cgarciamck87@gmail.com
Contributor
Would this be coded as 58571 or 58552 since he changed to lavh after already removing the tubes?
PREOPERATIVE DIAGNOSIS: The patient is a 40-year-old female who has a history of painful menstrual cycles, post-endometrial ablation syndrome, dyspareunia.
POSTOPERATIVE DIAGNOSIS: Status post laparoscopic-assisted vaginal hysterectomy as well as bilateral salpingectomy.
PROCEDURE PERFORMED: Laparoscopic-assisted vaginal hysterectomy as well as bilateral salpingectomy.
ESTIMATED BLOOD LOSS: 500 mL.
URINE OUTPUT: 100 mL.
ANTIBIOTICS: 2 grams of Ancef were given prior to the onset of surgery.
SPECIMENS: Includes the uterus as well as bilateral fallopian tubes.
DRAINS: Foley catheter.
FINDINGS:
1. Bilateral fallopian tubes filled with dark brown blood (hematosalpinx).
2. Normal size uterus.
3. Hemostasis.
4. Clear urine.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room after informed consent was obtained. She was placed in the supine position and general endotracheal anesthesia was induced. The patient was prepped and draped in the usual sterile fashion. She was then converted to the dorsal lithotomy position. At this point, a surgical timeout was performed and all parties present were noted to be in agreement.
A weighted speculum was placed into the vagina and the cervix was identified. The anterior surface of the cervix was then grasped with a single-tooth tenaculum. Stay sutures of 0 Vicryl were placed on the surface of the cervix. At this point, the VCare uterine manipulator was placed; however, due to the patient's history of endometrial ablation the device could not be inserted to the fundus.
Our attention was then turned to the abdominal portion of the procedure. 0.25% Marcaine was infiltrated into the inferior portion of the umbilicus. Through this area of infiltration, a 5 mm incision was made. An Optiview trocar was introduced with the camera in place. The central obturator was removed and the camera was then reinserted showing no signs of injury. The abdomen was insufflated to approximately 15 mmHg.
Two other incisions were made, one in the left upper quadrant and one in the left lower quadrant. With the use of these incisions, a LigaSure device was then used to clamp, cauterize and cut the left and right fallopian tubes away from the uterus. Of note, the left and right fallopian tubes were filled with dark brown blood consistent with endometriosis. The fallopian tubes were removed through the left lower quadrant 8 mm trocar after deflating.
Attention was then turned to dissection of the uterus. The uteroovarian ligaments were clamped, cut, and cauterized. This continued dissection traveled down through the broad ligament ending at the uterosacral ligaments.
As the uterine manipulator could not be inserted to its full extent, the plastic ring of the VCare device could not be identified laparoscopically. The decision was then made to proceed with the remaining portion of the procedure as a laparoscopic-assisted vaginal hysterectomy. The patient's abdomen was desufflated and covered with a sterile drape. The patient's legs were then converted to high lithotomy.
A weighted speculum was introduced into the vagina. The cervix was then identified once again and grasped with 2 thyroid clamps. A circumferential incision was made upon the cervix. The epithelium was then dissected with the use of Metzenbaum scissors. The posterior cul-de-sac was entered sharply using Mayo scissors and a longer weighted speculum was introduced.
At this point, the anterior cul-de-sac was entered with the use of Metzenbaum scissors and a Deaver retractor was introduced.
At this point, the remaining attachment of the uterus to the pelvic sidewall was clamped, cut and suture ligated. The specimen was removed. The vaginal cuff was then closed using 0 Vicryl in a running locking fashion. Hemostasis was noted after closure.
Our gloves were changed and attention was then turned once again to the laparoscopic portion of the procedure. The abdomen was then reinsufflated. Irrigation was performed and no residual bleeding was identified. At this point, the decision was made to terminate the procedure. The trocars were removed after the carbon dioxide was allowed to escape. The incisions were then closed with 4-0 Monocryl. A layer of Dermabond was applied to the incisions. At this point, the patient was reversed from general anesthesia. She was transferred to the recovery room after extubation.
PREOPERATIVE DIAGNOSIS: The patient is a 40-year-old female who has a history of painful menstrual cycles, post-endometrial ablation syndrome, dyspareunia.
POSTOPERATIVE DIAGNOSIS: Status post laparoscopic-assisted vaginal hysterectomy as well as bilateral salpingectomy.
PROCEDURE PERFORMED: Laparoscopic-assisted vaginal hysterectomy as well as bilateral salpingectomy.
ESTIMATED BLOOD LOSS: 500 mL.
URINE OUTPUT: 100 mL.
ANTIBIOTICS: 2 grams of Ancef were given prior to the onset of surgery.
SPECIMENS: Includes the uterus as well as bilateral fallopian tubes.
DRAINS: Foley catheter.
FINDINGS:
1. Bilateral fallopian tubes filled with dark brown blood (hematosalpinx).
2. Normal size uterus.
3. Hemostasis.
4. Clear urine.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room after informed consent was obtained. She was placed in the supine position and general endotracheal anesthesia was induced. The patient was prepped and draped in the usual sterile fashion. She was then converted to the dorsal lithotomy position. At this point, a surgical timeout was performed and all parties present were noted to be in agreement.
A weighted speculum was placed into the vagina and the cervix was identified. The anterior surface of the cervix was then grasped with a single-tooth tenaculum. Stay sutures of 0 Vicryl were placed on the surface of the cervix. At this point, the VCare uterine manipulator was placed; however, due to the patient's history of endometrial ablation the device could not be inserted to the fundus.
Our attention was then turned to the abdominal portion of the procedure. 0.25% Marcaine was infiltrated into the inferior portion of the umbilicus. Through this area of infiltration, a 5 mm incision was made. An Optiview trocar was introduced with the camera in place. The central obturator was removed and the camera was then reinserted showing no signs of injury. The abdomen was insufflated to approximately 15 mmHg.
Two other incisions were made, one in the left upper quadrant and one in the left lower quadrant. With the use of these incisions, a LigaSure device was then used to clamp, cauterize and cut the left and right fallopian tubes away from the uterus. Of note, the left and right fallopian tubes were filled with dark brown blood consistent with endometriosis. The fallopian tubes were removed through the left lower quadrant 8 mm trocar after deflating.
Attention was then turned to dissection of the uterus. The uteroovarian ligaments were clamped, cut, and cauterized. This continued dissection traveled down through the broad ligament ending at the uterosacral ligaments.
As the uterine manipulator could not be inserted to its full extent, the plastic ring of the VCare device could not be identified laparoscopically. The decision was then made to proceed with the remaining portion of the procedure as a laparoscopic-assisted vaginal hysterectomy. The patient's abdomen was desufflated and covered with a sterile drape. The patient's legs were then converted to high lithotomy.
A weighted speculum was introduced into the vagina. The cervix was then identified once again and grasped with 2 thyroid clamps. A circumferential incision was made upon the cervix. The epithelium was then dissected with the use of Metzenbaum scissors. The posterior cul-de-sac was entered sharply using Mayo scissors and a longer weighted speculum was introduced.
At this point, the anterior cul-de-sac was entered with the use of Metzenbaum scissors and a Deaver retractor was introduced.
At this point, the remaining attachment of the uterus to the pelvic sidewall was clamped, cut and suture ligated. The specimen was removed. The vaginal cuff was then closed using 0 Vicryl in a running locking fashion. Hemostasis was noted after closure.
Our gloves were changed and attention was then turned once again to the laparoscopic portion of the procedure. The abdomen was then reinsufflated. Irrigation was performed and no residual bleeding was identified. At this point, the decision was made to terminate the procedure. The trocars were removed after the carbon dioxide was allowed to escape. The incisions were then closed with 4-0 Monocryl. A layer of Dermabond was applied to the incisions. At this point, the patient was reversed from general anesthesia. She was transferred to the recovery room after extubation.
