AR2728
Expert
I have an interesting situation and I'm unsure how to procedue billing for my surgeons portion. He was called by OBGYN when blood was noticed in the trocar and concern whether there was a vascular bleed. OBGYN was unsure whether he had actually entered pelvic cavity due to the patients size/panniculitis. Surgeon assisted with proper placement of trocar-bleed was noted to be simply rectus muscular separation and the bleeding did stop on its own and required no therapy. Below is the surgeon's report--What do I bill for his portion of the work?
I did scrub into the case and the patient did have an infraumbilical incision which was slightly scythed to the right. The anterior fascia on evaluation had been opened and dissection was down in the underlying rectus sheath. Arterial bleeding had been noted on attempts at cannulation at the infra-umbillical port site by report. The anterior fascia was further opened up slightly towards the left over the midline. Stay sutures were placed in the anterior fascia. Dissection was carried through the underlying rectus muscle. The patient was very deep with a thick panniculus. Further dissection was carried down to the posterior fascia and peritoneum which were identified under direct vision, grasped, and opened. During attempts at placement of the trocar initially there had been some bleeding and concern about possible puncture of iliac vessel. It did appear on evaluation that the abdominal cavity had not been entered. The patient was very deep and even after opening up the peritoneum it did take some manipulation in order to place retractors through the peritoneal opening in order to get the Hassan trocar placed under direct vision. The initial incision had scythed slightly off to the right. All bleeding appeared to be from the rectus muscle itself and there was no evidence of bleeding from the epigastric vessels. The Hassan trocar was placed and pneumoperitoneum induced. There was a small amount of venous and muscular type of blood which did drop into the peritoneal cavity during placement of the port. Once the Hassan was in pneumoperitoneum was induced and the laparoscope was inserted and careful evaluation performed. There was some old blood that appeared to have dropped in from the dissection through the rectus muscle and entrance into the peritoneal cavity. This was old and careful evaluation revealed no small bowel or colon injury. There was no damage to the posterior peritoneum or to the ileac vessels. The suprapubic port was placed and the laparoscopic tubal was completed by Dr. OBGYN. The laparoscopic exploration through both ports revealed no damage to small bowel or colon. There was no damage to the posterior peritoneum. The initial dissection when the bleeding had occurred, which led to my consultation, appeared to be from the rectus muscle itself. Careful intraabdominal evaluation was performed and the small bowel was run laparoscopically in the right lower quadrant. The colon was evaluated. The small bowel in the left side and colon were also evaluated. There was no evidence of intraabdominal entrance prior to my consultation. The peritoneum was identified and opened under direct vision by myself and ports were placed. There is no evidence of intraabdominal abnormality and/ or bleed. Bleed appeared to be coming from the rectus muscle and had stopped. Intraabdominal evaluation was performed.
I did scrub into the case and the patient did have an infraumbilical incision which was slightly scythed to the right. The anterior fascia on evaluation had been opened and dissection was down in the underlying rectus sheath. Arterial bleeding had been noted on attempts at cannulation at the infra-umbillical port site by report. The anterior fascia was further opened up slightly towards the left over the midline. Stay sutures were placed in the anterior fascia. Dissection was carried through the underlying rectus muscle. The patient was very deep with a thick panniculus. Further dissection was carried down to the posterior fascia and peritoneum which were identified under direct vision, grasped, and opened. During attempts at placement of the trocar initially there had been some bleeding and concern about possible puncture of iliac vessel. It did appear on evaluation that the abdominal cavity had not been entered. The patient was very deep and even after opening up the peritoneum it did take some manipulation in order to place retractors through the peritoneal opening in order to get the Hassan trocar placed under direct vision. The initial incision had scythed slightly off to the right. All bleeding appeared to be from the rectus muscle itself and there was no evidence of bleeding from the epigastric vessels. The Hassan trocar was placed and pneumoperitoneum induced. There was a small amount of venous and muscular type of blood which did drop into the peritoneal cavity during placement of the port. Once the Hassan was in pneumoperitoneum was induced and the laparoscope was inserted and careful evaluation performed. There was some old blood that appeared to have dropped in from the dissection through the rectus muscle and entrance into the peritoneal cavity. This was old and careful evaluation revealed no small bowel or colon injury. There was no damage to the posterior peritoneum or to the ileac vessels. The suprapubic port was placed and the laparoscopic tubal was completed by Dr. OBGYN. The laparoscopic exploration through both ports revealed no damage to small bowel or colon. There was no damage to the posterior peritoneum. The initial dissection when the bleeding had occurred, which led to my consultation, appeared to be from the rectus muscle itself. Careful intraabdominal evaluation was performed and the small bowel was run laparoscopically in the right lower quadrant. The colon was evaluated. The small bowel in the left side and colon were also evaluated. There was no evidence of intraabdominal entrance prior to my consultation. The peritoneum was identified and opened under direct vision by myself and ports were placed. There is no evidence of intraabdominal abnormality and/ or bleed. Bleed appeared to be coming from the rectus muscle and had stopped. Intraabdominal evaluation was performed.