Question
The patient was taken to the operating room and placed in the dorsal lithotomy position following adequate general endotracheal anesthesia. Her legs were placed in
The patient was taken to the operating room and placed in the dorsal lithotomy position following adequate general endotracheal anesthesia. Her legs were placed in the Allen stirrups. She was then prepped and draped in the usual sterile fashion and a speculum was placed into the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum and a cone cannula was introduced. Her bladder was then straight-cathed with approximately 100 cc of clear urine. The catheter was then removed. Next, a small incision was made infraumbilically of approximately 7mm. A Verres’needle was introduced. The opening pressure was 2, and the abdomen was filled with CO2 gas. The 7 mm trocar was then introduced with entry verified by the laparoscope into the intra-abdominal contents. Severe adhesions on the anterior abdominal wall were noted. A second 7 mm trocar was placed under direct visualization after making a skin incision suprapubically. The blunt probe was introduced through the suprapubic port. Both tubes were identified. The right tube appeared to have a distal hydrosalpinx. The left tube was grasped approximately a third of the way from its proximal end, a Falope ring was applied and a picture was taken. Next, the blunt probe was used again to lay out the right tube. The Falope ring applicator was then reintroduced, and the tube was grasped approximately a third of the way from the proximal end. A second Falope ring was
placed on the right side. A picture was taken of the right tube. The patient tolerated the procedure well and all instruments were removed. The suprapubic port was removed under direct visualization and found to be hemostatic. The infraumbilical incision was closed using 4-0 Vicryl in a running fashion. The suprapubic site was closed in the same fashion. The patient was taken to the recovery room in stable condition.
Operative Report
Preoperative Diagnosis: Multigravida
Postoperative Diagnosis: Multigravida
Operation Performed: Laparoscopic bilateral ligation via Falope rings
Anesthesia: General
Questions
1. Identity the procedure/procedures performed:
2. Identify the preoperative diagnosis(es) / reason(s) for the procedure:
3. In your own words, describe the procedure performed:
4. What approach was used to perform the procedure?
(i.e., open, endoscopic, puncture, external, etc.):
5. What anatomic sites were evaluated?
6. What anatomic sites were treated?
7. What complications or unusual circumstances were encountered during the procedure?
8. Based on your complete review of the operative report: Was the postoperative diagnosis(es) the same as the preoperative diagnosis?
YES/ NO
9. If NO, what was/should be listed as the final/postoperative diagnosis?
10. What keyword did you use to look up the procedure code in the index?
11. Enter the CPT Code(s) for this case including the complete code descriptors.
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