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Posted By Mary Peabody on 03-25-2020, 13:28:03 in Ob-Gyn
Hello Melanie
Would you code this procedure with CPT 58150-22 or 58953. I am confused with what is meant be radical abdominal hysterectomy

PREOPERATIVE DIAGNOSIS:  
1. Stage IIIC high-grade serous tubo/ovarian cancer, s/p 5 cycles of neoadjuvant chemotherapy with excellent response
OPERATION: Exploratory laparotomy, modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, tumor debulking, cystoscopy
We started with the omentum. I first mobilized the left side sigmoid and descending colon along the line of Toldt to the splenic flexure. I also mobilized the ascending colon in order to reach the hepatic flexure. As mentioned in findings, the greater omentum appeared to have been obliterated by tumor and then contracted with chemotherapy and appeared as a small hard cord along the length of the transverse colon. After careful dissection and sharp lysis of adhesions, I was able to get th is off the transverse colon without damaging colon serosa. We then proceeded with gastro-colic omentectomy. We entered the lesser sac from the right side and then used the LigaSure to isolate, fulgarate and divide the gastro-epiploic vessels and remove the omentum from the greater curvature of the stomach. We moved from right to left. Omentum was removed and passed off the field to send for pathology.
We then packed the bowel and attempted to obtain exposure to the pelvis. We used 2 curved Pean clamps to grasp the bilateral cornua of the uterus, though at first this was barely visible. Given the poor visualization, I first opened the retroperitoneal spaces. I started on the left. The left round ligament was suture-ligated and divided. We extended the peritoneal incision parallel to the gonadal vessels and identified the ureter on the medial leaf of the broad ligament below the gonadal vessels. We placed a Vesseloop around the ureter. We identified and developed the pararectal and paravesical spaces, no enlarged nodes noted, the spaces opened easily. I repeated this on the right side. Of note, the parametria felt somewhat firm on the right, more-so than the left.
Prior to starting the hysterectomy, I attempted to bluntly open the adhesions caused by the cancer to expose the uterus. As I was attempting to separate the sigmoid and right adnexa from the back of the uterus, I encountered a hemorrhage and quickly used 2 Zepplin clamps to tamponade a vessel right around the utero-sacral ligament on the right. This bled much more than typical for a uterine artery laceration and I suspect the right adnexa had recruited some parasitic vessels. We then proceeded with a radical dissection on the right in order to isolate the uterine artery and ligate and divide it at the origin.
 We first isolated the gonadal vessels on the right, doulbly clamped the vessels, transected and suture-ligated the pedicle, taking care to note the ureter well-below. I was able to take down some posterior peritoneum to lift the right adnexa.  We took down the vesicouterine peritoneum to mobilize the bladder away from the lower uterine segment and cervix.  We identified the ureter and took the ureteral dissection down to the crossover of the cardinal ligament.  We identified the uterine artery at it's origin from the superior vesicle artery and doubly suture-ligated it, clipped it on the proximal side and divided it with the LigaSure.  We then mobilized the parametria medially while rolling the ureter laterally.  We carried out the ureteral dissection through the tunnel toward the bladder.  We mobilized the bladder away from the cervix and upper vagina. I divided the bladder ligament with the LigaSure.
then returned to the posterior peritoneal dissection, developing the rectovaginal septum from the right side. Te rectovaginal septum was disease-free and avascular, the rectum dropped away from the hemorrhage site easily. I then replaced the Zepplin clamps which had been tamponading the hemorrhage site basically as the parametrial and utero-sacral radical hysterectomy pedicles. I then used the LigaSure to divide these pedicles between the clamps and then suture-ligated to extra-assurance. In order to prevent back-bleeding while we worked on the left, I used the LigaSure to seal and divide the right parametrium from the specimen side, the right parametrium was then passed off as a
separate specimen.
FINAL PATHOLOGIC DIAGNOSIS
 A. Omentum, omentectomy:
1. Residual high-grade serous carcinoma, status-post neoadjuvant
chemotherapy; see comment.
2. Six benign lymph nodes (0/6).
B. Small bowel mesenteric nodule, excision: Fibrosis and inflammation,
no residual viable tumor is identified.
C. Right parametrium, excision:
1. Residual high-grade serous carcinoma, status-post neoadjuvant
chemotherapy; see comment.
2. Two benign lymph nodes (0/2).
D. Uterus, cervix, right and left ovaries and fallopian tubes,
hysterectomy and bilateral salpingo-oophorectomy:
- Cervix: No significant pathologic abnormality.

Comments (1)
Posted By Melanie Witt on 03-25-2020, 15:34:42
Mary this case is very similar to one you presented to me on 2/21/20 which involved a modified radical hysterectomy with omentectomy and appendectomy. As I indicated at that time, a modified radical hysterectomy removes the uterus, cervix, upper part of the vagina, and ligaments and tissues that closely surround these organs, but in this type of surgery not as many tissues and/or organs are removed as in a radical hysterectomy. Nearby lymph nodes may also be removed.

58150 is a radical, but he did not do a bilateral PLN and this code does not include debulking so in essence you can't report both a -52 and -22 with this code for the surgery he performed. I would opt for 58953 in this case as being the closest representative code for the work performed.
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