awest
Networker
How would you code this case, there were two docs... 58660..58662?..Thanks for any input.
First operative report:
OPERATIVE FINDINGS: The uterus was normal size for age and parity. The endometriotic implants were over the bladder reflection, cul-de-sac, right and left pelvic sidewalls, and ovaries and tubes, and there were extensive colonic adhesions as well as small bowel adhesions that were taken down by Dr. Shariat. The patient will be referred for possible TAH/BSO versus Depo-Lupron type therapy.
PROCEDURE: The patient was taken to the operating room, placed in the supine position, and given general anesthesia. She was then placed in the dorsolithotomy position, and prepped and draped in the usual sterile manner. The infraumbilical incision was made after the Acorn cannula was attached in the usual fashion and this was taken down through the layers with sharp and blunt dissection. The peritoneum was opened in the usual fashion and angle sutures were placed with 0 Vicryl suture. The Hasson cannula was placed. The abdomen was inflated. The second puncture was done in the suprapubic midline under direct visualization without difficulty. The adhesions were taken down by Dr. S after fulguration of endometriosis of the fundus of the uterus was done. A right overlain cyst was drained and cyst wall was sent for biopsy. After the procedure was performed, all instruments and CO2 were evacuated. The fascia was closed with 0 Vicryl, the subcutaneous tissue with 3-0 plain catgut, and the skin with 4-0 Prolene. Estimated blood loss was minimal. There were no complications.
Second operative report:
OPERATIVE FINDINGS: Operative findings revealed that the patient had evidence of extensive endometriosis in the pelvic cul-de-sac and around the ovaries, and there was a right ovarian cyst as well as endometriosis. There were adhesions bilaterally on the pelvic inlet of the colon and small bowel. The uterus was upper limit of normal. The left tube and ovary were essentially normal except some endometriosis.
PROCEDURE: Under satisfactory general endotracheal intubation anesthesia, the patient was prepped and draped in sterile fashion. An infraumbilical incision was made by Dr. R through the skin and subcutaneous tissue. The fascia was opened and the peritoneum was entered.
Upon entering the peritoneal cavity with a scope, the two anchoring sutures of 0 Vicryl was utilized followed by introduction of Hasson trocar and insufflation of the abdominal cavity. The scope was introduced and laparoscopic examination revealed the above findings. A 5-mm trocar was inserted suprapubically under direct vision. This aided laparoscopic examination. At this stage, Dr. Randolph fulgurated the endometriosis and drained the ovarian cyst from the right side and biopsied the ovary. Hemostasis was established. Then, extensive enterolysis of the bowel adhesion and omentum on the pelvic inlet and lower abdomen was carried with sharp dissection and electrocoagulation. After completing this part, the abdomen was reinspected. No evidence of any bleeding. Then, the scope and the trocar were removed under direct vision. The fascia was closed
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