valerieeanderson
Networker
I need some help with CPT choice. I'm pretty sure we need an UNL code but not sure what the right compare to CPT is. There was no EM performed and this was IP. Below is the report, any assistance is appreciated.
SPECIMENS:
Uterine C-section scar.
FINDINGS:
Hysteroscopic findings, uterine niche noted at the lower uterine segment
measuring approximately 1.5 cm. The endometrial cavity was noted to be
normal. No evidence of polyps or fibroids and bilateral fallopian tube ostia
noted.
PROCEDURE IN DETAIL:
The patient was taken to the operating room where anesthesia was obtained with
ease. She was then placed in dorsal lithotomy position using Allen stirrups.
She was examined under anesthesia with the above findings noted. She was
prepped and draped in the usual sterile fashion. A Foley catheter was
introduced. A room temperature bivalve speculum was placed in the vagina.
The cervix was grasped with a single-tooth tenaculum and a 5-mm hysteroscope
was introduced without difficulties. The uterine niche/isthmocele was
identified and the anterior cervical uterine junction with an indentation
protruding into the endocervix. Additional hysteroscopic findings include a
normal endometrial cavity. No polyps or fibroids noted. Bilateral fallopian
tube ostia noted. No evidence of injury or trauma. Attention was then turned
to the abdomen where the umbilical fold was incised to about 8 mm. A Veress
needle was introduced at the base and introduced with ease. Intraabdominal
placement was suspected with negative initial pressures followed by sequential
rise to 15 mmHg. An 8-mm robotic trocar and sleeve were introduced through
this incision and intraabdominal placement was confirmed by the laparoscope.
Inspection of the entry point revealed no evidence of trauma or injury.
Inspection of the upper abdomen and pelvis revealed anatomy as described above
with a normal liver edge, peritoneal, and diaphragmatic surfaces, normal
gallbladder. No evidence of endometriosis. The uterus, bilateral fallopian
tubes, and ovaries appeared normal. The anterior and posterior cul-de-sac
appeared normal. The bladder was slightly adhesed to the lower uterine
segment and over the niche. The hysteroscopic light was immediately
visualized at the location of the niche. Three accessory ports were placed, 2
on the right, 1 on the left, all using 8-mm robotic trocars, all placed under
direct laparoscopic guidance. The patient was placed in the Trendelenburg
position and the bowel was mobilized away from the pelvis. The robotic
docking took place and instruments were introduced under direct guidance. The
lower uterine segment and niche area were infiltrated with diluted solution of
vasopressin. The hysteroscopy was continued at this point as the bladder flap
was developed from lateral to medial. The broad ligament was taken down to
identify the cervicovaginal junction, the pubocervical fascia, and mobilizing
the bladder away from the niche location. Once the bladder was mobilized, the
niche was entered with robotic scissors. Prompt spillage of hysteroscopic
fluid was noted. The defect measured approximately a centimeter and a half.
The edges were resected with cold scissors and the area was reapproximated
with interrupted sutures of 2-0 PDS x3. Hysteroscopy was again performed at
this time and the niche area was noted to be flattened out hysteroscopically
and there was no leakage of fluid noted in the pelvis. An imbricating layer
of 2-0 V-Loc was then placed over the repair to strengthen the scar. The
operative site was inspected and noted to be hemostatic. The bladder was
backfilled with 150 mL of sterile saline and the bladder was noted to be
intact. All instruments were removed from the patient's abdomen. The robot
was undocked. The pneumoperitoneum was evacuated. The skin incisions were
reapproximated using 4-0 Monocryl in a subdermal fashion followed by
Steri-Strip application. The instruments were removed from the patient's vagina. The cervix was
inspected and noted to be hemostatic.
Diagnosis:
C-section scar lesion, excision:
- Dense fibrotic tissue with scant chronic inflammation, consistent with cicatrix.
- No atypia identified.
Specimen Source:
C-section scar lesion.
Clinical Information:
Uterine scar from previous cesarean delivery, isthmocele defect.
SPECIMENS:
Uterine C-section scar.
FINDINGS:
Hysteroscopic findings, uterine niche noted at the lower uterine segment
measuring approximately 1.5 cm. The endometrial cavity was noted to be
normal. No evidence of polyps or fibroids and bilateral fallopian tube ostia
noted.
PROCEDURE IN DETAIL:
The patient was taken to the operating room where anesthesia was obtained with
ease. She was then placed in dorsal lithotomy position using Allen stirrups.
She was examined under anesthesia with the above findings noted. She was
prepped and draped in the usual sterile fashion. A Foley catheter was
introduced. A room temperature bivalve speculum was placed in the vagina.
The cervix was grasped with a single-tooth tenaculum and a 5-mm hysteroscope
was introduced without difficulties. The uterine niche/isthmocele was
identified and the anterior cervical uterine junction with an indentation
protruding into the endocervix. Additional hysteroscopic findings include a
normal endometrial cavity. No polyps or fibroids noted. Bilateral fallopian
tube ostia noted. No evidence of injury or trauma. Attention was then turned
to the abdomen where the umbilical fold was incised to about 8 mm. A Veress
needle was introduced at the base and introduced with ease. Intraabdominal
placement was suspected with negative initial pressures followed by sequential
rise to 15 mmHg. An 8-mm robotic trocar and sleeve were introduced through
this incision and intraabdominal placement was confirmed by the laparoscope.
Inspection of the entry point revealed no evidence of trauma or injury.
Inspection of the upper abdomen and pelvis revealed anatomy as described above
with a normal liver edge, peritoneal, and diaphragmatic surfaces, normal
gallbladder. No evidence of endometriosis. The uterus, bilateral fallopian
tubes, and ovaries appeared normal. The anterior and posterior cul-de-sac
appeared normal. The bladder was slightly adhesed to the lower uterine
segment and over the niche. The hysteroscopic light was immediately
visualized at the location of the niche. Three accessory ports were placed, 2
on the right, 1 on the left, all using 8-mm robotic trocars, all placed under
direct laparoscopic guidance. The patient was placed in the Trendelenburg
position and the bowel was mobilized away from the pelvis. The robotic
docking took place and instruments were introduced under direct guidance. The
lower uterine segment and niche area were infiltrated with diluted solution of
vasopressin. The hysteroscopy was continued at this point as the bladder flap
was developed from lateral to medial. The broad ligament was taken down to
identify the cervicovaginal junction, the pubocervical fascia, and mobilizing
the bladder away from the niche location. Once the bladder was mobilized, the
niche was entered with robotic scissors. Prompt spillage of hysteroscopic
fluid was noted. The defect measured approximately a centimeter and a half.
The edges were resected with cold scissors and the area was reapproximated
with interrupted sutures of 2-0 PDS x3. Hysteroscopy was again performed at
this time and the niche area was noted to be flattened out hysteroscopically
and there was no leakage of fluid noted in the pelvis. An imbricating layer
of 2-0 V-Loc was then placed over the repair to strengthen the scar. The
operative site was inspected and noted to be hemostatic. The bladder was
backfilled with 150 mL of sterile saline and the bladder was noted to be
intact. All instruments were removed from the patient's abdomen. The robot
was undocked. The pneumoperitoneum was evacuated. The skin incisions were
reapproximated using 4-0 Monocryl in a subdermal fashion followed by
Steri-Strip application. The instruments were removed from the patient's vagina. The cervix was
inspected and noted to be hemostatic.
Diagnosis:
C-section scar lesion, excision:
- Dense fibrotic tissue with scant chronic inflammation, consistent with cicatrix.
- No atypia identified.
Specimen Source:
C-section scar lesion.
Clinical Information:
Uterine scar from previous cesarean delivery, isthmocele defect.
