emilyadams1993@yahoo.com
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PREOPERATIVE DIAGNOSIS: Postoperative vaginal bleeding and pain.
POSTOPERATIVE DIAGNOSIS: Postoperative vaginal bleeding and pain.
PROCEDURE PERFORMED:
1. Examination under anesthesia, vaginal wound exploration,
hemostasis.
2. Partial excision and complex reconstruction of the vagina.
3. Cystourethroscopy.
INDICATIONS FOR PROCEDURE:a 34-year-old female with a
known history of a large urethral diverticulum. The patient underwent
urethral diverticulectomy and Martius labial flap on 02/23/2015.
Postoperatively, Foley catheter was removed in 1 week. The patient
continued to have significant vaginal pain and intermittent bleeding
from the vagina. The patient was previously admitted for similar
complaints a week ago, and also underwent a pelvic CT scan. This failed
to show any significant pelvic as well as perineal hematoma. After a
trial of conservative measures for about of 4 weeks, the patient
presented back with persistent pain and small ongoing vaginal bleeding.
It was very difficult to perform an examination in the office, and at
this point a decision was made to proceed with an examination under
anesthesia and wound exploration. An informed consent was obtained from
the patient, and perioperative complications were discussed including
ongoing pelvic pain, bleeding, infection, need for further procedures,
development of fistula.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the main
operating theater and placed in supine position. She underwent a smooth
induction of general anesthesia. The patient was then given intravenous
Zosyn. She was placed in dorsal lithotomy position with all her
pressure points carefully padded. Her perineum was sterilely prepped
and draped. An operative time-out was performed identifying the patient
and the surgical procedure.
An examination under anesthesia was performed. The meatus appeared
normal. There was a small amount of wound separation from the lateral
edge of the vaginal wound closure approximately 2 cm long. There was a
small slow ooze of blood was seen coming from this area. The labial
incision at the Martius flap site was completely intact and there was no
evidence of any palpable hematoma or any signs of cellulitis. The rest
of the perineal area was examined and there was no evidence of any
hematoma or cellulitis. The cervix was examined and appeared to be
normal, and there was no bleeding as well.
At this point, we decided to performed the cystourethroscopy. We used a
21-French rigid sheath with 30 degree telescope. The scope was very
carefully negotiated through the urethra and there was no evidence of
any urethral fistula or injury. There was no bleeding from the urethra
or bladder. The bladder was systematically examined and appeared to be
normal. There were no blood clots or any bladder lesions. Both
ureteric orifices were in their normal anatomic configuration. A 16-
French Foley catheter was inserted.
At this point, we used a Lone Star retractor and yellow hooks for
vaginal exposure. Careful exposure was performed and the above-
mentioned findings were confirmed. We decided to explore the vaginal
wound to look for the source of bleeding. The previously opened up
incision was further extended proximal and distally for approximately 1
cm each. Careful dissection was performed to raise the vaginal wall
flaps on either sides. The vaginal wall flaps were further retracted
with the help of yellow hooks. On careful examination the Martius flap
was seen coming from the labial wound into the vaginal wound. There
were 2 areas where there was a minimal amount of bleeding seen from the
Martius flap. We also found that the Martius flap was a little tight
and causing tension in this area. We used right-angle forceps and
passed around the Martius flap. The Martius flap was taken down with
the help of the LigaSure device. Two or 3 smaller areas of attachments
were also disconnected with the help of the LigaSure device in order to
achieve hemostasis and reduce the tension. Further dissection was
performed to mobilize the flap, and 1 area was identified where small
bleeding was seen. This area was under run with the help of 4-0 Maxon
suture in a continuous running fashion. Two other areas where there was
slow ooze was identified. We used 4-0 Maxon suture to under run areas.
Following this, the vaginal incision was copiously irrigated with
bacitracin containing solution. Again examination was performed and we
did not find any other obvious source of bleeding or any pockets of
hematoma. At this point, a decision was made to close the vagina
primarily. We excised the small edges of the vagina to get rid of some
of the redundant tissue. We also placed Floseal and Gelfoam in the
vagina for hemostasis. Following this, a single layer closure was
performed with the help of 3-0 Polysorb suture in a continuous running
fashion. At the completion of the procedure, there were no other areas
found to be bleeding. No other sites of hematoma were identified. We
placed a vaginal pack containing Premarin cream. The procedure was
completed at this point, and there were no complications.
What CPT code/s would you give this?
POSTOPERATIVE DIAGNOSIS: Postoperative vaginal bleeding and pain.
PROCEDURE PERFORMED:
1. Examination under anesthesia, vaginal wound exploration,
hemostasis.
2. Partial excision and complex reconstruction of the vagina.
3. Cystourethroscopy.
INDICATIONS FOR PROCEDURE:a 34-year-old female with a
known history of a large urethral diverticulum. The patient underwent
urethral diverticulectomy and Martius labial flap on 02/23/2015.
Postoperatively, Foley catheter was removed in 1 week. The patient
continued to have significant vaginal pain and intermittent bleeding
from the vagina. The patient was previously admitted for similar
complaints a week ago, and also underwent a pelvic CT scan. This failed
to show any significant pelvic as well as perineal hematoma. After a
trial of conservative measures for about of 4 weeks, the patient
presented back with persistent pain and small ongoing vaginal bleeding.
It was very difficult to perform an examination in the office, and at
this point a decision was made to proceed with an examination under
anesthesia and wound exploration. An informed consent was obtained from
the patient, and perioperative complications were discussed including
ongoing pelvic pain, bleeding, infection, need for further procedures,
development of fistula.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the main
operating theater and placed in supine position. She underwent a smooth
induction of general anesthesia. The patient was then given intravenous
Zosyn. She was placed in dorsal lithotomy position with all her
pressure points carefully padded. Her perineum was sterilely prepped
and draped. An operative time-out was performed identifying the patient
and the surgical procedure.
An examination under anesthesia was performed. The meatus appeared
normal. There was a small amount of wound separation from the lateral
edge of the vaginal wound closure approximately 2 cm long. There was a
small slow ooze of blood was seen coming from this area. The labial
incision at the Martius flap site was completely intact and there was no
evidence of any palpable hematoma or any signs of cellulitis. The rest
of the perineal area was examined and there was no evidence of any
hematoma or cellulitis. The cervix was examined and appeared to be
normal, and there was no bleeding as well.
At this point, we decided to performed the cystourethroscopy. We used a
21-French rigid sheath with 30 degree telescope. The scope was very
carefully negotiated through the urethra and there was no evidence of
any urethral fistula or injury. There was no bleeding from the urethra
or bladder. The bladder was systematically examined and appeared to be
normal. There were no blood clots or any bladder lesions. Both
ureteric orifices were in their normal anatomic configuration. A 16-
French Foley catheter was inserted.
At this point, we used a Lone Star retractor and yellow hooks for
vaginal exposure. Careful exposure was performed and the above-
mentioned findings were confirmed. We decided to explore the vaginal
wound to look for the source of bleeding. The previously opened up
incision was further extended proximal and distally for approximately 1
cm each. Careful dissection was performed to raise the vaginal wall
flaps on either sides. The vaginal wall flaps were further retracted
with the help of yellow hooks. On careful examination the Martius flap
was seen coming from the labial wound into the vaginal wound. There
were 2 areas where there was a minimal amount of bleeding seen from the
Martius flap. We also found that the Martius flap was a little tight
and causing tension in this area. We used right-angle forceps and
passed around the Martius flap. The Martius flap was taken down with
the help of the LigaSure device. Two or 3 smaller areas of attachments
were also disconnected with the help of the LigaSure device in order to
achieve hemostasis and reduce the tension. Further dissection was
performed to mobilize the flap, and 1 area was identified where small
bleeding was seen. This area was under run with the help of 4-0 Maxon
suture in a continuous running fashion. Two other areas where there was
slow ooze was identified. We used 4-0 Maxon suture to under run areas.
Following this, the vaginal incision was copiously irrigated with
bacitracin containing solution. Again examination was performed and we
did not find any other obvious source of bleeding or any pockets of
hematoma. At this point, a decision was made to close the vagina
primarily. We excised the small edges of the vagina to get rid of some
of the redundant tissue. We also placed Floseal and Gelfoam in the
vagina for hemostasis. Following this, a single layer closure was
performed with the help of 3-0 Polysorb suture in a continuous running
fashion. At the completion of the procedure, there were no other areas
found to be bleeding. No other sites of hematoma were identified. We
placed a vaginal pack containing Premarin cream. The procedure was
completed at this point, and there were no complications.
What CPT code/s would you give this?
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I look forward to hearing many different opinions to this case as well.