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Posted By Maria on 08-16-2019, 12:18:47 in Ob-Gyn
Hi Melanie,

Dr Coded 58571, 57283, 38571, 57135, S2900

I am thinking 57425 Lap Colpopexy , 58571 Lap Hyster, 38571 Lap Bil total pelvic lymphadenectomy, S2900 Robotic

Unless I am over looking I don't see resection vaginal lesions.

TIA

FINDINGS:
12 week size uterus. Lesions in vagina x 3. Uterine prolapse. Normal tubes, ovaries, vaginal lesions and nodes
 
PROCEDURE:
After assuring informed consent the patient was taken back to the operating suite and induction of general anesthesia was done. The patient was placed in the modified dorsal lithotomy position in Allen stirrups then prepped and draped in the normal sterile fashion. The weighed speculum was placed in the patient’s vagina and the cervix was grasped at the 12 O’clock position with a single tooth tenaculum. Three vaginal lesions were noted in the distal third of the vagina. They were dissected out with the bovie. The vagina was reapproximated in multi layer closure with 0 -vicryl. The uterus was sounded to 12 cm and the cervix was dilated with the hank dilators up to a number 15. A medium V-Care uterine manipulator was placed inside the uterine cavity. Foley catheter was placed. Gloves were changed and attention was then taken to the abdomen.
 
A supraumbilical skin incision was then made approximately 22 cm above the pubic symphysis and a veress needle was introduced into this incision. Once proper placement was noted by physical examination and sterile water flowing easily into this incision then CO2 gas was insufflated into the abdomen at a maximum pressure of 15 mmHg. A 10/12 blunt trocar was then inserted through this incision and the Robotic camera verified proper placement of this port. Bilateral blunt robotic trocars were then placed 10 cm lateral and 15 degrees inferior lateral from the midline camera port. An additional left flank robotic port was placed 10 cm lateral and 15 degrees upward from the prior robotic port. A 10/12 accessory port was placed beneath the right costal margin. The patient was then placed in steep trendelenberg position and the robot was docked. The monopolar scissors were placed in the right robotic arm; bipolar fenestrated graspers in the left robotic arm and the double fenestrated graspers were placed in the third robotic arm.
 
Bilateral round ligaments were taken down with monopolar cautery and the retroperitoneal space was opened. The underlying ureters were visualized and the infundibulopelvic ligaments bilaterally were cauterized with bipolar cautery and cut with monopolar cautery. The vesicouterine peritoneum was incised and the bladder was dissected off the lower uterine segment and cervix. The uterine vessels were then cauterized bilaterally with the bipolar and transected with the monopolar cautery. The cardinal and uterosacral ligaments were then cauterized with the bipolar and transected with the monopolar cautery. A posterior colpotomy was made at the level of the Vcare and brought around circumferentially freeing up the specimen, which was brought out through the vagina.
 
The vaginal cuff was then reapproximated with 0 PDS in a running fashion, starting from either end and tying in the middle. Bilateral external iliac lymph nodes were then removed with the margins of resection being the genitofemoral nerve laterally, the ureters medially, midportion of the common iliac artery superiorly and the distal circumflex iliac vein inferiorly. All nodes were removed through an Endo Catch bag through the 10/12 port. Locating the continuation of the hypogastric vessel and placing it on medial stretch then developed the bilateral paravesical spaces. The overlying obturator nodes were removed from the external iliac vein down to the obturator nerve bilaterally. These nodes were also placed in an Endo Catch bag and brought out through the 10/12 port.
 
The colon was then pushed laterally. The retroperitoneal space was opened medial to the colon from the sacrum to the vaginal cuff. A restorelle mesh was used to secure to the vaginal cuff and sacrospinus ligament and it was sutured in with 0 ethibond. It was noted to have good support of the vaginal cuff. The mesh was tacked down to the pelvis with 0 ethibond. The peritoneum was oversewen with 0-vicryl. The mesh was now underneath the peritoneum and no mesh was seen.
 
The pelvis was then irrigated and the vaginal cuff was noted to be hemostatic. The infundibulopelvic ligaments were noted to be hemostatic as well. The instruments were then removed and the robot was undocked. The pneumoperitoneum was then evacuated and all trocars were removed. The 12 mm trocar fascia sites were reapproximated with a figure of eight stitch of 0 vicryl. All skin incisions were closed with a 4-0 vicryl subcuticular stitch. Steri-strips were placed as well as bandages. The vagina was examined with sponge sticks x 2 and noted to be hemostatic. Sponge, lap, needle and instrument counts were correct x 2. The patient was taken to






Comments (2)
Posted By Maria on 08-21-2019, 05:31:17
Hi Melanie, Thank you so much for your help! I was reading right over that dissection part, and still not seeing it. Hope you have a fantastic time on your well deserved vacation!
Posted By Melanie Witt on 08-20-2019, 18:45:46
Well first, he does describe 3 vaginal tumors that were dissected - this is in the first paragraph. He did it first before starting the laparoscopic procedure. And you are correct that he did a laparoscopic colpopexy. I hope he understands that he won't get paid extra for using the robot but you should certainly report the S code.
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