karey
Networker
PROCEDURE: The patient was taken to the operating room, where she wasplaced under general anesthesia with endotracheal intubation. She was
prepared and draped in normal sterile fashion and was in the dorsal
lithotomy position with Allen stirrups. Care was taken not to have any
pressure points to avoid any neurologic injuries. Once the patient was
draped, we performed a time-out procedure and antibiotics were given
prior to skin incision. She had a large abdominal scar from her pubic
bone to her xiphoid with diasthesis and she requested that I
would revise her scar. Thus, we excised the entire scar (40 cm) with scalpel
and Bovie and then identified the fascia. The fascia was sharply
incised with a scalpel from the pubic bone to approximately the area
where her umbilicus would have been prior to her panniculectomy. Once
the fascia was incised, densely adherent loops of small bowel were
encountered and we carefully dissected bowel from the abdominal wall.
Finally we found a clear space in the right lower quadrant and we were
able to enter the peritoneal cavity, and then continued with enterolysis
in order to get access to the pelvis for approximately 1 hour.
Once the pelvic mass was visible, pelvic washings were obtained and the
bladder and sigmoid colon were carefully dissected off the pelvic mass,using sharp dissection. Once we had acces to the pelvic side walls, the retroperitoneum was opened over the left sidewall and the ureter was visualized in the retroperitoneum. The left ureter was marked with a vessel loop, and a window was then created above the
ureter and below the ovarian vessels, which were then clamped,
transected, and doubly ligated with 0 Dexon suture. We continued our
dissection of the of the mass and during this procedure the mass did
rupture for clear, dark fluid. The mass was then separated from the
remaining round ligament, as well as from the colon and cul-de-sac and
could then be removed and was handed off for pathologic evaluation and
frozen section. There was one area that was bleeding in the left lower
quadrant consistent with a remnant of her uterine artery. After the ureter
was mobilized medially, this pedicle was grasped and was
ligated with 2-0 Dexon suture for excellent hemostasis. We then turned
our attention to the right pelvic sidewall where the peritoneum over the
right pelvic sidewall was incised and extended. The retroperitoneum was
opened and the ureter was visualized. A window was created between the
ovarian vessels and the ureter. The IP ligament was clamped, transected
and doubly ligated with 0 Dexon suture. The ureter was then further
mobilized off of the medial leaf of the broad ligament and moved out of
harm's way. Other attachments from the pelvic sidewall and the previous
round ligaments were then clamped, transected, and ligated, and the
right tube and ovary were removed and handed off. The abdomen was
copiously irrigated and inspected for hemostasis. There was a small
area over the left ureter that had a bleeding vessel associated with
it. A 2-0 Dexon suture was placed around this vessel, taking great care
not to be close or injure the ureter while doing this. In addition we placed some FloSeal in this area.The bladder was then backfilled with methylene blue and distended nicely
without any injury to the bladder. The Foley was then emptied again.
The general surgeons came into evaluate the fascia and whether anything
needed to be done with the mesh. They recommended primary closure,
which we then did after we had correct sponge, lap and needle counts and
the cavity search was negative. The fascia was closed with interrupted
sutures of 0 Prolene in a Smead-Jones fashion, and once they were all
placed, they were tied and the fascia reapproximated nicely. The
subcutaneous tissues were irrigated and undermined in the superior part
and subcuticular 3-0 Dexon sutures were then placed in a subcuticular
fashion to take tension off the incision, and staples were used to close
the entire incision. The dressing was then placed and the patient was
woken up from anesthesia and brought to PACU in stable condition. Again
sponge, lap and needle counts were correct x2. As the attending
surgeon, I was present and scrubbed for the entire case.
the question is: Should I bill 50715-Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis along w/ the BSO (58720)? Or should I bill 58720-BSO w/ mod 22?