A Veress needle was placed above the prior supraumbilical incision and following negative aspiration and successful drop test the abdomen was distended to a pressure of 15. The patient had a prior lower midline incision in addition to his prior robotic trocar incisions it was elected to reuse his prior robotic incisions. In the left lateral prior incision incision was made and a 8 mm robotic trocar was advanced. Inspection was made of the peritoneum. The patient had significant adhesions to his prior lower midline incision. There are also small number of adhesions around the umbilicus near the prior supraumbilical incision. The Veress needle was identified it was removed there is no evidence of injury to viscus or vascular structures. On the right side the abdomen there were no adhesions. In the above the anterior superior iliac crest on the right in the anterior axillary line and then the prior incision site a 12 mm trocar was placed. In addition a 8 mm right lower quadrant trocar was placed. This allowed for lysis of adhesions. A clip was applied on one omental bleeder otherwise there is good hemostasis. This allowed for the remainder of the trochars and then replaced. The patient was then placed into a steep Trendelenburg position. The robot was docked and Dr. then broke scrub and sat at the robotic console. The patient side assistant remained for the duration of the case and was critical for tissue manipulation and assistance.
The peritoneum overlying the expected location of the vas deferens was then incised. Careful dissection was made and the vas deferens was identified. Was very thickened it was following a slightly tighter than expected course. It was dissected out circumferentially and followed towards the inguinal ring. With care to keep the inguinal ring intact of the vas was followed to the ring and transected when no further dissection could be performed. Of note the patient does have an open inguinal ring and this dissection was made medial to it. It was then followed all the way down towards the tip where it had been previously clipped and transected from the patient's prostatectomy and was followed with care to avoid any potential injury to the ureter and the surgical clip was identified and the vas was removed in its entirety. This was subsequently completed in identical fashion on the left side.
After good hemostasis was achieved the robot was undocked. Trochars were then removed. An incision was made following the skin lines in the lower aspect of the right inguinal area and the spermatic cord was identified distal to the inguinal ring. It was encircled. The vas deferens could be palpated. It was grasped with first a Babcock and then after some dissection and Allis. Dissection was made all the way towards the inguinal ring until the transected aspect was identified. It was then followed down towards the testicle. The vas was very inflamed thickened however it was friable and tore. Pieces of the external vas were passed off the field. In order to get the remainder of the thickened palpable vasa which was adjacent to the testicle an attempt was made to approach from that inguinal incision however after multiple attempts this was not palpable possible. Is therefore elected to make a small scrotal incision overlying the palpable thickened as adjacent to the upper pole of the testicle. The vas was then developed with standard technique similar to a vasectomy with tenotomy scissors going through the tissue around the vas the vas was then controlled and it was dissected all the way in and is completion. All palpable proximal vas structures had been removed. The only remaining vas deferens with a small amount that appeared normal adjacent to the epididymis.
The patient had a painful, chronically inflamed inguinal vas deferens. The doctor says he did robotic bilateral excision of painful intra abdominal vas deferens and then open rt scrotal and inquinal excision of vas. Will I just code an unlisted lap code, 55559? Seems like I should compare it to something more than just a vasectomy? Any help is appreciated!
The peritoneum overlying the expected location of the vas deferens was then incised. Careful dissection was made and the vas deferens was identified. Was very thickened it was following a slightly tighter than expected course. It was dissected out circumferentially and followed towards the inguinal ring. With care to keep the inguinal ring intact of the vas was followed to the ring and transected when no further dissection could be performed. Of note the patient does have an open inguinal ring and this dissection was made medial to it. It was then followed all the way down towards the tip where it had been previously clipped and transected from the patient's prostatectomy and was followed with care to avoid any potential injury to the ureter and the surgical clip was identified and the vas was removed in its entirety. This was subsequently completed in identical fashion on the left side.
After good hemostasis was achieved the robot was undocked. Trochars were then removed. An incision was made following the skin lines in the lower aspect of the right inguinal area and the spermatic cord was identified distal to the inguinal ring. It was encircled. The vas deferens could be palpated. It was grasped with first a Babcock and then after some dissection and Allis. Dissection was made all the way towards the inguinal ring until the transected aspect was identified. It was then followed down towards the testicle. The vas was very inflamed thickened however it was friable and tore. Pieces of the external vas were passed off the field. In order to get the remainder of the thickened palpable vasa which was adjacent to the testicle an attempt was made to approach from that inguinal incision however after multiple attempts this was not palpable possible. Is therefore elected to make a small scrotal incision overlying the palpable thickened as adjacent to the upper pole of the testicle. The vas was then developed with standard technique similar to a vasectomy with tenotomy scissors going through the tissue around the vas the vas was then controlled and it was dissected all the way in and is completion. All palpable proximal vas structures had been removed. The only remaining vas deferens with a small amount that appeared normal adjacent to the epididymis.
The patient had a painful, chronically inflamed inguinal vas deferens. The doctor says he did robotic bilateral excision of painful intra abdominal vas deferens and then open rt scrotal and inquinal excision of vas. Will I just code an unlisted lap code, 55559? Seems like I should compare it to something more than just a vasectomy? Any help is appreciated!