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Posted By Maria on 11-08-2019, 12:00:20 in Ob-Gyn
Hello Melanie,

What CPT code would you recommend for a Radical Robotic hysterectomy with Bil Pelivic Lymphadenectomy?
Path Malignant

1. Robotic assisted laparoscopy radical hysterectomy
2. Bilateral salpingectomy
3. Bilateral pelvic lymphadenectomy
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. The uterus was sounded to 13 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 with a sterile specimen cup placed between the two V-Care cups in order to delineate a 2 cm vaginal margin. 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. Bilateral pararectal and paravesical spaces were then developed. The underlying ureters were visualized and the uterine-ovarian 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, cervix, and superior aspect of the vagina well below the 2 cm margin required for the radical. The bilateral ureters were then dissected off the medial leaves of the broad ligament and careful meticulous ureterolysis was employed into the cardinal ligament tunnel close to the ureterovesical junction. The fallopian tubes were dissected off the overlying ovaries.
The continuation of the hypogastric vessels was then identified and skeletonized proximally identifying the origin of the uterine arteries bilaterally. The uterine arteries and veins were then isolated close to their origin, clamped and coagulated with bipolar cautery and cut with excellent hemostasis. The vessels along the adjoining parametrial tissue and cardinal ligament were then mobilized and dissected over the ureter as it entered into the tunnel and transversed towards the ureterovesical junction. The parametrial tissue was then brought medially over the ureter to o with the final specimen. Care was taken to dissect and drop down the lateral bladder pillars as well.
A posterior colpotomy was made at the impression of the sterile specimen cup placed between the V-care cups with a 2 cm margin. This was brought around circumferentially freeing up the uterus, cervix, fallopian tubes and ovaries, 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 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.

Thanks so much.
Comments (1)
Posted By Melanie Witt on 11-08-2019, 15:53:08
58548-52 as he did not do the para-aortic lymph node sampling, but the rest of the procedures described in the code match this documentation.
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