 cc. 

FLUIDS: 2500 cc of crystalloid. 

ESTIMATED BLOOD LOSS: Including blood obtained in the pelvis upon entry 4000 cc. 

Packed red blood cells 5 units, fresh frozen plasma 7 units. 

FINDINGS: A normal uterine incision, well closed, normal liver, gallbladder, upper abdominal contents, large amount of clot and free fluid, blood in the pelvis and in the upper abdomen, a left lower quadrant cervical branch bleeding of the uterine artery, normal right angle. 

INDICATIONS FOR PROCEDURE: The patient is a 28-year-old gravida 1, para 1, who is 3 days postop from the C-section for arrest of descent at time of C- section during that procedure. The patient recovered well until approximately 2 hours postoperatively. At that time, she was hypertensive and was given fluid and vascular support. She had an initial hemoglobin of 25, a 3-hour repeat showed a hemoglobin of 18. Her vital signs were stable. She received 2 units of packed RBCs at that time. Pulse remained 70 to 75. A 2-hour post-transfusion hematocrit was 27. The patient recovered well. Her vital signs remained stable. She had Foley catheter removed 24 hours after blood products were given. She had a repeat CBC at that 24-hour period which was again hematocrit of 27, hemoglobin of 9. The patient continued to recover well. She was tolerating a regular diet, ambulating, not requiring pain medication beyond Tylenol and NSAIDs. On postoperative day #3, the patient had a lightheaded dizzy episode while going to the bathroom with a questionable loss of consciousness. She became pale and slightly diaphoretic. Her blood pressure remained stable at 90/50, heart rate went up to 110, and immediate CBC at that time showed a hematocrit of 15. Ultrasound showed free fluid now in the pelvis. The diagnosis of intraabdominal bleeding was made, and the patient was taken to the OR after risks, benefits, alternatives of the procedure including possibility of hysterectomy were discussed with the patient, and the patient signed consent. 

PROCEDURE IN DETAIL: The patient was taken to the operating room where initially blood products were given until before intubation. Once blood products were started, the patient was intubated. The previous Pfannenstiel incision was opened using scissors. The fascia was also opened using scissors. Upon entry into the peritoneal cavity, large amount of clots were noted and removed. Upper abdominal clots were also noted and removed until visualization could be obtained. When blood had been removed enough for visualization, the left lower quadrant was identified to be a source of bleeding of bright red blood. Decision was made first to proceed with a uterine artery ligation to decrease the source of blood supply. This was performed x2 with a suture around the uterine artery into the broad ligament on the left above the uterine incision to start and at the uterine incision as a second suture. Despite uterine artery ligation, bleeding was still noted in the left lower quadrant. The bladder was carefully displaced inferiorly, and multiple attempts at isolating the bleeder were first performed with the uterus exteriorized. This was then unable to be performed, so the uterus was replaced into the abdominal cavity and with displacement superiorly within the abdominal cavity, the area was visualized better. At this point when the bleeder could be specifically identified, 2 sutures were placed. In addition, the area of the uterine artery ligation was transected to release and create further visualization in the left lower quadrant. Suture of this area demonstrated hemostasis. The upper abdomen was irrigated with copious amounts of normal saline, and further clot and blood were removed from the upper abdomen. A reinspection of the left lower quadrant again demonstrated hemostasis. An additional figure-of-eight was placed over the vessel area and the peritoneum closed laterally from the bladder flap to the broad ligament using a 2-0 Vicryl suture. All other sutures were 0 Vicryl sutures. Further inspection of the upper abdomen demonstrated a small amount more of clot, which was removed. Irrigation was then performed an additional time. The patient remained stable per Anesthesia throughout the procedure. Her ending blood pressure was 110/60, heart rate was 67. The patient's total fluid input was 2500 cc of crystalloid. She had 275 cc output of urine. The patient during the case per Anesthesia received 7 units of fresh frozen plasma and 5 units of packed RBCs. Attention was then turned to the rectus muscle, which was reapproximated in the midline using a 2-0 Vicryl suture in interrupted fashion. The fascia was reapproximated in a running fashion using an 0 PDS suture. The subcutaneous tissue was irrigated with normal saline solution and closed in a running fashion using a 3-0 plain suture. The skin was reapproximated using staples. All sponge, lap, needle counts were correct x2, and the patient was transferred directly to ICU in stable condition. 

I was thinking of using DX codes 998.11 hemorrhage complicating a procedure and 648.22 maternal anemia w/ delivery and current pp condition

The procedure code I think I should use is 37617 for ligation of abdominal artery w/ modifier 78. I don't think I need to use 49000 for exploratory laparotomy since the procedure turned into something else. Any advise greatly appreciated.  I don't know if there is a more appropriate code?


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## preserene (Sep 28, 2010)

*674.34 *other complications of Obs Surgical wounds, *666.24 *delayed and Secondary post partum hemorrhage, ( the term secondary PP hemorrhage is more important than the anemia coding)
998.1 is specifically excluded and we have more appropriate diag code(674.3x).
You can add anaemia  code after these if you would like to.

CPT codes I think we should use *49002, * in addition to37617, to show that this is  a reopening of a recent laporatomy .
Thank you


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## Airam0912 (Sep 28, 2010)

Thank-you, I appreciate your help!


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## Cathy Zardas (Sep 28, 2010)

Would this require a Modifier 78 or 79 be used?


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## preserene (Sep 28, 2010)

Thank you and yes it would be appended


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