How would you code this scenario? I have used CPT '58552'or '58554' in the past depending on the size of the uterus but have recently been told this is incorrect.
2. CHRONIC PELVIC PAIN
2. CHRONIC PELVIC PAIN
Procedure: Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy
Anesthesia: General endotracheal
Fluids: 2000 mL Lactated ringers
EBL: 200 mL
Urine output: 100 mL
Specimens: Uterus, cervix, bilateral fallopian tubes and ovaries
Indications: Jennifer is a 45 yo multiparous female who was evaluated for chronic pelvic pain. Laparoscopy June 2012 showed evidence of endometriosis in the posterior cul-de-sac as well as some adhesions in the left adnexa. After fulguration of endometriosis, lysis of adhesions, and use of Nuvaring, the patient had some pain relief. However, despite those efforts her pain returned and worsened, becoming daily. She desired to proceed with definitive management with hysterectomy and bilateral salpingo-oophorectomy.
1. Anteverted uterus, mildly enlarged and bulky, about 10 week size
2. Implants of endometriosis in the left adnexa, primarily on the fallopian tube with normal appearing ovary
3. Normal appearing right fallopian tube and ovary
After informed consent was obtained, the patient was taken to the operating room where general anesthesia was found to be adequate. Compression stockings were on and functioning prior to the start of the procedure. Preoperative antibiotic therapy with Flagyl and Levaquin was administered prior to the start of the procedure. The patient was prepped and draped in the normal sterile fashion in the dorsal lithotomy position using Yellowfin stirrups. A time out was performed with all operating room personnel present and in agreement with the planned procedure.
Bimanual exam under anesthesia revealed an antverted uterus that was mobile. The cervix had good descensus. No adnexal masses were palpable. A foley catheter was placed in the patient's bladder. An open-sided Grave's speculum was placed in the vagina to visualize the cervix. The anterior lip of the cervix was grasped with a single tooth tenaculum. An acor uterine manipulator was passed through the cervix and secured. The peculum was removed.
Attention was turned to the patient's abdomen. A 5 mm vertical skin incision was made at the lower edge of the umbilicus at the site of the patient's previous laparoscopy scar. A Veress needle was passed through this incision and intraperitoneal placement was confirmed. The abdomen was insufflated with CO2 gas. A 5 mm trocar was passed through the skin incision, and the laparoscope confirmed intraperitoneal placement. Brief survey of the abdomen and pelvis revealed a mildly enlarged uterus without obvious adnexal masses. Accessory ports were placed in the right and left lower quadrants at the site of her other laparoscopy scars. A 5 mm skin incision was made at each location and 5 mm trocars were passed through the incisions under direct visualization. More careful survey of the pelvis revealed a normal appearing right fallopian tube and ovary. The left fallopian tube contained implants of endometriosis. The left ovary appeared normal but was mildly adherent to the left fallopian tube. The cul de sac appeared free of any significant adhesions.
The left cornua was grasped with a clamp. The bipolar cautery device was used to cauterize and transect the infundibulopelvic ligament on the left. The round ligament on the left side was similarly cauterized and transected. The broad ligament was cauterized, transected, and the anterior and posterior leaves were separated. The bladder flap was started from the left side with blunt and minimal sharp dissection. This process was repeated on the right side. The bipolar cautery device was used to cauterize and transect the infundibulopelvic ligament followed by the round ligament on the right side. The broad ligament was dissected and the anterior and posterior leaves were separated. The bladder flap was continued from this side. The bladder did seem mildly adherent to the anterior uterus, and further attempts at full bladder attempt were not performed. Good hemostasis was noted at the infundibulopelvic and round ligament pedicles. The laparoscopic instruments were removed and the CO2 gas was exited.
Attention was returned to the vaginal area. A weighted speculum was placed in the posterior vagina. The anterior lip of the cervix was regrasped with a tenaculum. The uterine manipulator was removed. The cervix was circumferentially injected with 0.5% Marcaine with epinephrine. The cervix was circumferentially incised with the scalpel. This incision was carried deeper with Mayo scissors. The posterior vaginal wall and posterior peritoneum were tented up. The posterior cul de sac was entered sharply and atraumatically. A long weighted speculum was placed in the posterior cul de sac.
The uterosacral ligaments were clamped, transected, and suture ligated bilaterally. These pedicles were tagged for later use. A second pedicle was needed to capture each uterosacral ligament adequately. This second pedicle was clamped, transected, and suture ligated, then tagged with the first pedicle. The pubovesical fascia was attempted to be dissected off the anterior body of the uterus with blunt and sharp dissection. There was difficulty finding a clear plane between the bladder and anterior uterus, consistent with the scarring noted from the laparoscopic attempts at creating the bladder flap. Small pedicles of the cardinal ligament were then obtained, clamping, transecting, and suture ligating the tissue bilaterally. Further attempts at creating the bladder flap were still unsuccessful. Additional pedicles along the body of the uterus were taken. The uterus was then mobile enough to be rotated. Sharp towel clamps were used to grasp the posterior body and fundus of the uterus. The uterus was fully rotated to see the remaining pedicles. The uterine arteries were identified, clamped, transected, and suture ligated bilaterally. With better mobilization of the uterus, the remaining portion of the bladder flap was able to be identified more easily. Careful sharp dissection was used to identify the correct plane. Then the last remaining portion of the pubovesical fascia was clamped from each side, and the uterus and cervix were amputed and removed. The dissected peritoneum was sutured and hemostatic.
Examination of the pedicles showed good hemostasis. A small amount of bleeding was noted along the cuff peritoneum, which was thought to be able to be controlled with closure of the cuff. The anterior and posterior lips of the vaginal cuff were grasped with ring forceps. The vaginal cuff angles were secured to the uterosacral ligaments. The vaginal cuff was reapproximated with O Vicryl in a running locked fashion from the apex at the patient's left side to the patient's right side. Good hemostasis was noted.
Attention was returned to the abdomen. The abdomen was again insufflated with CO2 gas. Inspection of the pelvis revealed no evidence of active bleeding. The pelvis was irrigated with warm saline, and good hemostasis was noted. The trocars were removed under direct visualization. The laparoscope was removed, and the CO2 gas was exited from the abdomen. The skin incisions were reapproximated with a single subcuticular suture of 4-0 Vicryl and topical skin adhesive. The foley catheter was left in place.
The patient tolerated the procedure well. Sponge, sharp, and instrument counts were correct x 2. The patient was taken to the recovery room in stable condition.