I would like to get some input on how others would code this operative note. Thanks in advance.
Patient taken to OR. Endotracheal anesthesia obtained without any complication. Prepared in sterile fashion. Put into dorsal lithotomy position. Weighted speculum inserted into the vagina. The cervix was visualized, grasped with tenaculum, dilated down to 5 mm Hegar dilator and a 5 mm VK uterine manipulator was inserted into the uterine cavity and fixed to the uterus with 2-0 vicryl. Attention turned to the abdomen. Veress needle advanced to the abdominal cavity and pneumoperitoneum obtained with 4.5 liters carbon dioxide gas and the Veress needle was taken out from the abdominal cavity and trocars advanced from lateral quadrant and ______ upper quadrant without any complication. Robotic arms docked to the trocars and surgery started with PK bipolar grasper and unipolar hook device. The uterus was midline, slightly enlarged. She did have tubal ligation previously, but the tubes were there. First, the right uterine ovarian ligament cauterized and cut. Right ovary separated from the broad ligament. Then right broad ligament, by cauterization cutting technique with PK and unipolar hook device, separated from the uterus and uterine arteries. Uterine arteries were skeletonized. At this point I visualized and grasped with tenaculum, bipolar PK grasper and cauterized and cut. Then attention turned to the left side. Left side same procedure was applied. Left infundibulopelvic ligament cauterized and cut. The left ovary broad ligament separated from uterus and cervix by cauterization cutting technique. The left side and right side uterine arteries were skeletonized, cauterized and cut. Bladder flap created with sharp and blunt dissection, separated from the uterine wall. there were some adhesions between the bladder and the uterus. These adhesions were carefully separated from the uterine wall. Colpotomy performed around the ring by using hook device. Uterus and salpinx, specifically the left salpinx, taken out from the vaginal cavity. The vaginal cavity closed with V-loc suture in a running locked fashion. The colpopexy performed between uterosacral ligaments and utero-ovarian round ligaments without any complication. After irrigation and excellent hemostasis, surgery was completed, robotic arms undocked, trocars taken out from the abdominal cavity. Pneumoperitoneum deflated and incision closed with 4-0 Vicryl. The patient tolerated procedure well. Taken to recovery room in stable condition.
Pathology specimens were: Uterus and cervix, left tube.
Any input on the procedures is greatly appreciated. I have some ideas but wanted to see what others think. Thanks
Patient taken to OR. Endotracheal anesthesia obtained without any complication. Prepared in sterile fashion. Put into dorsal lithotomy position. Weighted speculum inserted into the vagina. The cervix was visualized, grasped with tenaculum, dilated down to 5 mm Hegar dilator and a 5 mm VK uterine manipulator was inserted into the uterine cavity and fixed to the uterus with 2-0 vicryl. Attention turned to the abdomen. Veress needle advanced to the abdominal cavity and pneumoperitoneum obtained with 4.5 liters carbon dioxide gas and the Veress needle was taken out from the abdominal cavity and trocars advanced from lateral quadrant and ______ upper quadrant without any complication. Robotic arms docked to the trocars and surgery started with PK bipolar grasper and unipolar hook device. The uterus was midline, slightly enlarged. She did have tubal ligation previously, but the tubes were there. First, the right uterine ovarian ligament cauterized and cut. Right ovary separated from the broad ligament. Then right broad ligament, by cauterization cutting technique with PK and unipolar hook device, separated from the uterus and uterine arteries. Uterine arteries were skeletonized. At this point I visualized and grasped with tenaculum, bipolar PK grasper and cauterized and cut. Then attention turned to the left side. Left side same procedure was applied. Left infundibulopelvic ligament cauterized and cut. The left ovary broad ligament separated from uterus and cervix by cauterization cutting technique. The left side and right side uterine arteries were skeletonized, cauterized and cut. Bladder flap created with sharp and blunt dissection, separated from the uterine wall. there were some adhesions between the bladder and the uterus. These adhesions were carefully separated from the uterine wall. Colpotomy performed around the ring by using hook device. Uterus and salpinx, specifically the left salpinx, taken out from the vaginal cavity. The vaginal cavity closed with V-loc suture in a running locked fashion. The colpopexy performed between uterosacral ligaments and utero-ovarian round ligaments without any complication. After irrigation and excellent hemostasis, surgery was completed, robotic arms undocked, trocars taken out from the abdominal cavity. Pneumoperitoneum deflated and incision closed with 4-0 Vicryl. The patient tolerated procedure well. Taken to recovery room in stable condition.
Pathology specimens were: Uterus and cervix, left tube.
Any input on the procedures is greatly appreciated. I have some ideas but wanted to see what others think. Thanks