AR2728
Expert
OBGYN performed TAH at the same time Surgeon performed Hernia Repair. OBGYN wants to bill her TAH along with Hernia Repair assist, and believes Surgeon should bill TAH assist with the Repair. However, after viewing the dictation I'm not sure this is truly the case. It appears to me that they each did their own procedure. I have attached the OBGYN note and can also attach the Surgeon note if necessary. What truly constitutes an assist?
The patient was taken to the operating room and prepped and draped in the usual
sterile fashion. Prior to prepping the skin of the abdomen and pelvis the pannus was taped cephalad to facilitate exposure. Vertical midline infraumbilical incision was made with a scalpel through the abdominal wall. This incision was extended down to the left of the rectus fascia using the Bovie cutting current. Hemostasis was achieved. It was noted that the most cephalad 15 cm. of incision was significant for the presence of a large hernia sac containing loops of large as well as small bowel. The rectus fascia was greatly retracted in that cephalad 15 cm. Upon entry into the abdomen and pelvis it was noted that numerous thick and filmy adhesions were both present throughout the abdomen and pelvis and extensive adhesiolysis was necessary in order to even begin the case. The left tubo-ovarian abscess was identified. Two sets of aerobic and anaerobic cultures were taken around the abscess. The Omni Tract abdominal retractor system was placed and the
tubo-ovarian abscess was carefully isolated from the bowel using extensive retraction. Once thepelvic field had adequate visualization the Ligasure Impact device was used to coagulate and cut the left infundibulopelvic ligament as well as a left ovarian pedicle thereby facilitating removal of the TOA intact. Coker clamps were used at each cornu of the uterus for elevation and retraction and once the TOA had been excised hysterectomy was performed using serial applications of the Ligasure Impact coagulate and cut the uterine arteries, cardinal ligament and uterosacral ligament. Immediately prior to this the bladder flap was developed sharply over the anterior wall of the uterus. This area was severely adhesed as a result of her three cesarean sections. Developing a dissection plane was accomplished using Metzenbaum scissors and pick ups with teeth. After serial applications of the Ligasure impact down to the level of the external os the cervix and uterus was amputated and handed off as one specimen. A circumferential incision was made around the vaginal cuff as the final step to freeing up the uterus and cervix. The four axis of the vagina was grasped with straight Coker clamps and the vaginal cuff was closed with interrupted figure of eight sutures of 0 vicryl. Hemostasis was achieved. The pelvic was irrigated and dried an intercede adhesion barrier was placed over the vaginal cuff. Attention was then turned to repair of the large hernia sac and I will defer to Dr. Surgeon to dictate this portion of the procedure as well as the abdominal closure.
The patient was taken to the operating room and prepped and draped in the usual
sterile fashion. Prior to prepping the skin of the abdomen and pelvis the pannus was taped cephalad to facilitate exposure. Vertical midline infraumbilical incision was made with a scalpel through the abdominal wall. This incision was extended down to the left of the rectus fascia using the Bovie cutting current. Hemostasis was achieved. It was noted that the most cephalad 15 cm. of incision was significant for the presence of a large hernia sac containing loops of large as well as small bowel. The rectus fascia was greatly retracted in that cephalad 15 cm. Upon entry into the abdomen and pelvis it was noted that numerous thick and filmy adhesions were both present throughout the abdomen and pelvis and extensive adhesiolysis was necessary in order to even begin the case. The left tubo-ovarian abscess was identified. Two sets of aerobic and anaerobic cultures were taken around the abscess. The Omni Tract abdominal retractor system was placed and the
tubo-ovarian abscess was carefully isolated from the bowel using extensive retraction. Once thepelvic field had adequate visualization the Ligasure Impact device was used to coagulate and cut the left infundibulopelvic ligament as well as a left ovarian pedicle thereby facilitating removal of the TOA intact. Coker clamps were used at each cornu of the uterus for elevation and retraction and once the TOA had been excised hysterectomy was performed using serial applications of the Ligasure Impact coagulate and cut the uterine arteries, cardinal ligament and uterosacral ligament. Immediately prior to this the bladder flap was developed sharply over the anterior wall of the uterus. This area was severely adhesed as a result of her three cesarean sections. Developing a dissection plane was accomplished using Metzenbaum scissors and pick ups with teeth. After serial applications of the Ligasure impact down to the level of the external os the cervix and uterus was amputated and handed off as one specimen. A circumferential incision was made around the vaginal cuff as the final step to freeing up the uterus and cervix. The four axis of the vagina was grasped with straight Coker clamps and the vaginal cuff was closed with interrupted figure of eight sutures of 0 vicryl. Hemostasis was achieved. The pelvic was irrigated and dried an intercede adhesion barrier was placed over the vaginal cuff. Attention was then turned to repair of the large hernia sac and I will defer to Dr. Surgeon to dictate this portion of the procedure as well as the abdominal closure.
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