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Wiki LAVH vs. TLH

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ltingle1

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Hello,

We have a Dr. that performs hysterectomies using the laparoscope for all portions of the surgery, except that she closes from below, vaginally. Would that make the hysterectomy an LAVH, or can it still be considered a TLH since she severs upper and lower connections through scope, as well as circumscribes the cervix from above to release the organ and pulls it through the vaginal canal? Thanks in advance for any help!
 
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This is an example of one of her op reports:

The patient was taken to the operating room. She was
prepped and draped in the usual sterile fashion after being placed in the
dorsal lithotomy position in Allen stirrups. The right angled retractor was
placed both posteriorly and anteriorly in order to visualize the cervix.
The cervix was grasped with a single-toothed tenaculum. I was then able to
carefully dilate the cervix and sound the uterus. The uterus sounded to 7
cm. A RUMI uterine manipulator with a small KOH ring was attempted to be
placed but the KOH ring was too wide for her introitus. The manipulator was
changed out to an extra small KOH ring and with that, the uterine
manipulator first placed followed by placement of the KOH ring without
difficulty. The patient was then repositioned and attention turned to the
abdomen. An incision was made in the umbilicus. The Veress needle was
placed. Admitting pressure was low. The pneumoperitoneum was then achieved.
The 5 mm trocar was then placed in the umbilicus. Bilateral lower trocars
were placed under direct visualization. Findings included slightly
irregular shaped uterus with a probable uterine fibroid to the left. Tubes
and ovaries appeared postmenopausal but normal. There was possibly some old
endometriosis changes. There was some hemosiderin changes on the
peritoneum. No particular lesions so no excrescences. The fimbriated end of
the tube was grasped. The infundibulopelvic ligament on the left isolated,
clamped, cauterized and cut with the LigaSure. This was carried down to and
through the mesosalpinx and then round ligament and then uterine arteries.
The same procedure was done on the right. The bladder flap was then
delineated and dissected down using the L-hook. The cardinal ligaments were
then clamped, cauterized and cut with the LigaSure. An anterior colpotomy
was then achieved using the L-hook. This was carried laterally anteriorly.
The uterosacral ligament bites were taken, clamping, cauterizing and
cutting with the LigaSure. A posterior colpotomy was then achieved using
the L-hook and the anterior and posterior incisions were then connected
using the L-hook without difficulty. The uterus, tubes and ovaries were
then removed. The patient was repositioned and the anterior and posterior
vaginal cuff was grasped with Allis clamps. The Wesson retractor was used
laterally. Her vaginal vault was narrow making it somewhat difficult but
angle sutures were placed and then the cuff was closed in an interrupted
figure-of-eight fashion from anterior to posterior. There were then hymenal
ring lacerations at 5 and 7 o'clock requiring suture with 3-0 chromic and
then 3-0 Vicryl. Once they were noted to be hemostatic, the
pneumoperitoneum was then achieved and attention turned to the abdomen. The
pelvis was copiously irrigated. The ureters were peristalsing and
non-dilated. There was no significant bleeding but a slight raw edge at the
cuff. Therefore hemostatic powder was placed. I believe it was Surgicel.
All appeared hemostatic. The pneumoperitoneum was released and trocar
sheaths removed. The incisions were then closed with sterile surgical glue.
Attention was then again turned vaginally and the area inspected. There was
a small area still bleeding requiring another figure-of-eight suture of 3-0
Vicryl along the hymenal ring. It was hemostatic. Premarin cream was then
placed. Urine appeared clear. The patient tolerated the procedure very well
and left for recovery in stable condition.
 
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This looks like TLH, not LAVH.
Here is a great link from ACOG regarding this:
https://www.acog.org/About-ACOG/ACO...pic-Hysterectomy-Procedures?IsMobileSet=false

I was instructed that the difference between 58550-58554 (laparoscopic vaginal hysterectomy) and 58570-58573 (laparoscopic total hysterectomy) is the approach for the surgical portion, not simply how the specimen was removed.
It is standard for a total laparoscopic hysterectomy (58570-58573) to have the specimen removed through the vagina. The difference in coding is whether the surgery itself was done through the ports with robotic or other laparoscopic tools or whether the bulk of the surgery was done through the vagina (with an incision through the vagina into the cul de sac), with the laparoscope used to provide visualization rather than surgical access. In my area, all the physicians are doing the surgery (including the vaginal cuff closure after removing the uterus/cervix) laparoscopic and simply removing the specimen through the vagina. The last time I needed to use 58550-58554 was probably before the 58570-58573 codes existed.
It appears all the ligament clamping/cauterizing/transecting were done through the laparoscopic ports; this is 58571.
 
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My boss and I are hung up on the fact that in the AMA OBGYN coding companion it states “The vagina is closed by laparoscopic suturing of the apex...” So it’s still considered a TLH even though she didn’t close laparoscopically?
 
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csperoni said:
This looks like TLH, not LAVH.
Here is a great link from ACOG regarding this:
https://www.acog.org/About-ACOG/ACO...pic-Hysterectomy-Procedures?IsMobileSet=false

I was instructed that the difference between 58550-58554 (laparoscopic vaginal hysterectomy) and 58570-58573 (laparoscopic total hysterectomy) is the approach for the surgical portion, not simply how the specimen was removed.
It is standard for a total laparoscopic hysterectomy (58570-58573) to have the specimen removed through the vagina. The difference in coding is whether the surgery itself was done through the ports with robotic or other laparoscopic tools or whether the bulk of the surgery was done through the vagina (with an incision through the vagina into the cul de sac), with the laparoscope used to provide visualization rather than surgical access. In my area, all the physicians are doing the surgery (including the vaginal cuff closure after removing the uterus/cervix) laparoscopic and simply removing the specimen through the vagina. The last time I needed to use 58550-58554 was probably before the 58570-58573 codes existed.
It appears all the ligament clamping/cauterizing/transecting were done through the laparoscopic ports; this is 58571.
Click to expand...

My boss and I are hung up on the fact that in the AMA OBGYN coding companion it states “The vagina is closed by laparoscopic suturing of the apex...” So it’s still considered a TLH even though she didn’t close laparoscopically?
 
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