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Posted By Mary Peabody on 02-18-2020, 15:02:29 in Ob-Gyn
Hello Melanie,

If a bilateral sentinel pelvic lymph node is performed with a TAH, would this be reported with 58150 and 38562-59 or 58150 and 38500-51? If ligation of vein is accidently performed, is the repair also reported./ Thank you for your advise.

POSTOPERATIVE DIAGNOSIS: Uterine sarcoma
 
OPERATION: Total abdominal hysterectomy with bilateral
salpingo-oophorectomy, bilateral sentinel pelvic lymph node
dissection, and venotomy repair
PROCEDURE: The patient was taken to the operating room. She
underwent epidural and then she was placed into the supine position
and underwent general anesthesia. She was sterilely prepped and
draped in the low lithotomy position in Allen stirrups and a Foley
catheter was placed under sterile conditions. An incision was made
from the symphysis pubis and carried up and around the umbilicus with
a scalpel. The incision was taken down to the fascia with the Bovie.
The fascia was opened with the Bovie. The peritoneum was entered
sharply. We took our washings. We then placed a Bookwalter
retractor, packed the bowels, and started the procedure. At the time
of placing the Foley, we also injected ICG into the cervix, 25 mg in
40 mL of water concentration; a total of 4 mL were used in the usual
fashion. We then opened up the retroperitoneal spaces bilaterally by
making an incision lateral and parallel to the infundibulopelvic
ligament. We opened up bilateral pararectal spaces and on the
patient's right side we were able to identify a sentinel lymph node
posterior to the external iliac vein. This was removed with a
combination of monopolar cautery and blunt dissection with excellent
hemostasis. We then turned our attention to the left side.
Similarly, there was a node that was medial and posterior to the
external iliac vein. The nerve on this side was assessed and
skeletonized. It was free of injury, and this dissection was done
with monopolar cautery with excellent hemostasis. We then proceeded
to take down the bladder off the uterus and cervix. We transected
the round ligaments. These were suture ligated. We skeletonized the
uterine arteries. We skeletonized the infundibulopelvic ligaments.
These were clamped, transected, and suture ligated. We then clamped,
transect, and suture ligated the uterine arteries as well as the
cardinal ligaments. We were then able to clamp across the upper
vagina and amputated the uterus and cervix. These were delivered for
frozen section. The ovarian had already been handed off for
permanent section. We closed the cuff using a running 0 Vicryl
suture called a Berman stitch. Again, there was excellent hemostasis
in the pelvis, but we encountered bleeding from the right pelvic
sidewall. There was bleeding along the psoas, along the route of the
right genitofemoral nerve. The bleeding was clipped. There was
further bleeding from the obturator space, so we opened the obturator
space further. We determined that there had been injury to a torn
accessory obturator vein coming off posterior and lateral to the
distal external iliac vein. This was retracted, the spaces were
opened up, we clipped distally, and then we used 5-0 Prolene on a C1
needle to make a figure-of-eight suture on the external iliac vein
with excellent hemostasis. We then filled the space with FloSeal and
applied pressure with no bleeding. The case was hemostatic at the
end of the case. We then removed the laps and retractors. We closed
the fascia using 0 PDS in a running stitch. We closed the
subcutaneous tissues with Vicryl, and the skin was closed with 4-0
Monocryl.
 
Comments (1)
Posted By Melanie Witt on 02-19-2020, 15:31:08
The repair is included. I would go with 38562-52 (reduced service). This code is not bundled with 58150 so a modifier -59 is not reported.
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