rockylopez
Networker
I wanted to ask for someones opinion regarding does the drainage of the ovarian cyst include with the cpt code 49300??
Post-op Diagnosis:
1. Diagnostic laparoscopy
2. Exploratory laparotomy
3. Drainage of L ovarian simple cyst
4. Evacuation of clot from R ovarian cyst
5. Repair of superficial uterine fundal laceration
6. Further procedures by trauma surgeon, please see op note
Indication: Patient is a 38 yo F presenting to ED with complaints of acute RLQ abdominal pain. US showed L ovarian cyst and limited blood flow to both ovaries. Patient counseled on expectant management vs diagnostic laparoscopy. She elected for diagnostic laparoscopy given significant abdominal pain and concern for possible ovarian torsion.
Anesthesia: General
Findings:
1. No intraabdominal injury found, no vascular injury found
2. Moderate hemoperitoneum
3. Simple L ovarian cyst
4. Actively bleeding R hemorrhagic cyst
5. Small liver laceration
Specimen:
1. None
Prep/Antibiotics
1. Abdominal chloraprep
2. Vaginal betadine
Procedure:
Patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in a sterile manner in the dorsal lithotomy position. Cervix visualized with graves speculum, anterior lip of the cervix grasped with a single tooth tenaculum and hulka uterine manipulator placed. Attention then turned to abdominal portion of the procedure. 0.25% marcaine with epinephrine injected at the umbilicus. 5mm incision made and 5mm optiview trochar inserted with camera in place. Entry into the abdomen somewhat difficult due to adhesive disease. Trochar noted to be in omental adhesion. Abdomen insufflated and additional RLQ port placed under direct visualization. Abdomen inspected, significant adhesions to anterior abdominal wall. Adhesion that was entered at umbilicus inspected, did not appear to be bleeding. L ovary seen to be enlarged with simple cyst. I then asked for trendelenburg to begin taking down adhesions. Anesthesia then alerted me that patient was bradycardic and then lost pulse. They asked insufflation be dropped. Gas off and all trochars removed. Chest compressions immediately started. Patient did not recover immediately and therefore I made the decision to check for intraabdominal bleeding as abdomen had just been entered with some difficulty. Scalpel used to make midline incision from pubic bone to above the umbilicus. Bleeding noted on entry to the abdomen. I immediately placed pressure over the aorta just bellow the diaphragm and packed with laps. Shortly after I could feel pulse, anesthesia confirmed ROSC. Massive transfusion protocol initiated, additional lines obtained, cell saver called for etc. Abdomen was explored throughly and systematically. Bowel run with no injury found, small serosal tear oversewn, no retroperitoneal injury found, no vascular injury found, liver with small laceration that was repaired (likely iatrogenic with aortic compression), spleen and stomach without injury, appendix visualized to be normal. Pelvis inspected. L simple ovarian cyst that spontaneously drained with manipulation. Small laceration to uterine fundus, oversewn with silk. R ovary enlarged with significant clot where hemorrhagic cyst had ruptured. Likely the source of hemoperitoneum found. Decision made to leave abdomen open. X-rays taken as no count prior to opening. Wound vac placed. Foley placed and uterine manipulator removed. Patient taken to ICU in stable condition.
Post-op Diagnosis:
- Simple L ovarian cyst
- R hemorrhagic cyst with large blood clot
1. Diagnostic laparoscopy
2. Exploratory laparotomy
3. Drainage of L ovarian simple cyst
4. Evacuation of clot from R ovarian cyst
5. Repair of superficial uterine fundal laceration
6. Further procedures by trauma surgeon, please see op note
Indication: Patient is a 38 yo F presenting to ED with complaints of acute RLQ abdominal pain. US showed L ovarian cyst and limited blood flow to both ovaries. Patient counseled on expectant management vs diagnostic laparoscopy. She elected for diagnostic laparoscopy given significant abdominal pain and concern for possible ovarian torsion.
Anesthesia: General
Findings:
1. No intraabdominal injury found, no vascular injury found
2. Moderate hemoperitoneum
3. Simple L ovarian cyst
4. Actively bleeding R hemorrhagic cyst
5. Small liver laceration
Specimen:
1. None
Prep/Antibiotics
1. Abdominal chloraprep
2. Vaginal betadine
Procedure:
Patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in a sterile manner in the dorsal lithotomy position. Cervix visualized with graves speculum, anterior lip of the cervix grasped with a single tooth tenaculum and hulka uterine manipulator placed. Attention then turned to abdominal portion of the procedure. 0.25% marcaine with epinephrine injected at the umbilicus. 5mm incision made and 5mm optiview trochar inserted with camera in place. Entry into the abdomen somewhat difficult due to adhesive disease. Trochar noted to be in omental adhesion. Abdomen insufflated and additional RLQ port placed under direct visualization. Abdomen inspected, significant adhesions to anterior abdominal wall. Adhesion that was entered at umbilicus inspected, did not appear to be bleeding. L ovary seen to be enlarged with simple cyst. I then asked for trendelenburg to begin taking down adhesions. Anesthesia then alerted me that patient was bradycardic and then lost pulse. They asked insufflation be dropped. Gas off and all trochars removed. Chest compressions immediately started. Patient did not recover immediately and therefore I made the decision to check for intraabdominal bleeding as abdomen had just been entered with some difficulty. Scalpel used to make midline incision from pubic bone to above the umbilicus. Bleeding noted on entry to the abdomen. I immediately placed pressure over the aorta just bellow the diaphragm and packed with laps. Shortly after I could feel pulse, anesthesia confirmed ROSC. Massive transfusion protocol initiated, additional lines obtained, cell saver called for etc. Abdomen was explored throughly and systematically. Bowel run with no injury found, small serosal tear oversewn, no retroperitoneal injury found, no vascular injury found, liver with small laceration that was repaired (likely iatrogenic with aortic compression), spleen and stomach without injury, appendix visualized to be normal. Pelvis inspected. L simple ovarian cyst that spontaneously drained with manipulation. Small laceration to uterine fundus, oversewn with silk. R ovary enlarged with significant clot where hemorrhagic cyst had ruptured. Likely the source of hemoperitoneum found. Decision made to leave abdomen open. X-rays taken as no count prior to opening. Wound vac placed. Foley placed and uterine manipulator removed. Patient taken to ICU in stable condition.