Hospital Outpatient Surgery Services
Hospital Outpatient Surgery Services
Preoperative Diagnosis: Right ectopic pregnancy
Postoperative Diagnosis: Same
Anesthesia: General
Operation: Diagnostic laparoscopy
Right salpingostomy with removal of ectopic pregnancy
Rationale for Surgery: This patient is a 36-year-old gravida III, para I, AB I, at 8 weeks gestation, who has a positive pregnancy test with right adnexal mass that is a gestational sac with FHTs, and right ectopic pregnancy diagnosis was made. She was admitted at this time for laparoscopy with removal of this right ectopic pregnancy. We did talk about possibly sacrificing the tube on that side if we did get into problems with bleeding. This patient has a history of pelvic adhesions with blocked left tube. She is aware that we may have to sacrifice the right tube and that essentially she would be unable to become pregnant in all probability if we’re not able to save the tube. She is also aware of the risks and benefits of surgery, including hemorrhage, bowel and bladder injury, and infection.
Procedure: With the patient in the lithotomy position and under satisfactory general anesthesia, the abdomen and perineum were prepped and draped in the usual manner. A weighted speculum was placed in the vaginal vault. The anterior lip of the cervix was grasped with a single-toothed tenaculum. The uterus was sounded to about 9 cm, and it was retroverted. The endocervical canal was dilated with Pratt dilators, and the Zumi uterine manipulator was placed and the bulb insufflated with approximately 8 cc of air. A red rubber catheter was placed to gravity and attached to the Zumi uterine manipulator. Attention was then turned to the abdominal area, where a small skin incision was made with a scalpel. A large trocar was placed in the direct insertion technique, and pneumoperitoneum was established without difficulty. It is noted she did have some blood in the cul-de-sac. The right tube and ovary looked grossly within normal limits except the fimbriated end on the right was somewhat blunted. The ectopic pregnancy was really at the fimbriated end and had a small clot that was extruded from the fimbriated end. She also had the ovarian cyst on that side, which was not complicating this pregnancy. It was opened and drained. She also had a peritubular cyst, which I left intact. I isolated the ectopic pregnancy and then made a small cut using the needle coagulator over the ectopic pregnancy and extruded this with the needle nose forceps. Had some oozing along the fimbriated end. I did put Avitene in this area and then topped it with some Surgicel. We watched it for several minutes, and it seemed to control the small amount of oozing. We irrigated the pelvic region with copious amounts of irrigation and then aspirated it. We again checked the operative field, and it seemed to be dry. We watched it as we deflated the abdominal pressure. I then removed all the instruments, used .25 mg of Marcaine injection at the injection sites, and closed the incisions with staples. Vaginal instruments were removed. She was taken to the recovery room in good condition. Estimated blood loss approximately 50 cc. Sponge and needle count was correct × 2. Patient did tolerate the procedure well and left the operating room in good condition.
Assign the correct ICD-10-CM and CPT codes for this encounter.
ICD-10-CM Code(s):
CPT Code(s):
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