I have no idea what to code for the following op report. I am new to OB-GYN and would love any help you can offer. Thanks in advance.
The right side of the vaginal wall was palpated and Bartholin gland noted. Vasopressin was used to inject into the Bartholin gland. An incision was made in the right lateral vagina inside of the hymenal ring. A large amount of dark fluid was expressed consistent with Bartholin gland cyst. The incision was extended to expose the cyst wall. Deeper exploration with the Metzenbaum scissors allowed for excision of the entire Bartholin gland. Hemostasis was obtained through cautery using 0 Vicryl in a several-layer closure. The area was then reapproximated. The specimen was handed off to be sent to pathology. The vaginal mucosa was again reapproximated with a 2-layer closure of 3-0 Vicryl suture. Excellent hemostasis was noted.
Attention was then drawn to the vaginal cuff where the left aspect of the apex of the vaginal cuff was noted to be with scar tissue. Using the Mayo scissors, this scar tissue was excised. The vaginal cuff was revised. No entrance into the peritoneum was noted. The vaginal mucosa overlying this scar tissue was then reapproximated using an 0 Vicryl suture. Indigo carmine was given.
Cystoscopy was then carried out. The 30-degree cystoscope was used. Normal saline was used for suspension medium. The bladder was viewed in its entirety. Normal saline was allowed to distend the bladder to approximately 200 mL. Visualization of the bladder was noted in its entirety. Blue urine was noted to jet from the ureters, both on the right and left. No bladder concerns were noted. The cystoscope was then removed, and urine was allowed to be drained.
Again, inspection of the vaginal cuff was carried out. Hemostasis noted. Inspection of the right side of the lateral vagina was carried out. Hemostasis noted. Specimens were sent to pathology. All sponge, lap, instrument and needle counts were noted to be correct. The patient was stable to the recovery room.
The right side of the vaginal wall was palpated and Bartholin gland noted. Vasopressin was used to inject into the Bartholin gland. An incision was made in the right lateral vagina inside of the hymenal ring. A large amount of dark fluid was expressed consistent with Bartholin gland cyst. The incision was extended to expose the cyst wall. Deeper exploration with the Metzenbaum scissors allowed for excision of the entire Bartholin gland. Hemostasis was obtained through cautery using 0 Vicryl in a several-layer closure. The area was then reapproximated. The specimen was handed off to be sent to pathology. The vaginal mucosa was again reapproximated with a 2-layer closure of 3-0 Vicryl suture. Excellent hemostasis was noted.
Attention was then drawn to the vaginal cuff where the left aspect of the apex of the vaginal cuff was noted to be with scar tissue. Using the Mayo scissors, this scar tissue was excised. The vaginal cuff was revised. No entrance into the peritoneum was noted. The vaginal mucosa overlying this scar tissue was then reapproximated using an 0 Vicryl suture. Indigo carmine was given.
Cystoscopy was then carried out. The 30-degree cystoscope was used. Normal saline was used for suspension medium. The bladder was viewed in its entirety. Normal saline was allowed to distend the bladder to approximately 200 mL. Visualization of the bladder was noted in its entirety. Blue urine was noted to jet from the ureters, both on the right and left. No bladder concerns were noted. The cystoscope was then removed, and urine was allowed to be drained.
Again, inspection of the vaginal cuff was carried out. Hemostasis noted. Inspection of the right side of the lateral vagina was carried out. Hemostasis noted. Specimens were sent to pathology. All sponge, lap, instrument and needle counts were noted to be correct. The patient was stable to the recovery room.