New to OB and I am not sure what to pick up for CPT codes for this procedure.
Thanks!
Melissa Bedford,CCS,CPC
ANESTHESIA:
General ETA.
PREOPERATIVE DIAGNOSIS(ES):
Abnormal Hysterosalpingogram consistent with tubal factor infertility
POSTOPERATIVE DIAGNOSIS(ES):
Same.
Pelvic adhesions
Bilateral hydrosalpinges
PROCEDURE(S)/OPERATION(S) PERFORMED:
Diagnostic laparoscopy.
Lysis of adhesions
Removal of bilateral hydrosalpinges
ESTIMATED BLOOD LOSS:
Less that 15 cc
INTRAOPERATIVE FLUIDS:
1100 CC of RL
SUMMARY:
After the risks and benefits of the procedure were explained to the patient
in clinic, consents were signed. The patient was taken the operative
suite, where general ETA anesthesia was obtained. Once anesthesia was
found be adequate, she was examined under anesthesia.
She was then prepped and draped in the usual sterile fashion. Initial attention
was placed to her pelvis. The cervix was easily visualized on speculum
examination, and a single-tooth tenaculum was placed on the anterior lip of
the cervix. An acorn manipulator was placed without any difficulties. Foley was also place.
Attention was then turned to her abdominal cavity. Intraumbilical access was obtained using a Veress needle, and a pneumoperitoneum was obtained. A 10 mm trocar port was then placed through the intraumbilical incision. The abdominal contents were
examined.
Finding: There were no signs of any bowel. trauma secondary to the abdominal entry.
Examination of the pelvis showed adhesions involving the bowel and omentum to the left adnexal area and fundus of the uterus. Both fallopian tubes were encased in adhesions both fallopian tubes were blocked distally. Under chromopertubation both fallopian tubes filled however there were dilated distally and no dye was seen coming at the end of the either fallopian tube[/B][/B]. At this point her husband was contacted over the found and I explained the findings and he game me permission to go ahead and proceed with the removal of both hydrosalpinx right and left. He does understand that by doing so we are increasing the promotility of a successful pregnancy with IVF. He knows that the presence of hydrosalpinx decreases the pregnancy rate and IVF.
A Left lower and right lower quadrant 5 mm ports were then placed under direct visualization. Attention was then placed to the pelvic adhesions and with the use of the harmonic the adhesions were taken down exposing both fallopian tubes and ovaries. The adhesions involving the right fallopian tube and ovary were also to remove. The left hydrosalpinx was removed using the harmonic, the ovary was left in place. Also using the harmonic the right hydrosalpinx was removed and the right ovary was left in place. Both ovaries were normal. The patient also had adhesions in the anterior cul-de-sac area there were not removed to maintain the uterus in a superior position. The cul-de-sac was free of adhesions. And under chromopertubation we noticed feeling of both fallopian tips but no spilling. her right fallopian tube and ovary
.
The pelvis was then copiously irrigated and hemostasis was noted. The left lower and right lower quadrant ports were removed under direct visualization. The pneumoperitoneum was then released. The intraumbilical port was then removed. The fascia was then closed with 00 Polysorb for the 10 mm intraumbilical port. The skin was then closed with interrupted sutures of Biosyn on all 3 ports.
Attention was then placed back to her pelvis. The acorn manipulator was removed. The Foley Catheter was also removed.
The sponge, instruments, needle and lap count was correct x2. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Thanks!
Melissa Bedford,CCS,CPC
ANESTHESIA:
General ETA.
PREOPERATIVE DIAGNOSIS(ES):
Abnormal Hysterosalpingogram consistent with tubal factor infertility
POSTOPERATIVE DIAGNOSIS(ES):
Same.
Pelvic adhesions
Bilateral hydrosalpinges
PROCEDURE(S)/OPERATION(S) PERFORMED:
Diagnostic laparoscopy.
Lysis of adhesions
Removal of bilateral hydrosalpinges
ESTIMATED BLOOD LOSS:
Less that 15 cc
INTRAOPERATIVE FLUIDS:
1100 CC of RL
SUMMARY:
After the risks and benefits of the procedure were explained to the patient
in clinic, consents were signed. The patient was taken the operative
suite, where general ETA anesthesia was obtained. Once anesthesia was
found be adequate, she was examined under anesthesia.
She was then prepped and draped in the usual sterile fashion. Initial attention
was placed to her pelvis. The cervix was easily visualized on speculum
examination, and a single-tooth tenaculum was placed on the anterior lip of
the cervix. An acorn manipulator was placed without any difficulties. Foley was also place.
Attention was then turned to her abdominal cavity. Intraumbilical access was obtained using a Veress needle, and a pneumoperitoneum was obtained. A 10 mm trocar port was then placed through the intraumbilical incision. The abdominal contents were
examined.
Finding: There were no signs of any bowel. trauma secondary to the abdominal entry.
Examination of the pelvis showed adhesions involving the bowel and omentum to the left adnexal area and fundus of the uterus. Both fallopian tubes were encased in adhesions both fallopian tubes were blocked distally. Under chromopertubation both fallopian tubes filled however there were dilated distally and no dye was seen coming at the end of the either fallopian tube[/B][/B]. At this point her husband was contacted over the found and I explained the findings and he game me permission to go ahead and proceed with the removal of both hydrosalpinx right and left. He does understand that by doing so we are increasing the promotility of a successful pregnancy with IVF. He knows that the presence of hydrosalpinx decreases the pregnancy rate and IVF.
A Left lower and right lower quadrant 5 mm ports were then placed under direct visualization. Attention was then placed to the pelvic adhesions and with the use of the harmonic the adhesions were taken down exposing both fallopian tubes and ovaries. The adhesions involving the right fallopian tube and ovary were also to remove. The left hydrosalpinx was removed using the harmonic, the ovary was left in place. Also using the harmonic the right hydrosalpinx was removed and the right ovary was left in place. Both ovaries were normal. The patient also had adhesions in the anterior cul-de-sac area there were not removed to maintain the uterus in a superior position. The cul-de-sac was free of adhesions. And under chromopertubation we noticed feeling of both fallopian tips but no spilling. her right fallopian tube and ovary
.
The pelvis was then copiously irrigated and hemostasis was noted. The left lower and right lower quadrant ports were removed under direct visualization. The pneumoperitoneum was then released. The intraumbilical port was then removed. The fascia was then closed with 00 Polysorb for the 10 mm intraumbilical port. The skin was then closed with interrupted sutures of Biosyn on all 3 ports.
Attention was then placed back to her pelvis. The acorn manipulator was removed. The Foley Catheter was also removed.
The sponge, instruments, needle and lap count was correct x2. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
