hnybee101
New
can someone help me with the proper coding of the procedure below. Breif hx the OBGYN did an open hysterectomy closed the pt. he couldnt do a cystoscope to check the bladder and our Urologist was consulted. Urology did a urethral dilation and saw a retained stitch in the bladder so repaired.
part of the op note below:
I decided to take down the vaginal
cuff closure transvaginally and explore. We performed an exam under
anesthesia and we cut all of the sutures from the vaginal cuff. There
was one suture clearly involving the bladder and this was cut with Metz as
well. At this point, the entire bladder was free from the vaginal cuff
and using cystoscopy we were able to identify the precise spot of injury.
Cysto fluid was seen coming out of a small, probably 2 mm hole in the
trigone of the bladder. I was able to close this hole without difficulty
with a 2-0 Vicryl on a UR-6 needle in a double figure of eight fashion.
We performed cysto again and the previously seen spot with the stitch was
now slightly elevated as a result of our closure and there was no
further leakage of urine through the vagina. At this point, I was unable
to find any peritoneal fat or tissue to leave as a layer between the
cystotomy closure and the vaginal cuff. I did not think that a labial fat
flap would reach this proximally either so we elected to simply close
the vaginal cuff at this point.
part of the op note below:
I decided to take down the vaginal
cuff closure transvaginally and explore. We performed an exam under
anesthesia and we cut all of the sutures from the vaginal cuff. There
was one suture clearly involving the bladder and this was cut with Metz as
well. At this point, the entire bladder was free from the vaginal cuff
and using cystoscopy we were able to identify the precise spot of injury.
Cysto fluid was seen coming out of a small, probably 2 mm hole in the
trigone of the bladder. I was able to close this hole without difficulty
with a 2-0 Vicryl on a UR-6 needle in a double figure of eight fashion.
We performed cysto again and the previously seen spot with the stitch was
now slightly elevated as a result of our closure and there was no
further leakage of urine through the vagina. At this point, I was unable
to find any peritoneal fat or tissue to leave as a layer between the
cystotomy closure and the vaginal cuff. I did not think that a labial fat
flap would reach this proximally either so we elected to simply close
the vaginal cuff at this point.