ellie.phelps@gmail.com
Guest
Op Note
Through existing laparoscopic incisions, the patient abdomen was reentered and a pneumoperitoneum was created. A laparoscopic omentectomy was created as the omentum was separated from the transverse colon and an infra-gastric omentectomy was performed. The lesser sac was entered and the gastroepiploic vessels were salvaged and remained intact. The large omentum was placed into a bag and removed through a port which was enlarged. Several biopsies were taken of the peritoneum to provide the specimens for staging. The bilateral peripelvic gutters were biopsied extensively and the bilateral subdiaphragmatic peritoneal surfaces were biopsied as well. The appendix was involved with some scar tissue and this did not appear normal and this appendix was therefore removed using a GIA-45 linear stapler.
Pathalogy
1. Benign portion of the greater omentum, with foci of minor chronic inflammation
2. Benign fragments of fibroadipose tissue, peritoneum of right diaphragm (b) Left diaphragm (c) right pericolic gutter (d) left colic gutter (e) regions biopsies
3. Partial fibroadipose obliteration of lumen and mucosal melanosis, appendix, appendectomy
There is a history of poorly differentiated endometrial carcinoma. Involvement by neoplasm is not identified within present specimens.
I am looking at codes 44955 -59 & 49321 dx of 180.9
Please let me know if this is appropriate
Through existing laparoscopic incisions, the patient abdomen was reentered and a pneumoperitoneum was created. A laparoscopic omentectomy was created as the omentum was separated from the transverse colon and an infra-gastric omentectomy was performed. The lesser sac was entered and the gastroepiploic vessels were salvaged and remained intact. The large omentum was placed into a bag and removed through a port which was enlarged. Several biopsies were taken of the peritoneum to provide the specimens for staging. The bilateral peripelvic gutters were biopsied extensively and the bilateral subdiaphragmatic peritoneal surfaces were biopsied as well. The appendix was involved with some scar tissue and this did not appear normal and this appendix was therefore removed using a GIA-45 linear stapler.
Pathalogy
1. Benign portion of the greater omentum, with foci of minor chronic inflammation
2. Benign fragments of fibroadipose tissue, peritoneum of right diaphragm (b) Left diaphragm (c) right pericolic gutter (d) left colic gutter (e) regions biopsies
3. Partial fibroadipose obliteration of lumen and mucosal melanosis, appendix, appendectomy
There is a history of poorly differentiated endometrial carcinoma. Involvement by neoplasm is not identified within present specimens.
I am looking at codes 44955 -59 & 49321 dx of 180.9
Please let me know if this is appropriate