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  1. User id : 4467 Posted 2 years ago

    LOOKING FOR A CODE FOR:

    POSTOPERATIVE DIAGNOSES:
    1. Vaginal agenesis.
    2. Cervical agenesis.

    PROCEDURE:
    1. Exam under anesthesia.
    2. Exploratory laparoscopy.
    3. Exploratory laparotomy.
    4. Vaginoplasty.
    5. Cystoscopy.
    6. Abdominal hysterectomy.

    FINDINGS:
    1. Absent vagina.
    2. Fibrous cervical tissue not communicating with endometrial cavity.
    3. Two separate analogous uteri with left greater than right.
    Normal ovaries bilaterally.

    ANESTHESIA: General endotracheal anesthesia.

    SPECIMENS TISSUE REMOVED: Bilateral analogous uteri.

    ESTIMATED BLOOD LOSS: Less than 100 mL.

    IV FLUIDS: 3 L.

    URINE OUTPUT: 850 mL.

    DRAINS: Foley.

    COMPLICATIONS: None.

    COUNTS: Correct x3.

    DICTATION: The patient was taken back to the operating
    room where she was placed in dorsal lithotomy position and prepped and draped
    in normal sterile fashion after induced under anesthesia. A 5 mm
    infraumbilical port placed and trocar introduced using an Excel trocar under
    direct visualization. Findings as noted above. Lateral 5 mm trocar sites
    placed under direct visualization with transillumination of the skin in order
    to avoid the epigastric vessels. Patient was placed in Trendelenburg and
    bowels were moved cephalad in order for better visualization. While operator
    was continuing to look from above, the attending went down below the legs and
    opened up the vaginal cuff and dissected the vaginal tissues posterior to where
    the cervical entrance was thought to be and attempts were made to dissect through connective tissue in order to reach the cervical layer, however, this proved to be unsuccessful. After several attempts this was aborted and attention was then returned to the abdomen where a laparotomy was
    made. A skin incision was made in a Pfannenstiel fashion and carried down to
    the underlying layer of the fascia with the Bovie. Bovie was used to nick the
    fascia in the midline and to cut the fascia while it was undermined with the
    Adson clamp. Kocher clamps x2 used to grasp the superior aspect of the fascial
    incision and the underlying rectus muscles dissected off sharply with the
    Bovie. The inferior aspect was handled in a similar manner. Rectus muscles
    were separated in the midline and peritoneum grasped with hemostats and entered
    sharply with the Metzenbaum scissors. Once inside the peritoneal cavity,
    stretching was used to separate the muscles and the peritoneum. The patient
    was again placed in Trendelenburg and bowel was packed away with tagged
    laps. Self retaining retractor used for better visulaization. Uteri were again identified and left uterus was grasped and transected across the fundus. Area was seen where the left fallopian tube
    communicated with the left hemiuterus; however, there is no direct connection
    between the fibrous cervical tissue and the endometrial cavity. Secondary to not having a chance of creating a successful outflow tract this at that point Dr. left the OR to discuss the findings with the family. The plans were made to proceed with hysterectomy to remove the
    uterine tissue. The round ligament on the left was grasped and suture ligated
    and the leafs of the broad ligament were then opened. Window was created
    beneath the uterine ovarian ligament and Heaney clamps x2 placed across the
    window. Mayo scissors were used to cut between the 2 clamps and the pedicle
    was then suture ligated with 0 Vicryl in a free pass and then stick tied with 0
    Vicryl. Excellent hemostasis was noted. The pedicle was then skeletonized and
    the Heaney clamps were placed across the uterine artery. Pedicles were created
    using Mayo scissors and this was suture ligated x2 to secure the pedicle.
    Another straight Heaney was used to create a pedicle along the cervical tissue
    and then this was suture ligated with 0 Vicryl and then a curved clamp placed
    across the base below the cervical fibrous tissue and this was suture ligated
    in a modified Heaney manner. Good hemostasis was noted. Attention was then
    turned to the right hemiuterus. In a similar manner the uterine ovarian
    pedicle was ligated with Kelly clamps x2 and Mayo scissors were used to cut the
    intervening tissue and this pedicle was suture ligated. Another Kelly clamp
    was used to clamp along the broad ligament along the side of the uterus. This
    again was suture ligated and then a final clamp was placed across the uterine
    tissue and the right hemiuterine was free and this was free tied. Copious
    irrigation was performed. Attention was then turned below and a space was
    created posterior and the posterior cul-de-sac was noted to be free enough to
    pull the peritoneum down to create a vaginal oriface. The abdominal
    peritoneum was then suture ligated to the vaginal mucosa in an interrupted fashion in a circumferential pattern. Hagar dilator was placed vaginally to
    maintain the window into the abdominal cavity and a pursestring closure was
    done abdominally of the peritoneum above the dilator to create the neovagina.
    Good results were performed with 6 cm vagina created at the end of procedure.
    All laps were removed from the abdominal cavity. The muscles were
    reapproximated using 0 Vicryl in figure-of-eight fashion. The fascia was
    closed 0 Vicryl in a running fashion. The subcutaneous layers were
    reapproximated using a 0 Vicryl in a subdermal fashion. The skin was closed
    with 4-0 Monocryl in subcuticular fashion, as well as the 3-5 mm laparoscopic
    sites. The patient tolerated the procedure well. Estrogen
    vaginal cream was placed vaginally and the patient was taken awake
    in a stable condition to recovery room.

  2. SuperCoder Posted 2 years ago

    Hi Robin,

    I'm the Ob-gyn Coding Alert editor, and I'm checking on this.

    Thanks,
    Suzanne

  3. User id : 4467 Posted 2 years ago

    Hi Suzanne,

    Trying to see if you came up with any CPT codes for the Vaginal agenesis surgery.

    Thanks
    Robin

About this Question

  • Posted by 4467, 2 years ago. There are 3 posts. The latest reply is from 4467.