Jenetteis
Networker
I am stuck on deciding whether or not to code 51860 for repair of bladder with 58260. Any help would be much appreciated. Thank you
58260
58160, 59 [N32.9]
PREOPERATIVE DIAGNOSES:
1. Intractable menorrhagia and severe dysmenorrhea, unresponsive to all previous attempts at medical management.
2. Chronic blood loss anemia, desiring definitive surgery.
3. Previous cesarean section times 3.
POSTOPERATIVE DIAGNOSES:
1. Intractable menorrhagia and severe dysmenorrhea, unresponsive to all previous attempts at medical management.
2. Chronic blood loss anemia, desiring definitive surgery.
3. Previous cesarean section times 3.
NAME OF OPERATIONS: Total vaginal hysterectomy, lysis of adhesions of the anterior lower uterine segment and repair of bladder.
COMPLICATIONS: Severe adhesions of the lower uterine segment and bladder from site of 3 previous cesarean sections with weakened thin bladder mucosa requiring repair.
BLOOD REPLACEMENT PRODUCTS: None.
GRAFTS AND IMPLANTS: None.
DRAINS: Foley to gravity.
DISPOSITION: The patient was taken to the recovery room in stable condition. It is anticipated that she will be discharged home tomorrow morning if criteria for stability are met with instructions to follow up with me in my office for Foley catheter removal in approximately 2 weeks.
DESCRIPTION OF OPERATION: The patient was taken to the OR and satisfactory general anesthesia obtained, the patient was draped and prepped in the usual sterile fashion, placed in the dorsal lithotomy position. After an appropriate timeout was accomplished and all OR personnel in attendance in agreement, a weighted speculum was placed in the posterior vaginal vault and cervix visualized. The cervix visualized with a Deaver retractor. Single-tooth tenaculum was used to grasp the anterior lip of the cervix and it was circumferentially infiltrated with 1% Xylocaine with epinephrine to promote hemostasis. At this time, a scalpel was used to circumferentially excise the vaginal mucosa within the base of the cervix. Dissection was accomplished posteriorly to the posterior peritoneum, which was entered with Metzenbaum scissors and the posterior cul-de-sac was visualized and a long gooseneck retractor advanced posteriorly to reflect the rectum. Dissection was then accomplished anteriorly up across the anterior lower uterine segment. There was severe scarring from 3 previous cesarean sections. Scar tissue was lysed with Metzenbaum scissors. Care was taken to dissect the bladder from the uterus; however, the bladder wall was extremely thin at the point of adhesiolysis and there appeared to be extravasation of urine through the bladder mucosa that could be visualized in the operative field. This area of weakened bladder was oversewn with 2-0 chromic sutures after the bladder was fully dissected off the uterus and the area secured with serosa of the bladder in a second in a running imbricating layer. Methylene blue dye was then instilled via a Foley catheter and the bladder was seen to be watertight. There was no longer any extravasation through any very thin bladder mucosa. At this time, the remainder of the hysterectomy procedure was accomplished. The left and right uterosacral ligaments were isolated, ligated with 0-Vicryl and plicated the vaginal cuff for postoperative support. The EnSeal device was then used in serial fashion up through the cardinal ligaments, through the uterine arteries bilaterally. The EnSeal device was then used up through the lower broad ligament up to and including the round ligaments. The uterus was then rotated posteriorly. The left and right ovarian ligaments and fallopian tubes were cross-clamped, cut and ligated with 0-Vicryl times 2. Hemostasis seemed to be achieved at both ligation sites. The ovaries appeared to be anatomically and structurally normal and were preserved for future hormone purposes in this patient. No abnormalities were noted of the bowel serosal surfaces. Once again, the bladder was inspected and noted to be watertight at this time. Hemostasis seemed to be achieved at all surgical areas and at this time closure of the vaginal cuff and peritoneum was accomplished with 0-Vicryl in a continuous running interlocking fashion. A vaginal packing moistened with sterile saline was placed into the vaginal vault to promote support during the initial healing process and the procedure ended at this time. The patient tolerated the procedure well and was taken to recovery room in stable condition. Sponge and needle counts were correct times 3 and appropriate debriefing was done with the OR staff at the end of the procedure.
58260
58160, 59 [N32.9]
PREOPERATIVE DIAGNOSES:
1. Intractable menorrhagia and severe dysmenorrhea, unresponsive to all previous attempts at medical management.
2. Chronic blood loss anemia, desiring definitive surgery.
3. Previous cesarean section times 3.
POSTOPERATIVE DIAGNOSES:
1. Intractable menorrhagia and severe dysmenorrhea, unresponsive to all previous attempts at medical management.
2. Chronic blood loss anemia, desiring definitive surgery.
3. Previous cesarean section times 3.
NAME OF OPERATIONS: Total vaginal hysterectomy, lysis of adhesions of the anterior lower uterine segment and repair of bladder.
COMPLICATIONS: Severe adhesions of the lower uterine segment and bladder from site of 3 previous cesarean sections with weakened thin bladder mucosa requiring repair.
BLOOD REPLACEMENT PRODUCTS: None.
GRAFTS AND IMPLANTS: None.
DRAINS: Foley to gravity.
DISPOSITION: The patient was taken to the recovery room in stable condition. It is anticipated that she will be discharged home tomorrow morning if criteria for stability are met with instructions to follow up with me in my office for Foley catheter removal in approximately 2 weeks.
DESCRIPTION OF OPERATION: The patient was taken to the OR and satisfactory general anesthesia obtained, the patient was draped and prepped in the usual sterile fashion, placed in the dorsal lithotomy position. After an appropriate timeout was accomplished and all OR personnel in attendance in agreement, a weighted speculum was placed in the posterior vaginal vault and cervix visualized. The cervix visualized with a Deaver retractor. Single-tooth tenaculum was used to grasp the anterior lip of the cervix and it was circumferentially infiltrated with 1% Xylocaine with epinephrine to promote hemostasis. At this time, a scalpel was used to circumferentially excise the vaginal mucosa within the base of the cervix. Dissection was accomplished posteriorly to the posterior peritoneum, which was entered with Metzenbaum scissors and the posterior cul-de-sac was visualized and a long gooseneck retractor advanced posteriorly to reflect the rectum. Dissection was then accomplished anteriorly up across the anterior lower uterine segment. There was severe scarring from 3 previous cesarean sections. Scar tissue was lysed with Metzenbaum scissors. Care was taken to dissect the bladder from the uterus; however, the bladder wall was extremely thin at the point of adhesiolysis and there appeared to be extravasation of urine through the bladder mucosa that could be visualized in the operative field. This area of weakened bladder was oversewn with 2-0 chromic sutures after the bladder was fully dissected off the uterus and the area secured with serosa of the bladder in a second in a running imbricating layer. Methylene blue dye was then instilled via a Foley catheter and the bladder was seen to be watertight. There was no longer any extravasation through any very thin bladder mucosa. At this time, the remainder of the hysterectomy procedure was accomplished. The left and right uterosacral ligaments were isolated, ligated with 0-Vicryl and plicated the vaginal cuff for postoperative support. The EnSeal device was then used in serial fashion up through the cardinal ligaments, through the uterine arteries bilaterally. The EnSeal device was then used up through the lower broad ligament up to and including the round ligaments. The uterus was then rotated posteriorly. The left and right ovarian ligaments and fallopian tubes were cross-clamped, cut and ligated with 0-Vicryl times 2. Hemostasis seemed to be achieved at both ligation sites. The ovaries appeared to be anatomically and structurally normal and were preserved for future hormone purposes in this patient. No abnormalities were noted of the bowel serosal surfaces. Once again, the bladder was inspected and noted to be watertight at this time. Hemostasis seemed to be achieved at all surgical areas and at this time closure of the vaginal cuff and peritoneum was accomplished with 0-Vicryl in a continuous running interlocking fashion. A vaginal packing moistened with sterile saline was placed into the vaginal vault to promote support during the initial healing process and the procedure ended at this time. The patient tolerated the procedure well and was taken to recovery room in stable condition. Sponge and needle counts were correct times 3 and appropriate debriefing was done with the OR staff at the end of the procedure.
