Good Morning,
I need guidance on which approach to use for this surgery please:
Procedure:
Diagnostic Laparoscopy
Laparoscopic left salpingectomy
Laparoscopic left broad ligament myomectomy (pathology specimen now resulted)
Conversion to Laparotomy
Incidental thermal injury to bowel repair
Left ovarian mass/cyst removal
Left Cornu over sewn (endometrial cavity maintained integrity, uterus was not entered during broad ligament dissection).
OPERATIVE REPORT
Patient Name: XXXXXXXX
DOB: XX/XX/XX Date of Service: 8/17/2024
Date of Admission: 8/16/2024 5:19 PM
Patient Name:XXXXXXX
Procedures Date: 8/16/2024 - 8/17/2024
Pre-op Diagnosis:
1. 31 yo G2P1001 female LMP 6/31/24
2. Suspected ruptured ectopic pregnancy
a. +UPT, B-hcg 10,140
b. TVUS findings:
i. Heterogeneous structure in the left adnexal area adjacent to the left ovary which appears to contain a small gestational sac and fetal pole. The collection in total measures 4.4 x 5.5 x 3.5 cm.
ii. The presumed gestational sac measures 0.6 cm.
iii. The presumed fetal pole measures 0.5 cm corresponding to a gestational age of 6 weeks and 1 day.
iv. Mild free fluid seen in the pelvis.
c. Hgb 11.8
d. Hemodynamically stable
3. Urinary tract Infection, asymptomatic
a. 3+ leukocyte esterase, positive nitrite
4. Hx of CS x 1
a. In 2015 d/t breech presentation
Post-operative Diagnosis:
1. Pregnancy of unknown location
2. S/p Left Salpingectomy, left broad ligament mass removal (suspected leiomyoma) and Dilation & Curettage
3. No hemoperitoneum was noted, normal physiologically fluid was seen.
Procedure(s):
LAPAROSCOPY
SALPINGECTOMY
REMOVAL OVARIAN CYST / PARATUBAL CYST
Surgeon(s):
DO
Resident: DO PGY-4, DO PGY-1
Anesthesia: General
Findings: Uterus was found to be retroverted with a large left broad ligament mass measuring approximately 5 x 4 cm encompassing and extending into the left cornu. Left fallopian tube slightly enlarged, left ovarian mass measuring approximately 1 cm. Normal bilateral round ligaments, normal right ovary. The anterior and posterior cul-de-sac contained normal physiologic peritoneal fluid.
Estimated Blood Loss: 300 ml
Total IV Fluids: 700 mL
Urine output: 400 mL
Complications: None; patient tolerated the procedure well.
Indication and Consent:
Patient presented to the hospital with vaginal bleeding and mild abdominal pain positive pregnancy test and beta hCG of approximately ~10,000, crown-rump length of 6 weeks 1 day, and possible free fluid in the pelvis. Concern for suspected ruptured ectopic pregnancy was diagnosed at that time and the decision was made to proceed with surgical management with diagnostic laparoscopy, possible salpingectomy, possible salpingo-oophorectomy, possible laparotomy and all other indicated procedures. The risks, benefits, alternatives, and indications for the procedure were discussed with the patient. She understood the risks of procedure include but are not limited to possible injury to bowel, bladder, and ureters, future infertility, potential miscarriage of current pregnancy, and possible death. The possibilities of bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient stated understanding and desired to proceed. All questions were answered.
Procedure Details
The patient was taken to the Operating Room with IV fluid running and SCDs placed on bilateral lower extremeties. Patient was identified as XXXXXX and the procedure verified as. diagnostic laparoscopy, possible salpingo-oophorectomy possible laparotomy and all other indicated procedures. A Time Out was held and the above information confirmed.
After induction of general anesthesia, the patient was placed in modified dorsal lithotomy position in Allen type stirrups where she was prepped, draped, and catheterized in the normal, sterile fashion. The cervix was visualized and a sponge stick was placed. A vertical skin incision was made across the umbilical folds after skin was inflitrated with 1/4% marcaine with epinephrine. A 5mm trocar was then advanced under direct visualization of the laparoscope. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. Two 5 mm trocars were inserted in the bilateral lower quadrants (8cm from midline) under direct laparoscopic visualization after skin was infiltrated as above with marcaine.Patient was then placed in trendelenburg position. The above findings were noted. The uterus was elevated from the pelvis with sponge stick. Both ovaries and tubes visualized.
A LigaSure device was used to transect the left fallopian tube at the mesosalpinx. Due to the size of the left broad ligament mass careful dissection was taken using the LigaSure device to transect the mass from its origin. The left ureter was identified coursing over the pelvic brim and the intention was paid to not damage the IP ligament and ureter. The serosal layer of the uterus was entered and careful dissection circumferentially around the mass was taken in order to remove it. The mass was dropped in the posterior cul-de-sac. The Cornu of the uterus and serosal edges were cauterized with L-hook and ligature device. Due to concern of possible entry into the myometrial cavity and large size of left broad ligament mass a decision was made to convert to laparotomy in order to remove mass and ensure oversewing of the left cornu of the uterus. 2 g of Ancef was given.
A Pfannenstiel skin incision was made with the scalpel and incision was carried down to the fascia with sharp dissection. Fascia was incised and then extended. The superior part of the fascia was grasped with Kocher clamps. The underlying rectus muscle was dissected off bluntly as well as with a Bovie. In a similar fashion, the inferior part of the fascia was elevated with Kocher's and the rectus muscle was dissected off with sharp dissection. Hemostasis was achieved with a Bovie. Preperitoneal fatty tissue was bluntly dissected to expose peritoneum. As the peritoneal cavity was entered small bowel extruded and was lightly grazed with electrocautery device. Intraoperative consult to general surgery was made for assessment of ~2 mm incidental bowel injury. General surgery resident (Dr. XXX) presented to patient bedside and performed oversewing of serosal thermal injury using 3-0 ethibond suture with 2 interrupted stitches. Please see operative report for further detail. Once repaired the peritoneum was entered and incision was extended superiorly and inferiorly to the bladder reflection. An Alexis retractor was placed with bowel packed away using moist laparotomy sponges. The patient was put in slight Trendelenburg. Upward traction was applied to facilitate to exposure and dissection.
The left fallopian tube specimen was removed along with the left broad ligament mass. The left ovary was noted to have a 1 cm suspicious structure which was removed with electrocautery. All specimens were sent to pathology. The uterus was oversewn in a 2 layer fashion with 0 Vicryl, and 2-0 chromic. Additional figure of eights performed to ensure hemostasis and Hemostasis was.The blood clots and fluid were wiped out of the abdomen and pelvis with moist laparotomy sponges. Arista was placed on the left uterine cornu and ovary. The muscle layer was closed. The fascial layer was closed in a running fashion. The skin was closed with suture in a subcuticular fashion. The laparoscopic port sites were closed with 4-0 Monocryl suture and dermabond.
At the procedure a D&C was performed in order to obtain endometrial sampling for pathology for confirmation of ectopic pregnancy. A weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with a single tooth tenaculum. Sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. Endometrial curettings were collected and sent to pathology. After the procedure, all instruments were removed from the vagina. The cervix was noted to be hemostatic. The patient tolerated the procedure well. All counts were correct. The patient was taken from the operating room in stable condition after she was cleaned. Patient was giving 200 of IV doxycycline for infection prophylaxis postoperatively.
Attending present for entire procedure.
Would I consider using the Laparotomy codes? 58700 for the Laparotomy Removal of left tube or for possible ectopic removal since ectopic was suspected? 59120 And then use modifier 22 for the additional work? And then the D&C would also be billable? Please advise.
SURGICAL PATHOLOGY REPORT
----------------------------------------
Diagnosis:
A. Left broad ligament mass, excision:
- Benign leiomyoma (5.5 cm) with features of ischemia.
- Negative for malignancy.
- No chorionic villi present; the specimen is extensively sampled, including all of the soft tissue around the leiomyoma.
B. Left fallopian tube, salpingectomy:
- Benign fallopian tube tissue with no significant pathologic alteration.
- No chorionic villi present; the specimen is submitted entirely.
C. Endometrium, curettage:
- Fragments of benign endo- and ectocervical tissue in a background of blood clot.
- No endometrial tissue has been sampled.
- Negative for dysplasia and malignancy.
- No chorionic villi present.
D. Left ovarian mass, cystectomy:
- Benign corpus luteum cyst (2.0 cm).
- Negative for malignancy.
- No chorionic villi present.
Thank you in advance so much for your assistance.
I need guidance on which approach to use for this surgery please:
Procedure:
Diagnostic Laparoscopy
Laparoscopic left salpingectomy
Laparoscopic left broad ligament myomectomy (pathology specimen now resulted)
Conversion to Laparotomy
Incidental thermal injury to bowel repair
Left ovarian mass/cyst removal
Left Cornu over sewn (endometrial cavity maintained integrity, uterus was not entered during broad ligament dissection).
OPERATIVE REPORT
Patient Name: XXXXXXXX
DOB: XX/XX/XX Date of Service: 8/17/2024
Date of Admission: 8/16/2024 5:19 PM
Patient Name:XXXXXXX
Procedures Date: 8/16/2024 - 8/17/2024
Pre-op Diagnosis:
1. 31 yo G2P1001 female LMP 6/31/24
2. Suspected ruptured ectopic pregnancy
a. +UPT, B-hcg 10,140
b. TVUS findings:
i. Heterogeneous structure in the left adnexal area adjacent to the left ovary which appears to contain a small gestational sac and fetal pole. The collection in total measures 4.4 x 5.5 x 3.5 cm.
ii. The presumed gestational sac measures 0.6 cm.
iii. The presumed fetal pole measures 0.5 cm corresponding to a gestational age of 6 weeks and 1 day.
iv. Mild free fluid seen in the pelvis.
c. Hgb 11.8
d. Hemodynamically stable
3. Urinary tract Infection, asymptomatic
a. 3+ leukocyte esterase, positive nitrite
4. Hx of CS x 1
a. In 2015 d/t breech presentation
Post-operative Diagnosis:
1. Pregnancy of unknown location
2. S/p Left Salpingectomy, left broad ligament mass removal (suspected leiomyoma) and Dilation & Curettage
3. No hemoperitoneum was noted, normal physiologically fluid was seen.
Procedure(s):
LAPAROSCOPY
SALPINGECTOMY
REMOVAL OVARIAN CYST / PARATUBAL CYST
Surgeon(s):
DO
Resident: DO PGY-4, DO PGY-1
Anesthesia: General
Findings: Uterus was found to be retroverted with a large left broad ligament mass measuring approximately 5 x 4 cm encompassing and extending into the left cornu. Left fallopian tube slightly enlarged, left ovarian mass measuring approximately 1 cm. Normal bilateral round ligaments, normal right ovary. The anterior and posterior cul-de-sac contained normal physiologic peritoneal fluid.
Estimated Blood Loss: 300 ml
Total IV Fluids: 700 mL
Urine output: 400 mL
Complications: None; patient tolerated the procedure well.
Indication and Consent:
Patient presented to the hospital with vaginal bleeding and mild abdominal pain positive pregnancy test and beta hCG of approximately ~10,000, crown-rump length of 6 weeks 1 day, and possible free fluid in the pelvis. Concern for suspected ruptured ectopic pregnancy was diagnosed at that time and the decision was made to proceed with surgical management with diagnostic laparoscopy, possible salpingectomy, possible salpingo-oophorectomy, possible laparotomy and all other indicated procedures. The risks, benefits, alternatives, and indications for the procedure were discussed with the patient. She understood the risks of procedure include but are not limited to possible injury to bowel, bladder, and ureters, future infertility, potential miscarriage of current pregnancy, and possible death. The possibilities of bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient stated understanding and desired to proceed. All questions were answered.
Procedure Details
The patient was taken to the Operating Room with IV fluid running and SCDs placed on bilateral lower extremeties. Patient was identified as XXXXXX and the procedure verified as. diagnostic laparoscopy, possible salpingo-oophorectomy possible laparotomy and all other indicated procedures. A Time Out was held and the above information confirmed.
After induction of general anesthesia, the patient was placed in modified dorsal lithotomy position in Allen type stirrups where she was prepped, draped, and catheterized in the normal, sterile fashion. The cervix was visualized and a sponge stick was placed. A vertical skin incision was made across the umbilical folds after skin was inflitrated with 1/4% marcaine with epinephrine. A 5mm trocar was then advanced under direct visualization of the laparoscope. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. Two 5 mm trocars were inserted in the bilateral lower quadrants (8cm from midline) under direct laparoscopic visualization after skin was infiltrated as above with marcaine.Patient was then placed in trendelenburg position. The above findings were noted. The uterus was elevated from the pelvis with sponge stick. Both ovaries and tubes visualized.
A LigaSure device was used to transect the left fallopian tube at the mesosalpinx. Due to the size of the left broad ligament mass careful dissection was taken using the LigaSure device to transect the mass from its origin. The left ureter was identified coursing over the pelvic brim and the intention was paid to not damage the IP ligament and ureter. The serosal layer of the uterus was entered and careful dissection circumferentially around the mass was taken in order to remove it. The mass was dropped in the posterior cul-de-sac. The Cornu of the uterus and serosal edges were cauterized with L-hook and ligature device. Due to concern of possible entry into the myometrial cavity and large size of left broad ligament mass a decision was made to convert to laparotomy in order to remove mass and ensure oversewing of the left cornu of the uterus. 2 g of Ancef was given.
A Pfannenstiel skin incision was made with the scalpel and incision was carried down to the fascia with sharp dissection. Fascia was incised and then extended. The superior part of the fascia was grasped with Kocher clamps. The underlying rectus muscle was dissected off bluntly as well as with a Bovie. In a similar fashion, the inferior part of the fascia was elevated with Kocher's and the rectus muscle was dissected off with sharp dissection. Hemostasis was achieved with a Bovie. Preperitoneal fatty tissue was bluntly dissected to expose peritoneum. As the peritoneal cavity was entered small bowel extruded and was lightly grazed with electrocautery device. Intraoperative consult to general surgery was made for assessment of ~2 mm incidental bowel injury. General surgery resident (Dr. XXX) presented to patient bedside and performed oversewing of serosal thermal injury using 3-0 ethibond suture with 2 interrupted stitches. Please see operative report for further detail. Once repaired the peritoneum was entered and incision was extended superiorly and inferiorly to the bladder reflection. An Alexis retractor was placed with bowel packed away using moist laparotomy sponges. The patient was put in slight Trendelenburg. Upward traction was applied to facilitate to exposure and dissection.
The left fallopian tube specimen was removed along with the left broad ligament mass. The left ovary was noted to have a 1 cm suspicious structure which was removed with electrocautery. All specimens were sent to pathology. The uterus was oversewn in a 2 layer fashion with 0 Vicryl, and 2-0 chromic. Additional figure of eights performed to ensure hemostasis and Hemostasis was.The blood clots and fluid were wiped out of the abdomen and pelvis with moist laparotomy sponges. Arista was placed on the left uterine cornu and ovary. The muscle layer was closed. The fascial layer was closed in a running fashion. The skin was closed with suture in a subcuticular fashion. The laparoscopic port sites were closed with 4-0 Monocryl suture and dermabond.
At the procedure a D&C was performed in order to obtain endometrial sampling for pathology for confirmation of ectopic pregnancy. A weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with a single tooth tenaculum. Sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. Endometrial curettings were collected and sent to pathology. After the procedure, all instruments were removed from the vagina. The cervix was noted to be hemostatic. The patient tolerated the procedure well. All counts were correct. The patient was taken from the operating room in stable condition after she was cleaned. Patient was giving 200 of IV doxycycline for infection prophylaxis postoperatively.
Attending present for entire procedure.
Would I consider using the Laparotomy codes? 58700 for the Laparotomy Removal of left tube or for possible ectopic removal since ectopic was suspected? 59120 And then use modifier 22 for the additional work? And then the D&C would also be billable? Please advise.
SURGICAL PATHOLOGY REPORT
----------------------------------------
Diagnosis:
A. Left broad ligament mass, excision:
- Benign leiomyoma (5.5 cm) with features of ischemia.
- Negative for malignancy.
- No chorionic villi present; the specimen is extensively sampled, including all of the soft tissue around the leiomyoma.
B. Left fallopian tube, salpingectomy:
- Benign fallopian tube tissue with no significant pathologic alteration.
- No chorionic villi present; the specimen is submitted entirely.
C. Endometrium, curettage:
- Fragments of benign endo- and ectocervical tissue in a background of blood clot.
- No endometrial tissue has been sampled.
- Negative for dysplasia and malignancy.
- No chorionic villi present.
D. Left ovarian mass, cystectomy:
- Benign corpus luteum cyst (2.0 cm).
- Negative for malignancy.
- No chorionic villi present.
Thank you in advance so much for your assistance.
