Sample Operative Dictation OBGYN

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CL8A1lvL ulC1A1lCn: C8S1L18lCS & C?nLCCLCC?

l

Co|en ub||sh|ng, LLC
21444 Parper Ave.
SalnL Clalr Shores, Ml
48080

LdlLor: Chalm 8. Colen, M.u., h.u.
Managlng LdlLor: 8oxanne L. Colen
LdlLorlal AsslsLanL: kaLherlne M. Anderson and 8enee ascouau

CC?8lCP1 2010 by Colen ubllshlng, LLC. 1hls book, lncludlng all parLs Lhereof, ls legally
proLecLed by copyrlghL. Any use, explolLaLlon, or commerclallzaLlon ouLslde Lhe narrow llmlLs
seL by copyrlghL leglslaLlon wlLhouL Lhe auLhor's consenL lf lllegal and llable Lo prosecuLlon.
1hls applles ln parLlcular Lo phoLosLaL reproducLlon, copylng, mlmeographlng or dupllcaLlon of
any klnd, LranslaLlng, preparaLlon of mlcrofllms, and elecLronlc daLa processlng and sLorage.

Some of Lhe producL names, paLenLs, and reglsLered deslgns referred Lo ln Lhls book are ln facL
reglsLered Lrademarks or proprleLary names even Lhough speclflc reference Lo Lhls facL ls noL
always made ln Lhe LexL. 1herefore, Lhe appearance of a name wlLhouL deslgnaLlon as
proprleLary ls noL Lo be consLrued as a represenLaLlon by Lhe publlsher LhaL lL ls ln Lhe publlc
domaln.

rlnLed ln Chlna

lS8n 13: 9781933343077
lS8n 10: 1933343079

noLe: knowledge ln medlclne ls consLanLly changlng. 1he auLhor has consulLed sources
belleved Lo be rellable ln Lhe efforL Lo provlde lnformaLlon LhaL ls compleLe and ln accord wlLh
Lhe sLandards aL Lhe Llme of publlcaLlon. 1here ls a posslblllLy of human error by Lhe auLhor ln
preparaLlon of Lhls work. Powever, Lhe auLhor warranLs LhaL Lhe lnformaLlon conLalned hereln
ls accuraLe and compleLe Lo Lhe besL of hls or her knowledge and ls noL responslble for any
errors or omlsslons or for Lhe resulLs obLalned from use of such lnformaLlon. 1he reader ls
advlsed Lo conflrm Lhe lnformaLlon conLalned hereln wlLh oLher sources. 1hls ls especlally
lmporLanL ln connecLlon wlLh new or lnfrequenLly used drugs. ln such lnsLances, Lhe producL
lnformaLlon sheeL lncluded ln Lhe package wlLh each drug should be revlewed. ?ou should
consulL an offlclal C1 book for accuraLe codlng for Lhe purposes of relmbursemenL.

ll

CCN1LN1S
1ab|e of Contents
CCN1LN1S .......................................................................................................... ||
ACkNCWLLDGLMLN1S ...................................................................................... |v
DLDICA1ICN ....................................................................................................... v
ICkLWCkD ....................................................................................................... v|
kLIACL ........................................................................................................... v||
CLkA1IVL INS1kUMLN1S.................................................................................. 8
Clamps ......................................................................................................... 10
1enaculums ................................................................................................. 11
1lssue lorceps ............................................................................................. 12
Sclssors ........................................................................................................ 13
8eLracLors .................................................................................................... 14
vaglnal 8eLracLors ....................................................................................... 13
vaglnal ManlpulaLors .................................................................................. 13
ullaLaLlon And CurreLage............................................................................. 16
Laparoscoplc LqulpmenL ............................................................................. 17
CperaLlve vaglnal uellvery LqulpmenL ....................................................... 18
C8S1L1kICS ...................................................................................................... 19
VAGINAL DLLIVLk...................................................................................... 20
SponLaneous vaglnal uellvery..................................................................... 21
lorceps-AsslsLed vaglnal uellvery............................................................... 22
vacuum-AsslsLed vaglnal uellvery .............................................................. 24
lourLh uegree LaceraLlon 8epalr ................................................................ 26
CLSAkLAN................................................................................................... 28
Cesarean SecLlon......................................................................................... 29
Cesarean SecLlon WlLh 8llaLeral 1ubal LlgaLlon........................................... 31
Cesarean PysLerecLomy .............................................................................. 34
CLkCLAGL ................................................................................................... 38
vaglnal Cerclage lacemenL ........................................................................ 39
Cerclage 8emoval ........................................................................................ 41
AMNICCLN1LSIS ......................................................................................... 43
ulLrasound Culded 1ransabdomlnal AmnlocenLesls................................... 44
GNLCCLCG ................................................................................................... 46
nS1LkLC1CM]MCMLC1CM...................................................................... 47
Abdomlnal Supracervlcal PysLerecLomy ..................................................... 48
1oLal Abdomlnal PysLerecLomy................................................................... 31
vaglnal PysLerecLomy ................................................................................. 34
Laparoscoplc Supracervlcal PysLerecLomy.................................................. 37


lll
Laparoscoplc 1oLal PysLerecLomy ...............................................................60
Laparoscoplc-AsslsLed vaglnal PysLerecLomy .............................................63
8oboLlc AsslsLed Laparoscoplc PysLerecLomy .............................................66
Abdomlnal MyomecLomy ............................................................................69
8oboLlc AsslsLed Laparoscoplc MyomecLomy .............................................71
S1LkILI2A1ICN............................................................................................. 74
Laparoscoplc 8llaLeral 1ubal LlgaLlon ..........................................................76
osL arLum 1ubal LlgaLlon..........................................................................78
PysLeroscoplc 1ubal LlgaLlon.......................................................................80
Lssure ..........................................................................................................80
Adlana..........................................................................................................82
UkCGNLCCLCG....................................................................................... 84
osLerlor Colporrhaphy ...............................................................................83
osLerlor 8epalr WlLh rollfL Mesh .............................................................87
1enslon-lree vaglnal 1aplng........................................................................89
1ransobLuraLor 1aplng (1C1) .......................................................................91
1ransvaglnal 1aplng (1v1 Secure)................................................................93
AnLerlor Colporrhaphy.................................................................................93
Abdomlnal Sacral Colpopexy .......................................................................97
8urch Colposuspenslon ...............................................................................99
CysLoureLhroscopy.....................................................................................100
nS1LkCSCC AND DILA1ICN AND CUkL11AGL...................................... 102
PysLeroscopy ullaLlon And CureLLage .......................................................103
Clobal LndomeLrlal AblaLlon .....................................................................103
PydroLhermal AblaLlon ..........................................................................103
8lpolar 8adlofrequency AblaLlon ...........................................................107
PysLeroscoplc MyomecLomy.....................................................................109
ullaLlon And CureLLage ..............................................................................111
SucLlon ullaLlon And CureLLage .................................................................113
ullaLlon And LvacuaLlon ............................................................................113
DIAGNCS1IC AND CLkA1IVL LAAkCSCC............................................ 117
Laparoscopy lor SuspecLed LcLoplc regnancy.........................................118
Laparoscoplc Cvarlan CysLecLomy.............................................................121
Laser AblaLlon Cf LndomeLrlosls ...............................................................123
C1nLk GNLCCLCG................................................................................. 12S
Cervlcal ConlzaLlon ....................................................................................126
Loop LlecLrosurglcal Lxclslon rocedure (Leep)/llscher ConlzaLlon .........126
Cold knlfe ConlzaLlon.................................................................................128
MarsuplallzaLlon Cf 8arLholln CysL............................................................130
erlneorrhaphy..........................................................................................132
Colpoclelsls ................................................................................................134
A88kLVIA1ICNS.............................................................................................. 136

lv

ACkNCWLLDGLMLN1S

A pro[ecL of Lhls callber ls only posslble wlLh Lhe asslsLance of many. 1hank you Lo Lhe
followlng physlclans for Lhelr Llme and lnslghL ln revlewlng LemplaLes for accuracy and
compleLeness.

Ne|| nam|||, M.D.
laculLy, MaLernal leLal Medlclne
MeLhodlsL PosplLal
Cmaha, nebraska

Chr|st|na A|f|er|, M.D.
PuLzel Womens PealLh SpeclallsL
ueLrolL Medlcal CenLer
ueLrolL, Mlchlgan

A|an Go|dsm|th, M.D.
WalnuL Lake C8/C?n
2300 PaggerLy 8oad SulLe 2070
WesL 8loomfleld, Ml

Cynth|a 8r|ncat, M.D.
urogynecology lellow
unlverslLy of Mlchlgan
Ann Arbor, Mlchlgan


v
DLDICA1ICN

1hls work ls dedlcaLed Lo Lhe obsLeLrlcs and gynecology resldenLs aL
PuLzel PosplLal whose hard work and dedlcaLlon Lo our fleld lmprove Lhe
llves of women ln ueLrolL.

-Polly k. ?eLLaw, M.u.

vl

ICkLWCkD

lL ls remarkable LhaL over Lhe course of four years of medlcal school, four years of
resldency, and perhaps even Lhe duraLlon of a fellowshlp, Lralnees recelve llLLle or
no lnsLrucLlon abouL performlng an adequaLe dlcLaLlon. As a resulL, a rlghL of
passage has developed for every resldenL when a dlcLaLlon ls sub-par. 8esldenLs
are made Lo repeaL a dlcLaLlon unLll lL ls correcL requlrlng one, Lwo, or even Lhree
or more aLLempLs wlLh llLLle Lo no dlrecLlon glven for lmprovemenL.

lL should come as no surprlse LhaL Lhe quallLy of dlcLaLlon ls poor. 8esldenLs are
llmlLed ln Lhe Llme LhaL Lhey can work, yeL, Lhey need Lo accompllsh Lhe same
amounL of work. As a consequence, dlcLaLlons move Lo Lhe boLLom of Lhelr ever
lengLhenlng Lo-do llsL and are vlewed as unlmporLanL when noLhlng could be
furLher from Lhe LruLh. We use dlcLaLlons Lo Lrlage paLlenLs, clarlfy paLhology,
gulde fuLure care, and Lo supporL our acLlons Lo oLhers boLh professlonally and
legally.

ur. ?eLLaw has made a greaL sLrlde for CbsLeLrlcs and Cynecology resldenLs by
provldlng Lhe Lools Lhey need Lo dlcLaLe effecLlvely. ln Lhls book, readers can
expecL Lo flnd comprehenslve LemplaLes of operaLlve procedures for CbsLeLrlcs
and Cynecology as well as a phoLo gallery of our speclalLy speclflc lnsLrumenLaLlon.
1he followlng pages wlll help Lo ensure LhaL Lralnees know Lhe Lools Lhey are uslng
and can comprehenslvely descrlbe Lhe essenLlal componenLs of each case. Cn
behalf of all former, currenL, and fuLure resldenLs, Lhank you ur. ?eLLaw for maklng
Lhls perlod of Lralnlng a llLLle easler.

nell A. Pamlll, M.u.
lormer resldenL ln CbsLeLrlcs and Cynecology
laculLy, MaLernal leLal Medlclne
MeLhodlsL PosplLal, Cmaha, nebraska


vll
kLIACL

"lo teocbloq otbets we teocb ootselves."

-Aoooymoos

1he pracLlce of medlclne requlres Lhe collaboraLlon of many. AccuraLe and
comprehenslve operaLlve dlcLaLlons are essenLlal Lo documenL Lhe evenLs of a
procedure and Lo convey compleLe lnformaLlon Lo fellow healLhcare provlders
lnvolved ln Lhe currenL and fuLure care of Lhe paLlenL.

CperaLlve llash-ulcLaLlons: C8-C?n ls a gulde Lo asslsL Lhe novlce surgeon ln Lhe
arL of dlcLaLlon. 1hls manual wlll provlde Lhe Lools necessary Lo produce well
sLrucLured, sysLemaLlc dlcLaLlons wlLh medlco-legal susLalnlng [argon and Lhe
approprlaLe C1 codes. ln addlLlon, lL provldes lmages of commonly used surglcal
equlpmenL ln Lhe fleld of gynecology and obsLeLrlcs.

ln no way ls Lhls book comprehenslve enough Lo cover all operaLlve dlcLaLlons
performed ln gynecology and obsLeLrlcs, raLher lL ls meanL Lo be a baslc gulde Lo
allow Lhe novlce surgeon Lhe scaffoldlng needed Lo dlcLaLe a baslc sLralghL forward
case. 1he common cases are descrlbed ln a conslsLenL formaL. 1here are many
Llmes durlng our operaLlve careers LhaL we devlaLe from Lhe norm, Lhls unlqueness
should be dlcLaLed on a per-case-basls. May Lhls book beneflL resldenLs and [unlor
sLaff ln Lhe fleld of CbsLeLrlcs and Cynecology.

Polly krlsLln ?eLLaw, M.u.

Lver mlndful of resldenL educaLlon, l encouraged Polly, Lhen a second year
resldenL ln C8-C?n, Lo asslsL me wlLh my passlon ln llfe - Lo make llfe easler for
oLhers LhaL follow ln our fooLsLeps.

1hese dlcLaLlon LemplaLes follow CperaLlve-llash ulcLaLlon: neurosurgery and
compose Lhe cornersLone of my quesL Lo esLabllsh a serles of CperaLlve ulcLaLlon
LemplaLes ln many oLher speclalLles. As Senlor LdlLor, l nurLured Lhe pro[ecL along
wlLh a vlslon Lo esLabllsh a vlable novelLy Lo C8-C?n professlonals. l humbly Lhank
all of Lhe sLaff aL Colen ubllshlng LhaL have asslsLed ln maklng Lhls book a reallLy.
May Lhls book prove Lo be a supporLlng plllar of knowledge, added Lo Lhe legacy of
medlclne.

Chalm 8en!oseph Colen, M.u., h.u.

8

&456789:5 9;<86=>5;8<
CL8A1lvL lnS18uMLn1S

&456789:5 9;<86=>5;8<
9
1. Allls Clamp
2. 8lnged lorceps
3. 8abcock Clamp
4. 1owel Clamps
CLAMS

1. kocher
2. kelly
3. uouble 1ooLh Peaney
4. Peaney
1 2 3 4
1 2 3 4

&?<85869@<
19
C8S1L18lCS

Decorum from the m|d-1800s: ln dlfference Lo
obsLeLrlcal care ln Lhe mld 1800s, whlch
requlred male obsLeLrlclans Lo averL Lhelr eyes
as much as posslble durlng paLlenL exams,
obsLeLrlcal ploneer WalLer Channlng creaLed a
legacy of compasslon LhaL has perslsLed lnLo
modern Llmes.

20

&?<85869@<

vAClnAL uLLlvL8?

1. SponLaneous vaglnal uellvery
2. lorceps-AsslsLed vaglnal uellvery
3. vacuum-AsslsLed vaglnal uellvery
4. lourLh uegree LaceraLlon 8epalr

&?<85869@<
21
SCn1AnLCuS vAClnAL uLLlvL8?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:

uLSC8l1lCn Cl 1PL 8CCLuu8L
AL (Llme) Lhe paLlenL dellvered a vlable/prevlable (gesLaLlonal age)/sLlllborn feLus welghlng x g
wlLh ACA8 scores of x and x aL one and flve mlnuLes, respecLlvely. 1he feLal verLex was
dellvered sponLaneously over lnLacLed perlneum/mldllne eplsloLomy/medlolaLeral eplsloLomy.

A tlqbt/loose oocbol cotJ tlmes \ wos lJeotlfleJ ooJ teJoceJ/clompeJ ooJ cot.

1he anLerlor shoulder was dellvered aLraumaLlcally by maLernal expulslve efforLs wlLh Lhe
asslsLance of downward LracLlon. 1he posLerlor shoulder dellvered wlLh maLernal expulslve
efforLs and upward LracLlon. 1he remalnder of Lhe feLus dellvered sponLaneously. upon
dellvery, Lhe cord was clamped and cuL. 1he lnfanL was Lhen passed Lo Lhe awalLlng
pedlaLrlclans. A segmenL of Lhe cord and cord blood was obLalned for analysls and blood gas
analysls. 1he placenLa dellvered sponLaneously/expressed/manually, lnLacL, wlLh a Lhree-
vessel cord aL (Llme). 1o enhance uLerlne conLracLlons, 20 unlLs of lv oxyLocln were
admlnlsLered. 1he cervlx, vaglna and perlneum were lnspecLed for laceraLlons. (uescrlbe any
laceraLlons LhaL were ldenLlfled.)
LS1lMA1Lu 8LCCu LCSS:

locetotloo tepolt.
1 lldocalne was ln[ecLed and Lhe laceraLlon was repalred uslng 2-0/3-0-
polygalacLln synLheLlc absorbable suLure (vlcryl) ln a runnlng non-locklng fashlon
Lo reapproxlmaLe Lhe laceraLlon ln layers. Cood hemosLasls was conflrmed.

ur. x was presenL and parLlclpaLed ln all/key porLlons of Lhe dellvery and repalr.

C1 CCDING
S9400 8ouLlne obsLeLrlc care lncludlng anLeparLum care, vaglnal dellvery (wlLh
or wlLhouL eplsloLomy, and/or forceps) and posLparLum care
S9610 8ouLlne obsLeLrlc care lncludlng anLeparLum care, vaglnal dellvery (wlLh
or wlLhouL eplsloLomy, and/or forceps) and posLparLum care, afLer prevlous
cesarean dellvery
S9409 vaglnal dellvery only (wlLh or wlLhouL eplsloLomy and/or forceps),
S9410 vaglnal dellvery only (wlLh or wlLhouL eplsloLomy and/or forceps),
lncludlng posLparLum care
S9612 vaglnal dellvery only, afLer prevlous cesarean dellvery (wlLh or wlLhouL
eplsloLomy and/or forceps),
S9614 vaglnal dellvery only, afLer prevlous cesarean dellvery (wlLh or wlLhouL
eplsloLomy and/or forceps), lncludlng posLparLum care

28 CL8A1lvL ulC1A1lCn: C8S1L18lCS & C?nLCCLCC?
&?<85869@<
CLSA8LAn

1. Cesarean SecLlon
2. Cesarean SecLlon wlLh 8llaLeral 1ubal LlgaLlon
3. Cesarean PysLerecLomy

&?<85869@<
29
CLSA8LAn SLC1lCn

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS:
SlngleLon (Lwln/LrlpleL) lnLrauLerlne pregnancy aL x weeks gesLaLlon (daLlng crlLerla)
(8eason for c-secLlon) l.e. prolonged repeLlLlve decels remoLe from dellvery/arresL
of dllaLlon/arresL of descenL/hlsLory of x prlor c-secLlons eLc.
CS1CL8A1lvL ulACnCSlS:
8CCLuu8L L8lC8MLu: rlmary/repeaL low Lransverse/classlcal/low verLlcal/lnverLed 1
cesarean secLlon

AnLS1PLSlA: Splnal/epldural/general endoLracheal anesLhesla
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: vlable male/female lnfanL dellvered aL (Llme) welghlng x g wlLh ACA8 scores of x
and x aL one and flve mlnuLes, respecLlvely. normal appearlng uLerus, ovarles, and falloplan
Lubes bllaLerally.
CCMLlCA1lCnS:
ulSCSl1lCn:

lnulCA1lCnS lC8 1PL 8CCLuu8L
PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx aL x weeks gesLaLlon by (daLlng crlLerla).
[ueLalled descrlpLlon of lndlcaLlons for procedure. lf Lhe lndlcaLlon for lnLervenLlon ls fallure Lo
progress, descrlbe Lhe flnal exam, Lhe duraLlon of arresL, Lhe conLracLlon paLLern, Lhe number
of unlLs of oxyLocln admlnlsLered, and Lhe feLal sLaLus. lf feLal hearL Lones are abnormal,
descrlbe Lhem, Lhe duraLlon of Lhelr deceleraLlon and Lhe correcLlve measures aLLempLed.]
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of the procedure. k|sks
|nc|uded, but were not ||m|ted to, b|eed|ng, |nfect|on, |n[ury to |nterna| organs, and poss|b|e
hysterectomy. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved. All quesLlons were
answered and Lhe paLlenL consenLed Lo Lhe procedure.

1he paLlenL was Laken Lo Lhe operaLlng room where a t|me out was performed Lo conflrm
correcL paLlenL and correcL procedure. Splnal / Lpldural / Ceneral anesLhesla was adequaLely
C1 CCDING
S9620 Cesarean dellvery only, followlng aLLempLed vaglnal dellvery afLer
prevlous cesarean dellvery,
S9622 Cesarean dellvery only, followlng aLLempLed vaglnal dellvery afLer
prevlous cesarean dellvery, lncludlng posLparLum care
S9S14 Cesarean dellvery only,
S9S1S Cesarean dellvery only, lncludlng posLparLum care
S9S10 8ouLlne obsLeLrlc care lncludlng anLeparLum care, cesarean dellvery,
and posLparLum care
S9618 8ouLlne obsLeLrlc care lncludlng anLeparLum care, cesarean dellvery,
and posLparLum care, followlng aLLempLed vaglnal dellvery afLer prevlous
cesarean dellvery

&?<85869@<
esLabllshed and prophy|act|c |ntravenous ant|b|ot|cs were admlnlsLered. 1he paLlenL was Lhen
placed ln Lhe dorsal suplne poslLlon wlLh a lefL LllL of Lhe hlps. ressure polnLs were padded
and a 8alr hugger was placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was
Lhen prepped and draped ln Lhe usual sLerlle fashlon for a fannensLell/verLlcal skln lnclslon.

CL8A1lvL 1LCPnlCuL: An lnclslon was made ln Lhe skln wlLh a surglcal scalpel and sharp
dlssecLlon was carrled ouL over subsequenL layers of Llssue lncludlng Lhe fascla, followed by
Lhe 8ovle elecLrocauLery for hemosLasls. 1he fascla was lnclsed aL mldllne and Lhe fasclal
lnclslon was exLended bllaLerally uslng Lhe curved Mayo sclssors.
1he superlor edge of Lhe fasclal lnclslon was grasped wlLh kocher clamps, LenLed up and Lhe
underlylng recLus muscles were dlssecLed off blunLly and sharply uslng Lhe curved Mayo
sclssors/scalpel/8ovle elecLrocauLery. ALLenLlon was Lhen Lurned Lo Lhe lnferlor edge, whlch
was grasped wlLh kocher clamps, LenLed up and Lhe underlylng recLus muscles were dlssecLed
off blunLly and sharply uslng Lhe curved Mayo sclssors/scalpel/8ovle elecLrocauLery.
1he recLus muscles were Lhen dlvlded aL mldllne and Lhe perlLoneum was ldenLlfled, LenLed up
wlLh hemosLaLs aL lLs upper margln Laklng care Lo avold Lhe bladder and Lhen enLered sharply
uslng Lhe scalpel (or Lhe perlLoneum was ldenLlfled and blunLly enLered aL lLs superlor margln
Laklng care Lo avold Lhe bladder). 1he perlLoneal lnclslon was exLended superlorly and
lnferlorly/laLerally uslng Lhe MeLzenbaum sclssors wlLh good vlsuallzaLlon of Lhe bladder. 1he
bladder blade was lnserLed and Lhe veslcouLerlne perlLoneum was ldenLlfled, grasped wlLh
8usslan forceps and cuL laLerally Lo boLh sldes uslng Lhe MeLzenbaum sclssors. A bladder flap
was Lhen creaLed uslng blunL and sharp dlssecLlon wlLh Lhe MeLzenbaum sclssors. 1he bladder
blade was relnserLed and a Lransverse lnclslon was made ln Lhe lower uLerlne segmenL uslng
Lhe scalpel. 1he uLerlne lnclslon was exLended bllaLerally uslng (bandage sclssors/blunL
dlssecLlon). 1he amnloLlc sac was enLered and Lhe amnloLlc fluld was noLed Lo be clear/sLalned
wlLh Lhln meconlum/Lhlck meconlum sLalned/bloody.
1he surgeon's hand was placed lnLo Lhe uLerlne cavlLy. 1he feLal head/posLerlor was ldenLlfled,
elevaLed lnLo Lhe abdomen and dellvered Lhrough Lhe uLerlne lnclslon wlLh Lhe asslsLance of
fundal pressure. 1he lnfanL was examlned for nuchal cord.
No oocbol cotJ wos lJeotlfleJ/A oocbol cotJ tlmes \ wos lJeotlfleJ ooJ teJoceJ.
1he lnfanL was Lhen dellvered wlLh LracLlon and Lhe asslsLance of fundal pressure. 1he lnfanL's
oral and nasal passages were bulb sucLloned. Cn dellvery Lhe cord was clamped and cuL. 1he
lnfanL was Lhen passed off Lhe Lable Lo Lhe pedlaLrlclans/8n for furLher care. Cord segmenL
and cord blood were obLalned for analysls and rouLlne blood LesLlng.
1be ploceoto JellveteJ spootooeoosly/wos exptesseJ/wos moooolly exttocteJ,
lotoct wltb o tbtee-vessel cotJ.
CxyLocln was admlnlsLered by lv lnfuslon Lo enhance uLerlne conLracLlon. 1he uLerus was
exLerlorlzed and cleared of all cloLs and remalnlng producLs of concepLlon. 1he uLerlne lnclslon
was reapproxlmaLed uslng 0-polygalacLln synLheLlc absorbable suLure (vlcryl) ln a runnlng
locked fashlon. A second horlzonLal/verLlcal embrlcaLlng sLlLch wlLh 0-polygalacLln synLheLlc
absorbable suLure (vlcryl) was applled. non-hemosLaLlc areas were relnforced uslng 0-
polygalacLln synLheLlc absorbable suLure (vlcryl) ln flgure of elghL sLlLches. Cood hemosLasls
was conflrmed. 1he uLerus was replaced lnLo Lhe abdomen and Lhe perlcollc guLLers were
cleared of all cloLs. (1he perlLoneum was reapproxlmaLed uslng runnlng, nonlocked 2-0-
polygalacLln synLheLlc absorbable suLure (vlcryl)). 1he fascla was reapproxlmaLed uslng 0-
polygalacLln synLheLlc absorbable suLure (vlcryl) ln a runnlng nonlocked fashlon. 1he skln was
reapproxlmaLed uslng 4-0-polygalacLln synLheLlc absorbable suLure (vlcryl) ln a runnlng
subcuLlcular sLlLch/uslng sLaples.
All needle, sponge, and lnsLrumenL counLs were noLed Lo be correcL x 2 aL Lhe end of Lhe
procedure. 1he paLlenL LoleraLed Lhe procedure well and was Lransferred Lo Lhe recovery room
ln sLable condlLlon. ur. x was presenL for all/key porLlons of Lhe procedure.

&?<85869@<
CL8CLACL

1. vaglnal Cerclage lacemenL
2. Cerclage 8emoval

&?<85869@<
39
vAClnAL CL8CLACL LACLMLn1

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS:
SlngleLon (Lwln/LrlpleL) lnLrauLerlne pregnancy aL x weeks gesLaLlon by (daLlng crlLerla)
PlsLory of cervlcal lncompeLence/advanced cervlcal dllaLlon x cm/shorL cervlx (x mm) on
Lransvaglnal ulLrasound (wlLh funnellng)
CS1CL8A1lvL ulACnCSlS: Same
8CCLuu8L L8lC8MLu: Mcuonald/modlfled Shlrodkar cerclage placemenL
AnLS1PLSlA: Splnal/general endoLracheal anesLhesla (CL1A)
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: x week slze uLerus wlLh conflrmed llve lnLrauLerlne pregnancy on ulLrasound. x cm
cervlcal dllaLlon. (8ulglng amnloLlc membranes).
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx aL x weeks gesLaLlon by (daLlng crlLerla)
wlLh a slngleLon (Lwln/LrlpleL) llve lnLrauLerlne pregnancy. 1he paLlenL has a hlsLory of: palnless
cervlcal dllaLlon wlLh dellverles aL x, ?, and Z weeks gesLaLlonal ages ln a prlor pregnancles/
shorL cervlx (x mm) wlLh/wlLhouL funnellng documenLed on Lransvaglnal ulLrasound/advanced
cervlcal dllaLlon Lo x cm wlLh/wlLhouL bulglng membranes on physlcal exam. [uescrlbe all prlor
pregnancy ouLcomes wlLh gesLaLlonal ages aL dellvery and lnformaLlon regardlng cerclage
placemenL ln prlor pregnancles.] [uescrlbe lnlLlal assessmenL of feLus lncludlng ulLrasound
assessmenL for feLal anaLomy, aneuploldy screenlng ln Lhe flrsL LrlmesLer, chorlonlc vlllus
sampllng/amnlocenLesls, eLc.] 1he paLlenL had screenlng for gonorrhea and Chlamydla, whlch
was negaLlve. 1ocomeLery demonsLraLed Lhe absence of conLracLlons conslsLenL wlLh labor.
|nc|uded, but were not ||m|ted to, rupture of membranes, preterm |abor and preterm
de||very a|| of wh|ch cou|d |ead to death of the fetus |n utero or fo||ow|ng premature
de||very. 1he pat|ent was a|so counse|ed on the materna| r|sks of b|eed|ng, |nfect|on, |n[ury
to the cerv|x, vag|na, b|adder, or surround|ng t|ssues. 1he paLlenL expressed undersLandlng of
Lhe rlsks lnvolved. All quesLlons were answered and Lhe paLlenL consenLed Lo Lhe procedure.

correcL paLlenL and correcL procedure. Splnal anesLhesla was placed and found Lo be
adequaLe/general anesLhesla was esLabllshed. 1he paLlenL was Lhen poslLloned on Lhe (bean
bag) operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups.
ressure polnLs were padded and a 8alr hugger/warm blankeL was placed Lo malnLaln conLrol
of core body LemperaLure. 1he perlneum was Lhen prepped and draped ln Lhe usual sLerlle
fashlon. A blmanual exam was performed and Lhe uLerus was noLed Lo be x week slze wlLh no
C1 CCDING
S9320 Cerclage of cervlx, durlng pregnancy, vaglnal

&?<85869@<
palpable masses. 1he cervlx was noLed Lo be x cm dllaLed wlLh x effacemenL. (A sLralghL
caLheLer was lnserLed lnLo Lhe bladder and x mL of clear yellow urlne was obLalned.)

CL8A1lvL 1LCPnlCuL: A welghLed/laLeral/blvalve speculum was lnserLed lnLo Lhe vaglna and
Lhe cervlx was vlsuallzed.

lf advanced cervlcal dllaLlon wlLh prolapslng of membranes: 1he membranes were noLed Lo
be prolapslng Lhrough Lhe cervlcal os. (lv nlLroglycerlne was admlnlsLered Lo effecL uLerlne
relaxaLlon.)
Membranes were reduced by placlng a 30 mL loley Lhrough Lhe cervlx and lnflaLlng
Lhe balloon Lo dlsplace Lhe membranes cephalad. 1he loley was gradually deflaLed
and removed as Lhe cerclage was LlghLened.
Membranes were reduced by placlng a loley caLheLer lnLo Lhe bladder and
dlsLendlng Lhe bladder wlLh x mL of normal sallne soluLlon soluLlon.

McDona|d cerc|age: 1he anLerlor llp of Lhe cervlx was vlsuallzed and grasped uslng rlng
forceps. A 3 mm Mersllene flber suLure/(nonabsorbable suLure) was used Lo Lake a blLe ln
Lhe body of Lhe cervlx aL Lhe 12 o'clock poslLlon as close as posslble Lo Lhe [uncLlon of Lhe
rugaLed vaglnal eplLhellum exlLlng aL Lhe x o'clock poslLlon. (8epeaL descrlpLlon of
successlve blLes ldenLlfylng Lhe locaLlon of each blLe.) 1he purse-sLrlng suLure was
LlghLened and Lled x Llmes (followed by an alr knoL Lo faclllLaLe fuLure removal). 1he knoL
was noLed Lo be aL Lhe x o'clock poslLlon.

Mod|f|ed Sh|rodkar cerc|age: 1he cervlx was grasped uslng rlng forceps and Lhe vaglnal
sldewall was reLracLed. A x cm horlzonLal lnclslon was made anLerlorly and posLerlorly aL
Lhe [uncLlon of Lhe rugaLed vaglnal eplLhellum and Lhe smooLh cervlx uslng a scalpel/8ovle
elecLrocauLery. 1he recLum was blunLly dlssecLed off Lhe cervlx uslng a flnger/sponge
sLlck/peanuL sponge and Lhe bladder was dlssecLed off Lhe anLerlor cervlx uslng a
flnger/sponge sLlck/peanuL sponge. 1he dlssecLlon was conLlnued unLll palpaLlon of Lhe
lnserLlon of Lhe uLerosacral and cardlnal llgamenLs aL Lhe level of Lhe lnLernal os was
posslble. PemosLasls was malnLalned uslng Lhe 8ovle elecLrocauLery. 1he laLeral edges of
Lhe anLerlor and posLerlor lnclslons were grasped uslng Allls clamps. A 33 mm Mersllene
flber suLure wlLh aLraumaLlc needles was used for Lhe cerclage. Cne needle was lnLroduced
anLerlorly aL Lhe laLeral edge of Lhe lnclslon and passed submucosally ad[acenL Lo Lhe
cervlcal sLroma and medlal Lo Lhe cervlcal branches of Lhe uLerlne vessels Lo emerge aL Lhe
laLeral edge of Lhe posLerlor lnclslon aL Lhe level of Lhe lnLernal os. 1he ldenLlcal procedure
was performed on Lhe conLralaLeral slde uslng Lhe oLher needle. (noLe: 1hls resulLs ln Lhe
knoL belng Lled posLerlorly. lf an anLerlor knoL ls deslred Lhe needles are passed from Lhe
posLerlor Lo Lhe anLerlor.) 1he needles were removed and Lhe cerclage was LlghLened and
Lled x Llmes. (1he cervlcal mucosa was reapproxlmaLed uslng 2-0/3-0 chromlc suLure ln a
runnlng, nonlocked fashlon.)

1he speculum was removed from Lhe vaglna and a blmanual exam was performed. 1he cervlx
was noLed Lo be closed/flnger Llp/x cm dllaLed wlLh Lhe cerclage knoL palpable aL Lhe x o'clock
poslLlon.

All needle, sponge, and lnsLrumenL counLs were noLed Lo be correcL x 2 aL Lhe compleLlon of
Lhe procedure. 1he paLlenL LoleraLed Lhe procedure well and was Lransferred Lo Lhe recovery
room ln sLable condlLlon. ur. x was presenL and parLlclpaLed ln all/key porLlons of Lhe
procedure.

&?<85869@<
43
AMnlCCLn1LSlS

1. ulLrasound-Culded 1ransabdomlnal AmnlocenLesls

1A;5@BCBDA

GNLCCLCG

!A<8565@8B>A 0 EAB>5@8B>A
47
nS1LkLC1CM]MCMLC1CM

l. Cpen
1. Abdomlnal Supracervlcal PysLerecLomy
2. 1oLal Abdomlnal PysLerecLomy
ll. vaglnal
1. vaglnal PysLerecLomy
lll. Laparoscoplc
1. Laparoscoplc Supracervlcal PysLerecLomy
2. Laparoscoplc 1oLal PysLerecLomy
3. Laparoscoplc-AsslsLed vaglnal PysLerecLomy
4. 8oboLlc-AsslsLed Laparoscoplc PysLerecLomy
lv. MyomecLomy
1. Abdomlnal MyomecLomy
2. 8oboLlc-AsslsLed Laparoscoplc MyomecLomy

!A<8565@8B>A 0 EAB>5@8B>A
37
LAA8CSCClC Su8ACL8vlCAL P?S1L8LC1CM?
(Wl1P 8lLA1L8AL SALlnCC-CCPC8LC1CM?)

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: (Age) year-old Cxxxxx wlLh uLerlne flbrolds/endomeLrlosls/
adenomyosls resulLlng ln: sympLomaLlc anemla, chronlc pelvlc paln, eLc.
8CCLuu8L L8lC8MLu: Laparoscoplc supracervlcal hysLerecLomy (wlLh bllaLeral salplngo-
oophorecLomy)
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: x cm slze anLeverLed/mldllne/reLroverLed uLerus wlLh (descrlpLlon of flbrolds and
any adheslons). uescrlbe Lhe adnexa/abnormallLles wlLhln Lhe uLerlne cavlLy/endomeLrlosls.
SLClMLnS: MorcellaLed uLerus (ovarles and falloplan Lubes bllaLerally)
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ______________ ls a (age) year old Cxxxxx wlLh a hlsLory of uLerlne
flbrolds/uLerlne prolapse/endomeLrlosls/eLc. 1he paLlenL aLLempLed medlcal managemenL
wlLh _______________ wlLhouL saLlsfacLory resoluLlon of sympLoms. ulLrasound flndlngs
demonsLraLed (slze and shape of uLerus and ovarles).
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a |aparoscop|c
supracerv|ca| hysterectomy (w|th b||atera| sa|p|ngo-oophorectomy). k|sks |nc|uded but were
not ||m|ted to b|eed|ng, |nfect|on, and |n[ury to surround|ng organs or t|ssues. 1he pat|ent
was counse|ed extens|ve|y that pregnancy fo||ow|ng hysterectomy |s not poss|b|e and the
pat|ent expressed comprehens|on of th|s. (1he pat|ent was counse|ed that b||atera|
oophorectomy resu|ts |n surg|ca| menopause for pre]per|menopausa| women.) 1he pat|ent
was counse|ed |n the poss|b|||ty of |aparotomy |f extens|ve adhes|ons or b|eed|ng were
encountered. (1he pat|ent was counse|ed that hysterectomy m|ght not resu|t |n reso|ut|on of
chron|c pe|v|c pa|n.) 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons
were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

correcL paLlenL and correcL procedure. 1he paLlenL was glven preoperat|ve prophy|act|c
|ntravenous ant|b|ot|cs. Ceneral anesLhesla was esLabllshed. 1he paLlenL was Lhen poslLloned
C1 CCDING:
S8S41 Laparoscopy, surglcal, supracervlcal hysLerecLomy, for uLerus 230 g or
less,
less, wlLh removal of Lube(s) and/or ovary(s)
S8S43 Laparoscopy, surglcal, supracervlcal hysLerecLomy, for uLerus greaLer
Lhan 230 g

1A;5@BCBDA
on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups.
All pressure polnLs were padded and a 8alr hugger was placed Lo malnLaln conLrol of core
body LemperaLure.

CL8A1lvL 1LCPnlCuL: 1he paLlenL was Lhen prepped and draped ln Lhe usual sLerlle fashlon.
A loley caLheLer was lnserLed lnLo Lhe bladder. A blmanual exam was Lhen performed and Lhe
uLerus was found Lo be anLeverLed/mldllne/reLroverLed, approxlmaLely x cm slze,
moblle/lmmoblle. 1here were no palpable adnexal masses. A welghLed/blvalve/laLeral
speculum was Lhen lnserLed lnLo Lhe vaglna. 1he anLerlor llp of Lhe cervlx was vlsuallzed and
grasped uslng a slngle-LooLh Lenaculum. A elosl/Puml/Pulka manlpulaLor was Lhen placed
Lhrough Lhe cervlx for uLerlne manlpulaLlon.

ALLenLlon was Lhen Lurned Lo Lhe abdomen, where a small verLlcal/horlzonLal lnclslon was
made lnfraumblllcal/approxlmaLely x cm superlor Lo Lhe umblllcus.

neumoper|toneum by Veress need|e: 1he veress needle was lnLroduced lnLo
Lhe perlLoneum. lacemenL of Lhe needle was conflrmed uslng normal sallne
soluLlon. neumoperlLoneum was Lhen esLabllshed wlLh approxlmaLely 3 llLers of
carbon dloxlde. 1he veress needle was removed.

A x mm Lrocar and sleeve were lnserLed Lhrough Lhe lnclslon lnLo Lhe perlLoneum.
Laparoscoplc vlsuallzaLlon conflrmed Lhe lnLraperlLoneal lnserLlon of Lhe porL. neumo-
perlLoneum was Lhen esLabllshed/malnLalned uslng carbon dloxlde.

SubsequenLly, Lwo addlLlonal small lnclslons were made, one approxlmaLely x cm Lo Lhe
rlghL/lefL aL (locaLlon of lnclslon) and anoLher Lo Lhe lefL/rlghL aL (locaLlon of lnclslon). 1wo
more porLs (x mm, xmm) were lnLroduced under dlrecL vlsuallzaLlon.

ulagnosLlc laparoscopy was Lhen performed. 1he llver was lnspecLed and noLed Lo appear
normal. 1here was no evldence of bowel, bladder, or vasculaLure ln[ury wlLh Lhe placemenL of
Lhe Lrocars. 1he uLerus was noLed Lo be approxlmaLely x cm slze. (uescrlbe any adheslons,
cysLs, flbrolds, or leslons conslsLenL wlLh endomeLrlosls.) (uescrlbe Lhe appearance of Lhe
ovarles and falloplan Lubes bllaLerally.)

ALLenLlon was Lhen dlrecLed Lo Lhe rlghL/lefL slde. 1he rlghL/lefL uLerlne fundus was grasped aL
Lhe level of Lhe falloplan Lube uslng a slngle-LooLh Lenaculum Lhrough Lhe lefL/rlghL porL. 1he
Cyrus/Parmonlc was Lhen used Lo coagulaLe and cuL Lhe round llgamenL. 1he Cyrus/Parmonlc
was Lhen used Lo coagulaLe and cuL Lhe falloplan and Lhe rlghL/lefL uLeroovarlan llgamenL. (If
sa|p|ngo-oophorectomy: 1he lefL/rlghL lnfundlbulopelvlc llgamenL was coagulaLed and cuL
uslng Lhe Cyrus/Parmonlc.) 1he Cyrus/Parmonlc was Lhen used Lo coagulaLe and cuL down
Lhe broad llgamenL Lo Lhe uLerlne arLery. Lyons/Parmonlc was Lhen used Lo coagulaLe Lhe
uLerlne arLery along Lhe rlghL/lefL. A bladder flap was Lhen creaLed and dlssecLed Lo Lhe
mldllne of Lhe uLerus aL Lhe level of Lhe lower uLerlne segmenL uslng Lhe Cyrus/Parmonlc and
pushed down.

1he lnsLrumenLs were Lhen swlLched ln Lhe porLs. 1he Cyrus/Parmonlc was Lhen used Lo
coagulaLe and cuL Lhe rlghL/lefL round llgamenL. 1he Cyrus/Parmonlc was Lhen used Lo
coagulaLe and cuL Lhe falloplan and Lhe rlghL/lefL uLeroovarlan llgamenL. (If sa|p|ngo-
oophorectomy: 1he lefL/rlghL lnfundlbulopelvlc llgamenL was coagulaLed and cuL uslng Lhe
Cyrus/Parmonlc.) 1he Cyrus/Parmonlc was Lhen used Lo coagulaLe and cuL down Lhe broad
llgamenL Lo Lhe uLerlne arLery. Lyons/Parmonlc was Lhen used Lo coagulaLe Lhe uLerlne arLery
along Lhe rlghL/lefL. A bladder flap was creaLed wlLh Lhe help of Lhe Cyrus/Parmonlc comlng
across Lhe uLerus Lo meeL Lhe lnclslon made on Lhe rlghL/lefL slde. 1he uLerus dld appear
compleLely blanched aL Lhls polnL and Lhe Cyrus/SpaLula/Parmonlc was used Lo lnclse Lhe

!A<8565@8B>A 0 EAB>5@8B>A
39
cervlx. 1he cervlx was Lhen cauLerlzed wlLh Lhe Lyons unLll Lhe effecLs of coagulaLlon were
noLed ln Lhe endocervlcal canal. 1he fleld was lrrlgaLed Lo ensure hemosLasls.

1he 13 mm morcellaLor was Lhen placed Lhrough Lhe rlghL/lefL porL, afLer removlng Lhe
laparoscoplc sleeve wlLh manlpulaLlon of Lhe uLerus from Lhe rlghL/lefL porL. 1he uLerus (and
ovarles and falloplan Lubes) was/were compleLely morcellaLed and removed Lhrough Lhe
rlghL/lefL porL. 1he pelvlc cavlLy was Lhen Lhoroughly lrrlgaLed. LxcellenL hemosLasls was
noLed. 1he Lndo SLlLch was used Lo reperlLoneallze Lhe surglcal fleld wlLh a conLlnuous sLlLch
of 2-0-polygalacLln synLheLlc absorbable suLure (vlcryl). Agaln, excellenL hemosLasls was
noLed. 1he morcellaLor was removed. 8oLh porL slLe lnclslons were closed uslng 0-polygalacLln
synLheLlc absorbable suLure (vlcryl) uslng an lnleL closure devlce. Agaln, excellenL hemosLasls
was noLed. 1hls was done under dlrecL vlsuallzaLlon wlLh Lhe laparoscope. 1he
pneumoperlLoneum was evacuaLed and Lhe x mm porL was removed from Lhe
supraumblllcal/subumblllcal reglon. 1he skln was Lhen reapproxlmaLed uslng uermabond. 1he
uLerlne manlpulaLor and Lhe slngle LooLh Lenaculum were removed from Lhe vaglna.

All needle, sponge, and lnsLrumenL counLs were noLed Lo be correcL x 2 aL Lhe end of Lhe
procedure. 1he paLlenL LoleraLed Lhe procedure well and was Laken Lo Lhe recovery room ln
sLable condlLlon. ur. x was presenL and parLlclpaLed ln all/key porLlons of Lhe procedure.

1A;5@BCBDA
LAA8CSCClC 1C1AL P?S1L8LC1CM?
(Wl1P 8lLA1L8AL SALlnCC-CCPL8LC1CM?)

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8CCLuu8L L8lC8MLu: Laparoscoplc asslsLed vaglnal hysLerecLomy

AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS: uLerus, cervlx (ovarles and falloplan Lubes)
CCMLlCA1lCnS:
ulSCSl1lCn:

flbrolds/uLerlne prolapse/eLc. 1he paLlenL aLLempLed medlcal managemenL wlLh
_______________ wlLhouL saLlsfacLory resoluLlon of sympLoms. ulLrasound flndlngs
demonsLraLed (slze and shape of uLerus and ovarles). 1he paLlenL was lnformed of Lhe rlsks
and beneflLs of a laparoscoplc asslsLed vaglnal hysLerecLomy.
SUkGICAL kISkS: 1he pat|ent was counse|ed the r|sks of the procedure |nc|uded, but were
not ||m|ted to, b|eed|ng, |nfect|on, |n[ury to surround|ng organs or t|ssues. 1he pat|ent was
counse|ed extens|ve|y that pregnancy |s not poss|b|e fo||ow|ng hysterectomy and pat|ent
expressed understand|ng of th|s. 1he pat|ent was counse|ed on poss|b|e |aparotomy |f
extens|ve adhes|ons or b|eed|ng were encountered. (1he pat|ent was counse|ed that
b||atera| oophorectomy resu|ts |n surg|ca| menopause for pre]per|menopausa| women.) 1he
paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons were answered, and Lhe
paLlenL consenLed Lo Lhe procedure.

C1 CCDING
S8S70 Laparoscopy, surglcal, wlLh LoLal hysLerecLomy, for uLerus 230 g or
less,
S8S71 Laparoscopy, surglcal, wlLh LoLal hysLerecLomy, for uLerus 230 g or
S8S72 Laparoscopy, surglcal, wlLh LoLal hysLerecLomy, for uLerus greaLer Lhan
230 g,
38373 Laparoscopy, surglcal, wlLh LoLal hysLerecLomy, for uLerus greaLer Lhan
230 g, wlLh removal of Lube(s) and/or ovary(s)

!A<8565@8B>A 0 EAB>5@8B>A
63
LAA8CSCClC-ASSlS1Lu vAClnAL P?S1L8LC1CM?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8CCLuu8L L8lC8MLu: Laparoscoplc asslsLed vaglnal hysLerecLomy
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS: uLerus, cervlx (ovarles and falloplan Lubes bllaLerally)
CCMLlCA1lCnS:
ulSCSl1lCn:

flbrolds/uLerlne prolapse/eLc. 1he paLlenL aLLempLed medlcal managemenL wlLh
_______________ wlLhouL saLlsfacLory resoluLlon of sympLoms. ulLrasound flndlngs
demonsLraLed (slze and shape of uLerus and ovarles). 1he paLlenL was lnformed of Lhe rlsks
and beneflLs of a laparoscoplc asslsLed vaglnal hysLerecLomy.
SUkGICAL kISkS: 1he pat|ent was counse|ed the r|sks of the procedure |nc|uded but were
not ||m|ted to b|eed|ng, |nfect|on, and |n[ury to surround|ng organs or t|ssues. 1he pat|ent
was counse|ed extens|ve|y that pregnancy |s not poss|b|e fo||ow|ng hysterectomy and
pat|ent expressed understand|ng of th|s. 1he pat|ent was counse|ed on poss|b|e |aparotomy
|f extens|ve adhes|ons or b|eed|ng were encountered. (1he pat|ent was counse|ed that
b||atera| oophorectomy resu|ts |n surg|ca| menopause for pre]per|menopausa| women.) 1he

C1 CCDING
S8SS0 Laparoscopy, surglcal, wlLh vaglnal hysLerecLomy, for uLerus 230 g or
less,
S8SS2 Laparoscopy, surglcal, wlLh vaglnal hysLerecLomy, for uLerus 230 g or
S8SS3 Laparoscopy, surglcal, wlLh vaglnal hysLerecLomy, for uLerus greaLer
Lhan 230 g
S8SS4 Laparoscopy, surglcal, wlLh vaglnal hysLerecLomy, for uLerus greaLer
Lhan 230 g, wlLh removal of Lube(s) and/or ovary(s)

1A;5@BCBDA
8C8C1lC ASSlS1Lu LAA8CSCClC P?S1L8LC1CM?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: (Age) year old Cxxxxx wlLh uLerlne flbrolds/endomeLrlosls/
8CCLuu8L L8lC8MLu: 8oboLlc asslsLed laparoscoplc supracervlcal/LoLal hysLerecLomy
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS: MorcellaLed uLerus (and cervlx, ovarles and falloplan Lubes)
CCMLlCA1lCnS:
ulSCSl1lCn:

flbrolds/uLerlne prolapse/pelvlc paln/known endomeLrlosls/eLc. 1he paLlenL aLLempLed
medlcal managemenL wlLh _______________ wlLhouL saLlsfacLory resoluLlon of sympLoms.
ulLrasound flndlngs demonsLraLed (slze and shape of uLerus and ovarles).
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a robot|c ass|sted
|aparoscop|c supracerv|ca|]tota| hysterectomy (w|th b||atera| sa|p|ngo-oophorectomy). k|sks
|nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, and |n[ury to surround|ng organs or
t|ssues. 1he pat|ent was counse|ed extens|ve|y pr|or to the procedure about the |nab|||ty to
become pregnant fo||ow|ng hysterectomy and the pat|ent expressed understand|ng of th|s.
(1he pat|ent was counse|ed that b||atera| oophorectomy resu|ts |n surg|ca| menopause for
C1 CCDING
less,
Lhan 230 g,
Lhan 230 g, wlLh removal of Lube(s) and/or ovary(s)
S8S70 Laparoscopy, surglcal, wlLh LoLal hysLerecLomy, for uLerus 230 g or less,
S8S71 Laparoscopy, surglcal, wlLh LoLal hysLerecLomy, for uLerus 230 g or less,
wlLh removal of Lube(s) and/or ovary(s)
230 g,
230 g, wlLh removal of Lube(s) and/or ovary(s)

!A<8565@8B>A 0 EAB>5@8B>A
69
A8uCMlnAL M?CMLC1CM?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: SympLomaLlc uLerlne flbrolds. luLure ferLlllLy ls deslred.
CS1CL8A1lvL ulACnCSlS: SympLomaLlc uLerlne flbrolds. luLure ferLlllLy ls deslred.
8CCLuu8L L8lC8MLu: Abdomlnal myomecLomy
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: x cm slze flbrold uLerus (descrlbe dlsLrlbuLlon of flbrolds). normal appearlng ovarles
bllaLerally. normal appearlng falloplan Lubes bllaLerally. (uescrlbe any evldence of adheslons
or evldence of endomeLrlosls.)
Speclmen: # of flbrolds
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ____________ ls a (age) year old Cxxxxx wlLh a hlsLory of heavy vaglnal
bleedlng resulLlng ln sympLomaLlc anemla/sponLaneous aborLlon aL x weeks/eLc. (uescrlbe
medlcal managemenL LhaL was aLLempLed and Lhe resulLs.)
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of an abdom|na|
myomectomy. 1he r|sks |nc|uded, but were not ||m|ted to, b|eed|ng, |nfect|on, |n[ury to
|nterna| organs, and |oss of fert|||ty. 1he pat|ent was counse|ed that when perform|ng a
myomectomy there |s r|sk that hysterectomy m|ght become necessary. 1he pat|ent
expressed understand|ng that |n the event a hysterectomy |s performed she w||| no |onger
be capab|e of carry|ng a pregnancy. All quesLlons were answered, Lhe paLlenL expressed
undersLandlng of Lhe rlsks lnvolved and consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was placed ln Lhe dorsal suplne poslLlon wlLh all pressure
polnLs padded and Lhen placed under general anesLhesla. A 8alr hugger was placed Lo
malnLaln conLrol of core body LemperaLure. 1he paLlenL was Lhen prepped and draped ln Lhe
usual sLerlle fashlon for a fannensLlel/verLlcal abdomlnal lnclslon. A perlneal and vaglnal prep
was performed as well and an lndwelllng loley caLheLer was lnserLed.

C1 CCDING
S8140 MyomecLomy, exclslon of flbrold Lumor(s) of uLerus, 1 Lo 4 lnLramural
myoma(s) wlLh LoLal welghL of 230 g or less and/or removal of surface
myomas, abdomlnal approach
S8146 MyomecLomy, exclslon of flbrold Lumor(s) of uLerus, 3 or more
lnLramural myomas and/or lnLramural myomas wlLh LoLal welghL greaLer Lhan
230 g, abdomlnal approach

!A<8565@8B>A 0 EAB>5@8B>A
71
8C8C1lC ASSlS1Lu LAA8CSCClC M?CMLC1CM?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: (Age) year old Cxxxxx wlLh uLerlne flbrolds resulLlng ln
sympLomaLlc anemla/chronlc pelvlc paln/menorrhagla/sponLaneous aborLlon aL x weeks eLc.
8CCLuu8L L8lC8MLu: 8oboLlc asslsLed laparoscoplc myomecLomy

AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: (x) week slze anLeverLed/mldllne/reLroverLed uLerus wlLh (descrlpLlon of flbrolds
and any adheslons). uescrlbe Lhe adnexa/abnormallLles wlLhln Lhe uLerlne
cavlLy/endomeLrlosls.
SLClMLnS: MorcellaLed flbrold
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ______________ ls a (age) year old Cxxxxx wlLh a hlsLory of uLerlne flbrolds
causlng pelvlc paln/menorrhagla/lnferLlllLy/eLc. 1he paLlenL aLLempLed medlcal managemenL
wlLh _______________ wlLhouL saLlsfacLory resoluLlon of sympLoms. ulLrasound flndlngs
demonsLraLed (slze and shape of uLerus and ovarles).
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a robot|c ass|sted
|aparoscop|c myomectomy. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, and
|n[ury to surround|ng organs or t|ssues. 1he pat|ent was counse|ed extens|ve|y pr|or to the
procedure about the r|sk of extens|ve b|eed|ng requ|r|ng hysterectomy and about the
|nab|||ty to become pregnant fo||ow|ng hysterectomy and the pat|ent expressed
understand|ng of th|s. 1he pat|ent was a|so counse|ed on poss|b|e |aparotomy |n the event
that extens|ve b|eed|ng or adhes|ons were encountered. 1he paLlenL expressed
undersLandlng of Lhe rlsks lnvolved wlLh Lhe procedure, all quesLlons were answered, and Lhe

correcL paLlenL and correcL procedure. 1he paLlenL was Lhen admlnlsLered preoperat|ve
prophy|act|c |ntravenous ant|b|ot|cs. 1he paLlenL was placed under general endoLracheal
anesLhesla. 1he paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy
poslLlon wlLh Lhe legs supporLed uslng sLlrrups. All pressure polnLs were padded and a 8alr
hugger was placed Lo malnLaln conLrol of core body LemperaLure. 1he abdomen and vaglna
were prepped and draped ln Lhe usual sLerlle fashlon.
C1 CCDING
S8S4S Laparoscopy, surglcal, myomecLomy, exclslon, 1 Lo 4 lnLramural
myomas wlLh LoLal welghL of 230 g or less and/or removal of surface myomas
S8S46 Laparoscopy, surglcal, myomecLomy, exclslon, 3 or more lnLramural
myomas and/or lnLramural myomas wlLh LoLal welghL greaLer Lhan 230 g

*8569C9F789B;

S1L8lLlZA1lCn

1. Laparoscoplc 8llaLeral 1ubal LlgaLlon
2. osL arLum 1ubal LlgaLlon
3. PysLeroscoplc 1ubal LlgaLlon
a. Lssure
b. Adlana

*8569C9F789B;
LAA8CSCClC 8lLA1L8AL 1u8AL LlCA1lCn

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: MulLlparlLy, famlly plannlng compleLe
CS1CL8A1lvL ulACnCSlS: MulLlparlLy, famlly plannlng compleLe
8CCLuu8L L8lC8MLu: Laparoscoplc bllaLeral Lubal llgaLlon (blpolar cauLery, monopolar
cauLery, fallope rlngs, fllshle cllps)
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: Appearance of exLernal genlLalla, appearance of vaglna, appearance of cervlx,
uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal masses, appearance
of abdomlnal/pelvlc organs on laparoscopy
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _________ ls a (age) year old Cxxxxx who has compleLed her famlly plannlng
and deslres a permanenL form of sLerlllzaLlon.
|nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vu|va, vag|na, or cerv|x,
and uter|ne perforat|on. 1he pat|ent was counse|ed on the r|sk of ster|||zat|on fa||ure be|ng
k on average. 1he pat|ent was |nformed that |n the event a pregnancy occurs, the r|sk of
ectop|c pregnancy |s |ncreased. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all
quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure. 1he paLlenL had valld
sLerlllzaLlon consenL aL Lhe Llme of Lhe procedure.

on Lhe (bean bag) operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed
uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger was placed Lo malnLaln
conLrol of core body LemperaLure. 1he paLlenL was Lhen prepped and draped ln Lhe usual
sLerlle fashlon. A blmanual exam was performed and Lhe uLerus was found Lo be
approxlmaLely x cm slze, anLeverLed/mldposlLlon/reLroverLed. A loley caLheLer was lnserLed.

CL8A1lvL 1LCPnlCuL: 1he welghLed speculum was Lhen lnserLed lnLo Lhe vaglna. 1he
anLerlor llp of Lhe cervlx was vlsuallzed and grasped uslng a slngle-LooLh Lenaculum. 1he cervlx
was dllaLed adequaLely for Lhe lnLroducLlon of Lhe uLerlne manlpulaLor uslng Lhe
raLL/Pegar/Pank dllaLors. 1he PuMl/Pulka uLerlne manlpulaLor was Lhen lnLroduced. 1he
C1 CCDING
S8670 Laparoscopy, surglcal, wlLh fulguraLlon of ovlducLs (wlLh or wlLhouL
LransacLlon)
S8671 Laparoscopy, surglcal, wlLh occluslon of ovlducLs by devlce (e.g., band,
cllp, or lalope rlng)

*8569C9F789B;
CS1 A81uM 1u8AL LlCA1lCn
(CML8C? 1LCPnlCuL)

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: MulLlparlLy, famlly plannlng compleLe
CS1CL8A1lvL ulACnCSlS: MulLlparlLy, famlly plannlng compleLe
8CCLuu8L L8lC8MLu: osL parLum bllaLeral Lubal llgaLlon

AnLS1PLSlA: Lpldural anesLhesla/splnal anesLhesla/CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: uLerus slze, adnexal masses, normal appearlng falloplan Lubes bllaLerally
SLClMLnS: orLlon of lefL and rlghL falloplan Lubes
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx who has compleLed her famlly plannlng
|nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, and |n[ury to |nterna| organs. 1he
pat|ent was counse|ed on the r|sk of ster|||zat|on fa||ure. 1he pat|ent was |nformed that |n
the event a pregnancy occurs the r|sk of ectop|c pregnancy |s |ncreased. 1he pat|ent was
counse|ed that b||atera| tuba| ||gat|on |s |ntended to be permanent and nonrevers|b|e. She
was a|so counse|ed that there are nonpermanent forms of b|rth contro| ava||ab|e to her. 1he
paLlenL consenLed Lo Lhe procedure. 1he paLlenL had valld sLerlllzaLlon consenL aL Lhe Llme of
Lhe procedure.

|ntravenous ant|b|ot|cs. Lpldural/splnal anesLhesla was admlnlsLered and found Lo be
adequaLe. lv sedaLlon was glven as needed for anxleLy. 1he paLlenL was Lhen placed ln Lhe
dorsal suplne poslLlon. All pressure polnLs were padded and a 8alr hugger/warm blankeL was
placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was Lhen prepped and
draped ln Lhe usual sLerlle fashlon. A loley caLheLer was lnserLed lnLo Lhe bladder.

CL8A1lvL 1LCPnlCuL: Cn palpaLlon Lhe posL parLum fundus was noLed Lo be flrm aL/x cm
below Lhe umblllcus. A x cm horlzonLal mlnllaparoLomy lnclslon was made ln Lhe skln [usL
lnferlor Lo Lhe umblllcus uslng Lhe scalpel and Lhe lnclslon was carrled Lhrough Lhe
subcuLaneous Llssue Lo Lhe level of Lhe fascla uslng Lhe 8ovle elecLrocauLery. 1he fascla was
Lhen lnclsed aL mldllne uslng Lhe scalpel/8ovle elecLrocauLery and Lhe fasclal lnclslon was
C1 CCDING
S860S LlgaLlon or LransecLlon of falloplan Lube(s), abdomlnal or vaglnal
approach, posLparLum, unllaLeral or bllaLeral, durlng same hosplLallzaLlon
(separaLe procedure)

*8569C9F789B;
P?S1L8CSCClC 1u8AL LlCA1lCn
LSSUkL

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: MulLlparlLy, famlly compleLed
CS1CL8A1lvL ulACnCSlS: MulLlparlLy, famlly compleLed
8CCLuu8L L8lC8MLu: PysLeroscoplc sLerlllzaLlon by Lssure

AnLS1PLSlA: lv sedaLlon/CL1A/paracervlcal block
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal masses
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx who has compleLed her famlly plannlng
and deslres and permanenL form of sLerlllzaLlon.
k on average. 1he pat|ent was |nformed that |n the event a pregnancy occurs, the r|sk of
ectop|c pregnancy |s |ncreased. 1he pat|ent was counse|ed on the need for an add|t|ona|
form of b|rth contro| for the three months fo||ow|ng the procedure and the need for a
hysterosa|p|ngogram three months post Lssure p|acement to conf|rm comp|ete tuba|
occ|us|on b||atera||y. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons
were answered, and Lhe paLlenL consenLed Lo Lhe procedure. 1he paLlenL had valld
sLerlllzaLlon consenL aL Lhe Llme of Lhe procedure.

correcL paLlenL and correcL procedure. 1he paLlenL was glven lv sedaLlon/general anesLhesla
was esLabllshed. 1he paLlenL was glven preoperat|ve prophy|act|c |ntravenous ant|b|ot|cs.
1he paLlenL was Lhen placed ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng
sLlrrups. All pressure polnLs were padded and a 8alr hugger was placed Lo malnLaln conLrol of
core body LemperaLure. 1he paLlenL was Lhen prepped and draped ln Lhe usual sLerlle fashlon.
A blmanual exam was performed and Lhe uLerus was found Lo be approxlmaLely x cm slze,
anLeverLed/mldposlLlon/reLroverLed. A sLralghL caLheLer was lnserLed lnLo Lhe bladder and x
mL of clear yellow urlne was obLalned.

CL8A1lvL 1LCPnlCuL: A welghLed/blvalve/laLeral speculum was lnserLed lnLo Lhe vaglna.
1he anLerlor llp of Lhe cervlx was vlsuallzed and grasped uslng a slngle-LooLh Lenaculum. 1he
C1 CCDING
S8S6S PysLeroscopy, surglcal, wlLh bllaLeral falloplan Lube cannulaLlon Lo
lnduce occluslon by placemenL of permanenL lmplanLs

*8569C9F789B;
P?S1L8CSCClC 1u8AL LlCA1lCn
ADIANA

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: MulLlparlLy, famlly compleLed
CS1CL8A1lvL ulACnCSlS: MulLlparlLy, famlly compleLed
8CCLuu8L L8lC8MLu: PysLeroscoplc sLerlllzaLlon by Adlana

AnLS1PLSlA: lv sedaLlon/CL1A/paracervlcal block
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _________ ls a (age) year old Cxxxxx who has compleLed her famlly plannlng
k on average. 1he pat|ent was |nformed that |n the event a pregnancy occurs the r|sk of
ectop|c pregnancy |s |ncreased. 1he pat|ent was counse|ed on the need for an add|t|ona|
form of b|rth contro| for the three months fo||ow|ng the procedure and the need for a
hysterosa|p|ngogram three months post Ad|ana p|acement to conf|rm comp|ete tuba|
occ|us|on b||atera||y. 1he pat|ent was counse|ed that b||atera| tuba| occ|us|on |s |ntended to
be permanent and nonrevers|b|e. She was a|so counse|ed that there are nonpermanent
forms of b|rth contro| ava||ab|e to her. 1he paLlenL expressed undersLandlng of Lhe rlsks
lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure. 1he
paLlenL had valld sLerlllzaLlon consenL aL Lhe Llme of Lhe procedure.

correcL paLlenL and correcL procedure. 1he paLlenL was glven lv sedaLlon/general anesLhesla
was esLabllshed. 1he paLlenL was glven preoperat|ve prophy|act|c |ntravenous ant|b|ot|cs. 1he
paLlenL was Lhen placed ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups.
body LemperaLure. 1he paLlenL was Lhen prepped and draped ln Lhe usual sLerlle fashlon. A
blmanual exam was performed and Lhe uLerus was found Lo be approxlmaLely x cm slze,
mL of urlne was obLalned.

C1 CCDING
S8S6S PysLeroscopy, surglcal, wlLh bllaLeral falloplan Lube cannulaLlon Lo
lnduce occluslon by placemenL of permanenL lmplanLs

G6BDA;5@BCBDA
u8CC?nLCCLCC?

1. osLerlor 8epalr
a. osLerlor Colporrhaphy
b. osLerlor 8epalr wlLh rollfL
2. Sllng
a. 1enslon lree 1aplng
b. 1ransobLuraLor 1aplng
c. 1v1 Secure
3. AnLerlor Colporrhaphy
4. Abdomlnal Sacral Colpopexy
3. 8ladder neck Suspenslon
a. 8urch Colposuspenslon
6. CysLoscopy

G6BDA;5@BCBDA
83
CS1L8lC8 CCLC88PAP?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: 8ecLocele
CS1CL8A1lvL ulACnCSlS: 8ecLocele
8CCLuu8L L8lC8MLu: osLerlor colporrhaphy (wlLh 8epllform grafL) (wlLh perlneorrhaphy)

AnLS1PLSlA: lv sedaLlon/CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: Appearance of exLernal genlLalla, appearance of vaglna (lncludlng presence of
recLocele and presence of cysLocele), appearance of cervlx, uLerus slze, anLeverLed/mld
poslLlon/reLroverLed, moblle/flxed, adnexal masses
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx wlLh complalnLs of dlfflculLy defecaLlng,
consLlpaLlon, and need for spllnLlng Lo defecaLe fully. Cn physlcal exam ln Lhe offlce, Lhe
paLlenL was noLed Lo have a recLocele.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a poster|or
co|porrhaphy (w|th kep||form graft) (w|th per|neorrhaphy). k|sks |nc|uded but were not
||m|ted to b|eed|ng, |nfect|on, |n[ury to the vag|na, rectum or recta| sph|ncter, and
|ncomp|ete reso|ut|on of symptoms. 1he paLlenL expressed undersLandlng of Lhe rlsks
lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was Lhen placed under general anesLhesla/lv sedaLlon.
1he paLlenL was Lhen placed ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng
sLlrrups. All pressure polnLs were padded and a 8alr hugger was placed Lo malnLaln conLrol of
core body LemperaLure. 1he paLlenL was prepped and draped ln Lhe usual sLerlle fashlon. A
sLralghL caLheLer was lnserLed and x mL of urlne was obLalned. A blmanual exam was
performed and Lhe uLerus was found Lo be x cm slze, anLeverLed/mldposlLlon/reLroverLed.
(uescrlbe uLerlne prolapse, presence of cysLocele, presence of recLocele, presence of
enLerocele, eLc.).

CL8A1lvL 1LCPnlCuL: x mL of hemosLaLlc soluLlon (le lldocalne wlLh eplnephrlne)/sallne
soluLlon was ln[ecLed submucosally for hydrodlssecLlon and malnLenance of hemosLasls. A
verLlcal lnclslon was made Lhrough Lhe perlneal skln and vaglnal mucosa. 1he skln was
C1 CCDING
S72S0 osLerlor colporrhaphy, repalr of recLocele wlLh or wlLhouL
perlneorrhaphy
4SS60 8epalr of recLocele (separaLe procedure)

G6BDA;5@BCBDA
87
CS1L8lC8 8LAl8 Wl1P 8CLll1 MLSP

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: 8ecLocele
CS1CL8A1lvL ulACnCSlS: 8ecLocele
8CCLuu8L L8lC8MLu: osLerlor repalr wlLh rollfL mesh

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx wlLh complalnLs of dlfflculLy defecaLlng,
consLlpaLlon, and need for spllnLlng Lo defecaLe fully. Cn physlcal exam ln Lhe offlce, Lhe
paLlenL was noLed Lo have a recLocele.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a poster|or repa|r
w|th ro||ft mesh. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the
vag|na, rectum or recta| sph|ncter, and |ncomp|ete reso|ut|on of symptoms. 1he paLlenL
expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL
consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was placed under general anesLhesla. 1he paLlenL was
Lhen placed ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups. All
pressure polnLs were padded and a 8alr hugger was placed Lo malnLaln conLrol of core body
LemperaLure. 1he paLlenL was prepped and draped ln Lhe usual sLerlle fashlon. A sLralghL
caLheLer was lnserLed and x mL of urlne was obLalned. A blmanual exam was performed and
Lhe uLerus was found Lo be x cm slze and anLeverLed/mldposlLlon/reLroverLed. (uescrlbe
uLerlne prolapse, presence of cysLocele, presence of recLocele, presence of enLerocele, eLc.).

CL8A1lvL 1LCPnlCuL: 1he recLovaglnal space was creaLed uslng vasopressln 40 mL ln 230
mL of normal sallne soluLlon. ApproxlmaLely 100 mL of Lhe soluLlon was ln[ecLed. 1hls was
done Lo malnLaln good hemosLasls and Lo esLabllsh a poLenLlal space. A 2 cm lnclslon was Lhen
performed lnLo Lhe posLerlor vaglnal wall verLlcally and Lhe recLovaglnal space was developed
C1 CCDING
S72S0 osLerlor colporrhaphy, repalr of recLocele wlLh or wlLhouL
perlneorrhaphy
4SS60 8epalr of recLocele (separaLe procedure)

G6BDA;5@BCBDA
89
1LnSlCn-l8LL vAClnAL 1AlnC

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: SLress urlnary lnconLlnence
CS1CL8A1lvL ulACnCSlS: SLress urlnary lnconLlnence
8CCLuu8L L8lC8MLu: 1enslon-free vaglnal Laplng

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ___________ ls a (age) year old Cxxxxx wlLh complalnLs of sLress urlnary
lnconLlnence. (1he paLlenL had a full bladder sLress LesL and demonsLraLed ureLhral
hypermoblllLy.) (1he paLlenL had urodynamlc LesLlng whlch showed ________________.)
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a tens|on-free
transvag|na| tap|ng. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the
vag|na, urethra, b|adder or |nterna| organs, mesh eros|on, ur|nary retent|on requ|r|ng
|nterm|ttent se|f-catheter|zat|on, new onset urge |ncont|nence, and |ncomp|ete reso|ut|on of
symptoms. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons were
answered, and Lhe paLlenL consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was Lhen placed under general anesLhesla and placed on
Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups. All
pressure polnLs were padded and a 8alr hugger was placed Lo malnLaln conLrol of core body
LemperaLure. 1he paLlenL was prepped and draped ln Lhe usual sLerlle fashlon. 1he bladder
was empLled uslng a sLralghL caLheLer and approxlmaLely x mL of urlne was obLalned. A
blmanual exam was Lhen performed and Lhe uLerus was found Lo be small/x cm slze,
anLeverLed/mldllne/reLroverLed. (CommenL on presence of cysLocele, recLocele, or
enLerocele.) A welghLed speculum was Lhen lnserLed lnLo Lhe vaglna. (uescrlbe cervlx and any
uLerlne prolapse.)

CL8A1lvL 1LCPnlCuL: ALLenLlon was Lhen Lurned Lo Lhe anLerlor porLlon of Lhe vaglna,
whlch was lnfllLraLed wlLh x mL of x vasopressln. A verLlcal lnclslon was made ln Lhe vaglnal
mucosa under Lhe mld-ureLhra sLarLlng approxlmaLely 1.3 cm from Lhe ureLhral meaLus and
conLlnulng proxlmally Loward Lhe cervlx. 1he MeLzenbaum sclssors were Lhen used Lo dlssecL
C1 CCDING
S7288 Sllng operaLlon for sLress lnconLlnence (e.g., fascla or synLheLlc)

G6BDA;5@BCBDA
91
18AnSC81u8A1C8 1AlnC (1C1)

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8CCLuu8L L8lC8MLu: 1ransobLuraLor Laplng
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

lnconLlnence. 1he paLlenL had urodynamlc LesLlng whlch showed ________________.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a transobturator
tap|ng. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vag|na,
urethra, b|adder or |nterna| organs, mesh eros|on, ur|nary retent|on requ|r|ng |nterm|ttent
se|f-catheter|zat|on, and |ncomp|ete reso|ut|on of symptoms. 1he paLlenL expressed
undersLandlng of Lhe rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed
Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was Lhen placed under general anesLhesla. 1he paLlenL
was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs
supporLed uslng (Lype) sLlrrups. All pressure polnLs were padded and a 8alr hugger was placed
Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was prepped and draped ln Lhe
usual sLerlle fashlon. 1he bladder was empLled uslng a sLralghL caLheLer and approxlmaLely x
mL of urlne was obLalned. A blmanual exam was Lhen performed and Lhe uLerus was found Lo
be small/x cm slze, anLeverLed/mldllne/reLroverLed. (CommenL on presence of cysLocele,
recLocele, or enLerocele.) A welghLed speculum was Lhen lnserLed lnLo Lhe vaglna. (uescrlbe
cervlx and any uLerlne prolapse.)

CL8A1lvL 1LCPnlCuL: A 2 cm mldllne verLlcal lnclslon was made 1.3 cm lnferlor Lo Lhe
ureLhral meaLus. MeLzenbaum sclssors were used Lo dlssecL Lhe vaglnal mucosa from Lhe
pubocervlcal fascla bllaLerally. 3 mm verLlcal lnclslons were Lhen made bllaLerally aL Lhe level
of Lhe cllLorls approxlmaLely 2 cm laLeral Lo laLeral edge of Lhe labla ma[ora uslng a scalpel. 1he
hellcal devlce was Lhen passed Lhrough Lhe skln and subcuLaneous Llssue and Lhrough Lhe
C1 CCDING

G6BDA;5@BCBDA
93
18AnSvAClnAL 1AlnC (1v1 SLCu8L)

uA1L Cl Su8CL8?:
8CCLuu8L L8lC8MLu: 1ransvaglnal Laplng (1v1 Secure)
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

lnconLlnence. 1he paLlenL had urodynamlc LesLlng whlch showed _____________. urlne
culLure was negaLlve for bacLerlurla.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a 1V1 Secure. k|sks
|nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vag|na, urethra, b|adder or
|nterna| organs, mesh eros|on, ur|nary retent|on resu|t|ng |n a need for |nterm|ttent se|f-
catheter|zat|on, and |ncomp|ete reso|ut|on of symptoms. 1he paLlenL expressed
Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was Lhen placed under general anesLhesla/lv sedaLlon.
1he paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh
Lhe legs supporLed uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger was
placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was prepped and draped ln
Lhe usual sLerlle fashlon. 1he bladder was empLled uslng a sLralghL caLheLer and approxlmaLely
x mL of urlne was obLalned. A blmanual exam was Lhen performed and Lhe uLerus was found
Lo be small/x cm slze, anLeverLed/mldllne/reLroverLed. (CommenL on presence of cysLocele,
recLocele or enLerocele.) A welghLed speculum was Lhen lnserLed lnLo Lhe vaglna. (uescrlbe
cervlx and any uLerlne prolapse.)

CL8A1lvL 1LCPnlCuL: 1he LoneSLar reLracLor was used Lo reLracL Lhe exLernal genlLalla. 1he
anLerlor vaglna was lnclsed uslng a scalpel aL mldllne approxlmaLely 1.3 cm from Lhe lnLrolLus.
1he lnclslon was 1 cm ln lengLh. 1he vaglnal mucosa was dlssecLed off Lhe pubocervlcal fascla
uslng Lhe MeLzenbaum sclssors. 1he Lransvaglnal Lape (1v1 Secure) lnserL was placed, securlng
Lhe sldes behlnd Lhe publc raml, wlLh care belng Laken Lo provlde Lhe approprlaLe amounL of
Lenslon as recommended by Lhe company. 1he lnserLlng devlces were Lhen removed.
C1 CCDING

G6BDA;5@BCBDA
93
An1L8lC8 CCLC88PAP?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: SLage x cysLocele
CS1CL8A1lvL ulACnCSlS: SLage x cysLocele
8CCLuu8L L8lC8MLu: AnLerlor colporrhaphy

AnLS1PLSlA: lv sedaLlon/splnal anesLhesla/CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
recLocele and presence of cysLocele), appearance of cervlx, descenL of cervlx, uLerus slze,
anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal masses
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _____________ ls a (age) year old Cxxxxx wlLh complalnLs of a vaglnal
proLruslon/dlfflculLy urlnaLlng. Cn physlcal exam ln Lhe offlce, Lhe paLlenL was noLed Lo have a
mldllne/laLeral anLerlor vaglnal defecL.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of an anter|or
co|porrhaphy. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, and |n[ury to the
vag|na, b|adder, or urethra, and |ncomp|ete reso|ut|on of symptoms. 1he paLlenL expressed
Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was Lhen placed under lv sedaLlon/splnal
anesLhesla/general anesLhesla. 1he paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe
dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups. All pressure polnLs were
padded and a 8alr hugger was placed Lo malnLaln conLrol of core body LemperaLure. 1he
paLlenL was prepped and draped ln Lhe usual sLerlle fashlon. A loley caLheLer was lnserLed. A
blmanual exam was performed and Lhe uLerus was found Lo be x cm slze,
anLeverLed/mldposlLlon/reLroverLed. (uescrlbe uLerlne prolapse, presence of cysLocele,
presence of recLocele, presence of enLerocele, eLc.). WlLh LracLlon, Lhe anLerlor vaglnal wall
was noLed Lo be x cm beyond Lhe hymen.

CL8A1lvL 1LCPnlCuL: A welghLed speculum was Lhen lnserLed lnLo Lhe vaglna and a surglcal
marklng pen was Lhen used Lo mark a mldllne verLlcal llne on Lhe anLerlor vaglna exLendlng
from 1 cm below Lhe posLerlor margln of Lhe ureLhral meaLus Loward Lhe vaglnal apex. (xml of
C1 CCDING
S7240 AnLerlor colporrhaphy, repalr of cysLocele wlLh or wlLhouL repalr of
ureLhrocele

G6BDA;5@BCBDA
97
A8uCMlnAL SAC8AL CCLCLx?

(1bls ptoceJote ls typlcolly petfotmeJ lo coojooctloo wltb otbet ptoceJotes. use
opptoptlote templote os loJlcoteJ.)
PlS1C8?: Ms. ______________ ls a (age) year old Cxxxxx wlLh a hlsLory of Crade x uLerlne
prolapse. (1he paLlenL aLLempLed managemenL wlLh a pessary wlLhouL saLlsfacLory resoluLlon
of sympLoms.)
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a sacra|
co|popexy. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to surround|ng
organs or t|ssues |nc|ud|ng the bowe| or b|adder, bowe| obstruct|on, mesh eros|on, or
dysparenur|a. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons were
answered, and Lhe paLlenL consenLed Lo Lhe procedure.

CL8A1lvL 1LCPnlCuL: Lnd-Lo-end anasLomosls slzers were placed lnLo Lhe vaglna and
recLum for manlpulaLlon of Lhe vaglnal apex. Whlle Lhe vaglna was elevaLed cephalad wlLh Lhe
LLA slzer, Lhe bladder was dlssecLed away from Lhe anLerlor wall of Lhe vaglna. 1he
perlLoneum over Lhe posLerlor vaglnal wall lnLo Lhe cul-de-sac was lnclsed longlLudlnally and
dlssecLed bllaLerally for several cenLlmeLers. 1he vaglnal apex was elevaLed bllaLerally wlLh
Allls clamps. olypropylene ?-shaped mesh was soaked ln baclLracln. 1he mesh was anchored
Lo Lhe anLerlor vaglnal wall uslng Lhree rows of lnLerrupLed 2-0 CorLex/uS wlLh Lhree sLlLches
per row. 1he posLerlor vaglnal arm of Lhe mesh was Lhen placed along Lhe posLerlor vaglnal
wall and excess mesh was Lrlmmed. 1he mesh was Lhen secured Lo Lhe posLerlor wall of Lhe
vaglna uslng Lwo rows of 2-0 CorLex/uS suLure ln lnLerrupLed sLlLches wlLh Lhree sLlLches per
row. 1he suLures were placed Lhrough Lhe full flbromuscular Lhlckness of Lhe vaglna Laklng
care noL Lo enLer Lhe vaglnal eplLhellum.

1he na|ban procedure was Lhen performed Lo obllLeraLe Lhe cul-de-sac. 0-
polygalacLln synLheLlc absorbable suLure (vlcryl) was placed saglLally beLween Lhe
uLerosacral llgamenLs ln a runnlng non-locklng fashlon lncorporaLlng Lhe deep
perlLoneum of Lhe cul-de-sac and Lhe posLerlor vaglnal wall.

1he Moschcow|tz procedure was Lhen performed Lo obllLeraLe Lhe cul-de-sac by
placlng 2-0 polypropylene suLure ln a purse-sLrlng suLure LhaL lncorporaLed Lhe
posLerlor vaglnal wall, Lhe rlghL pelvlc sldewall, Lhe serosa of Lhe slgmold, and Lhe
lefL pelvlc sldewall Lo obllLeraLe Lhe posLerlor cul-de-sac.

A verLlcal lnclslon approxlmaLely 4 cm long was Lhen made ln Lhe perlLoneum over Lhe sacral
promonLory Laklng care Lo avold Lhe aorLlc blfurcaLlon, Lhe common and lnLernal lllac vessels,
and Laklng care Lo ldenLlfy and avold Lhe rlghL ureLer. 1he bony sacral promonLory and anLerlor
longlLudlnal llgamenL were dlrecLly vlsuallzed and Lwo 2-0 CorLex suLures were placed Lhrough
Lhe anLerlor longlLudlnal llgamenL over Lhe sacral promonLory. 1he vaglna was Lhen elevaLed ln
a Lenslon-free manner and Lhe suLures from Lhe anLerlor longlLudlnal llgamenL were broughL
Lhrough Lhe mesh and Lled down flrmly Lo Lhe sacrum. 1he mesh was Lhen Lrlmmed Lo an
approprlaLe lengLh. 1he perlLoneum over Lhe presacral area was reapproxlmaLed uslng 0-
C1 CCDING
S7280 Colpopexy, abdomlnal approach
S742S Laparoscopy, surglcal, colpopexy (suspenslon of vaglnal apex)

G6BDA;5@BCBDA
99
8u8CP CCLCSuSLnSlCn

(1bls ptoceJote ls typlcolly petfotmeJ lo coojooctloo wltb otbet ptoceJotes. use
opptoptlote templote os loJlcoteJ.)

CL8A1lvL 1LCPnlCuL: 1he reLropublc space was enLered and Lhe ureLhra and anLerlor
vaglnal wall were depressed. 1he surgeon's nondomlnanL hand was lnserLed lnLo Lhe vaglna
and Lhe overlylng faL laLeral Lo Lhe ureLhra was dlssecLed away maklng vlsuallzaLlon of Lhe
perlureLhral fascla and vaglnal wall posslble. 2-0 CorLex/uS suLure was placed Lhrough Lhe
anLerlor vaglnal wall Laklng full Lhlckness of Lhe vaglnal wall excludlng Lhe vaglnal eplLhellum.
1here were Lwo suLures placed on each slde wlLh Lhe dlsLal suLure approxlmaLely 2 cm laLeral
Lo Lhe proxlmal Lhlrd of Lhe ureLhra and Lhe proxlmal suLure approxlmaLely 2 cm laLeral Lo Lhe
bladder aL Lhe level of Lhe ureLhroveslcal [uncLlon. 1he CorLex/uS suLures were Lhen placed
Lhrough Lhe pecLlneal llgamenL. 1he dlsLal suLures were Lhen Lled followed by Lhe proxlmal
suLures whlle Lhe vaglna was elevaLed by Lhe vaglnally placed flngers wlLh care Laken Lo avold
placlng excesslve Lenslon on Lhe vaglnal wall.
C1 CCDING
S1841 AnLerlor veslcoureLhropexy, or ureLhropexy (e.g., Marshall-MarcheLLl-
kranLz, 8urch), compllcaLed (e.g., secondary repalr)
31840 AnLerlor veslcoureLhropexy, or ureLhropexy (e.g., Marshall-MarcheLLl-
kranLz, 8urch), slmple

G6BDA;5@BCBDA
C?S1Cu8L1P8CSCC?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: SuspecLed lnLersLlLlal cysLlLls/suspecLed flsLula/eLc.
CS1CL8A1lvL ulACnCSlS: SuspecLed lnLersLlLlal cysLlLls/suspecLed flsLula/eLc.
8CCLuu8L L8lC8MLu: ulagnosLlc cysLoureLhroscopy
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: Appearance of exLernal genlLalla, appearance of vaglna, appearance of ureLhral
meaLus, appearance of bladder
SLClMLnS:
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ___________ ls a (age) year old Cxxxxx wlLh chronlc pelvlc paln/urlnary
lnconLlnence/eLc. 1he paLlenL had urodynamlc LesLlng LhaL showed ______________.
ConsequenLly, Lhe declslon was made Lo proceed Lo cysLoureLhroscopy ln order Lo assess for
________________ (reason why cysLo lndlcaLed).
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a d|agnost|c
cystourethroscopy. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, and |n[ury to
the urethra, b|adder, vu|va, vag|na, or surround|ng t|ssues. 1he paLlenL expressed
Lo Lhe procedure.

correcL paLlenL and correcL procedure. Ceneral anesLhesla/lv sedaLlon was admlnlsLered. 1he
paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe
legs supporLed uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger was placed Lo
malnLaln conLrol of core body LemperaLure. AfLer exam under anesLhesla, wlLh flndlngs as
noLed above, Lhe perlneum and vaglna were prepped and draped ln Lhe usual sLerlle fashlon. A
blmanual exam was performed and Lhe uLerus was noLed Lo be x week slze,
anLeverLed/mldposlLlon/ reLroverLed. (CommenL on Lhe presence of cysLocele, enLerocele or
recLocele.)

CL8A1lvL 1LCPnlCuL: 1he cysLoscope was Lhen lnLroduced, Lhe sheaLh removed, and Lhe
bladder dralned. 1hen, under dlrecL vlsuallzaLlon uslng normal sallne soluLlon dlsLendlng
C1 CCDING
S2000 CysLoureLhroscopy (separaLe procedure)
S2204 CysLoureLhroscopy, wlLh blopsy(s)
S2260 CysLoureLhroscopy, wlLh dllaLlon of bladder for lnLersLlLlal cysLlLls,
general or conducLlon (splnal) anesLhesla
S226S CysLoureLhroscopy, wlLh dllaLlon of bladder for lnLersLlLlal cysLlLls, local
anesLhesla

!A<856B<@B4A 7;H $9C789B; 7;H /=65887D5
P?S1L8CSCC? Anu ulLA1lCn Anu Cu8L11ACL

l. PysLeroscopy
a. PysLeroscopy u&C
b. LndomeLrlal AblaLlon
l. PydroLhermal AblaLlon
ll. novasure AblaLlon
c. PysLeroscoplc MyomecLomy
ll. ullaLlon and CureLLage
a. ullaLlon and CureLLage
b. SucLlon ullaLlon and CureLLage
c. ullaLlon and LvacuaLlon

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
103
P?S1L8CSCC? ulLA1lCn Anu Cu8L11ACL

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: osL menopausal bleedlng/dysfuncLlonal uLerlne bleedlng
/abnormal endomeLrlal llnlng on uS
CS1CL8A1lvL ulACnCSlS: osL menopausal bleedlng/dysfuncLlonal uLerlne bleedlng
/abnormal endomeLrlal llnlng on uS
8CCLuu8L L8lC8MLu: PysLeroscopy dllaLlon and cureLLage

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
Speclmen: LndomeLrlal cureLLlngs, endocervlcal cureLLlngs
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx wlLh posLmenopausal
bleedlng/dysfuncLlonal uLerlne bleedlng for xmonLhs. 1he paLlenL had an endomeLrlal blopsy
LhaL showed ___________. 1he paLlenL had an ulLrasound LhaL showed __________.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a hysteroscopy w|th
d||at|on and curettage. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to
the vu|va, vag|na, or cerv|x, and uter|ne perforat|on. 1he paLlenL expressed undersLandlng of
Lhe rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was glven lv sedaLlon/general anesLhesla was
esLabllshed. 1he paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy
hugger was placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was Lhen
prepped and draped ln Lhe usual sLerlle fashlon. A blmanual exam was performed and Lhe
uLerus was found Lo be approxlmaLely x cm slze, anLeverLed/mldposlLlon/reLroverLed.
(uescrlbe any palpable adnexal masses.) A sLralghL caLheLer was lnserLed lnLo Lhe bladder and
x mL of urlne was obLalned.

CL8A1lvL 1LCPnlCuL: 1he welghLed/blvalve/laLeral speculum was Lhen lnserLed lnLo Lhe
vaglna. 1he anLerlor llp of Lhe cervlx was vlsuallzed and grasped uslng a slngle-LooLh
Lenaculum. 1he cervlx was adequaLely dllaLed uslng raLL/Pegar/Pank dllaLors for Lhe
C1 CCDING
S8SS8 PysLeroscopy, surglcal, wlLh sampllng (blopsy) of endomeLrlum and/or
polypecLomy, wlLh or wlLhouL dllaLlon and curreLage
S8SSS PysLeroscopy, dlagnosLlc (separaLe procedure)

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
103
P?u8C1PL8MAL A8LA1lCn
CLC8AL LnuCML18lAL A8LA1lCn 8? P?u8C1PL8MAL LnuCML18lAL
A8LA1lCn

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: Menorrhagla
CS1CL8A1lvL ulACnCSlS: Menorrhagla
8CCLuu8L L8lC8MLu: PydroLhermal endomeLrlal ablaLlon
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal masses.
Speclmen: none
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ___________ ls a (age) year old Cxxxxx wlLh ovulaLory menorrhagla for x
monLhs. Medlcal managemenL for menorrhagla was aLLempLed wlLh ___________ wlLh
lnadequaLe resoluLlon of sympLoms. (1he paLlenL had an endomeLrlal blopsy LhaL showed
_______. 1he paLlenL had an ulLrasound LhaL showed __________.) 1he paLlenL was counseled
LhaL global endomeLrlal ablaLlon ls noL lndlcaLed lf she deslres conLlnued ferLlllLy. 1he paLlenL
expressed undersLandlng of Lhls and sLaLed LhaL her famlly plannlng ls compleLe and her
currenL form of conLracepLlon ls ___________.
and uter|ne perforat|on. 1he pat|ent was a|so |nformed of the r|sk that the hydrotherma|
endometr|a| ab|at|on may not resu|t |n fu|| reso|ut|on of symptoms. 1he paLlenL expressed
Lo Lhe procedure.

|ntravenous ant|b|ot|cs. Ceneral anesLhesla/lv sedaLlon was esLabllshed. 1he paLlenL was Lhen
poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed
sLerlle fashlon. A blmanual exam was performed and Lhe uLerus was found Lo be small/x cm
slze, anLeverLed/mldllne/reLroverLed, and moblle/lmmoblle. 1he adnexa were palpaLed
bllaLerally and Lhere were no palpable adnexal masses (lf mass ls palpable descrlbe
C1 CCDING
S8S63 PysLeroscopy, surglcal, wlLh endomeLrlal ablaLlon (e.g., endomeLrlal
resecLlon, elecLrosurglcal ablaLlon, LhermoablaLlon)

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
107
CLC8AL LnuCML18lAL A8LA1lCn 8? 8lCLA8 8AulCl8LCuLnC?
A8LA1lCn
(nCvASu8L LnuCML18lAL A8LA1lCn)

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: Menorrhagla
CS1CL8A1lvL ulACnCSlS: Menorrhagla
8CCLuu8L L8lC8MLu: novaSure endomeLrlal ablaLlon
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal masses. CavlLy depLh
and wldLh.
Speclmen: none
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _________ ls a (age) year old Cxxxxx wlLh ovulaLory menorrhagla for xmonLhs.
Medlcal managemenL for menorrhagla was aLLempLed wlLh ___________ buL was lnadequaLe
Lo resolve sympLoms. (1he paLlenL had an endomeLrlal blopsy LhaL showed _______. 1he
paLlenL had an ulLrasound LhaL showed __________.) 1he paLlenL was counseled LhaL global
endomeLrlal ablaLlon ls noL lndlcaLed lf she deslres conLlnued ferLlllLy. 1he paLlenL expressed
undersLandlng of Lhls and sLaLed LhaL her famlly plannlng ls compleLe and her currenL form of
blrLh conLrol ls ___________.
and uter|ne perforat|on. 1he pat|ent was a|so |nformed of the r|sk that the NovaSure
ab|at|on may not resu|t |n fu|| reso|ut|on of symptoms. 1he paLlenL expressed undersLandlng
of Lhe rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe
procedure.

uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger/warm blankeL was placed Lo
usual sLerlle fashlon. A blmanual exam was performed and Lhe uLerus was found Lo be small/x
cm slze, anLeverLed/mldllne/reLroverLed, and moblle/lmmoblle. 1he adnexa were palpaLed
C1 CCDING
S8S63 PysLeroscopy, surglcal, wlLh endomeLrlal ablaLlon (e.g., endomeLrlal
resecLlon, elecLrosurglcal ablaLlon, LhermoablaLlon)

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
109
P?S1L8CSCClC M?CMLC1CM?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: Menorrhagla secondary Lo a submucous myoma
CS1CL8A1lvL ulACnCSlS: Menorrhagla secondary Lo a submucous myoma
8CCLuu8L L8lC8MLu: PysLeroscoplc myomecLomy

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
Speclmen: Myoma Llssue
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx wlLh menorrhagla for x monLhs, whlch ls
llkely Lhe resulL of a submucous myoma dlagnosed on hysLeroscopy/ulLrasound/
hysLerosalplngogram/sallne lnfuslon sonohysLogram on (daLe). (uescrlbe any lnlLlal medlcal
managemenL such as Lhe admlnlsLraLlon of a gonadoLropln-releaslng hormone agonlsL.)
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a hysteroscop|c
myomectomy. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vu|va,
vag|na, or cerv|x, and uter|ne perforat|on. 1he paLlenL expressed undersLandlng of Lhe rlsks

uLSC8l1lCn Cl 8CCLuu8L
sLerlle fashlon. A blmanual exam was performed and Lhe uLerus was found Lo be small/x cm
slze, anLeverLed/mldllne/reLroverLed, and moblle/lmmoblle. 1he adnexa were palpaLed
bllaLerally and Lhere were no palpable adnexal masses (lf mass ls palpable descrlbe
approxlmaLe slze and moblllLy of mass). 1he bladder was empLled uslng a sLralghL caLheLer and
x mL of clear yellow urlne was obLalned.

CL8A1lvL 1LCPnlCuL: 1he welghLed/blvalve/laLeral speculum was Lhen lnserLed lnLo Lhe
vaglna. 1he anLerlor llp of Lhe cervlx was vlsuallzed and grasped uslng a slngle-LooLh
C1 CCDING
S8S61 PysLeroscopy, surglcal, wlLh removal of lelomyomaLa
S814S MyomecLomy, exclslon of flbrold Lumor(s) of uLerus, 1 Lo 4 lnLramural
myoma(s) wlLh LoLal welghL of 230 g or less and/or removal of surface
myomas, vaglnal approach

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
111
ulLA1lCn Anu Cu8L11ACL

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: osLmenopausal bleedlng/abnormal uLerlne bleedlng
CS1CL8A1lvL ulACnCSlS: osLmenopausal bleedlng/abnormal uLerlne bleedlng
8CCLuu8L L8lC8MLu: lracLlonal dllaLlon and cureLLage
AnLS1PLSlA: lv sedaLlon/local anesLhesla wlLh x lldocalne/marcalne
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
Speclmen: LndomeLrlal cureLLlng and endocervlcal cureLLlng
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx wlLh posLmenopausal bleedlng/
dysfuncLlonal uLerlne bleedlng for x monLhs. 1he paLlenL prevlously had an endomeLrlal blopsy
LhaL showed _______. Cn ulLrasound, Lhe endomeLrlal sLrlpe was noLed Lo be x mm.
and uter|ne perforat|on. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all
quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

correcL paLlenL and correcL procedure. 1he paLlenL was glven lv sedaLlon. When Lhe sedaLlon
was found Lo be adequaLe sLhe paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe
dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups. All pressure polnLs were
padded and a 8alr hugger was placed Lo malnLaln conLrol of core body LemperaLure. 1he
paLlenL was Lhen prepped and draped ln Lhe usual sLerlle fashlon. A blmanual exam was
performed and Lhe uLerus was found Lo be approxlmaLely x cm slze,
mL of clear yellow urlne was obLalned.

CL8A1lvL 1LCPnlCuL: A blvalve/laLeral/welghLed speculum was lnserLed lnLo Lhe vaglna and
Lhe cervlx was vlsuallzed and grasped uslng Lhe slngle LooLh Lenaculum. (Local anesLhesla wlLh
x lldocalne/marcalne was ln[ecLed x mL aL Lhe x o'clock poslLlons.) CenLle LracLlon was
applled Lo Lhe slngle LooLh Lenaculum and Lhe endocervlcal canal was cureLLed. Lndocervlcal
cureLLlngs were placed on a Lelfa and senL Lo paLhology. 1he uLerus was sounded and found Lo
be x cm. 1he cervlx was Lhen dllaLed adequaLely uslng Lhe raLL/Pank/Pegar dllaLors for Lhe
lnLroducLlon of Lhe sharp cureLLe. 1he cureLLe was advanced Lo Lhe fundus and Lhe uLerlne
cavlLy was cureLLed ln a sysLemaLlc manner wlLh care Laken Lo cover all surfaces. LndomeLrlal
cureLLlngs were placed on a Lelfa and senL Lo paLhology. 1he cureLLe was Lhen wlLhdrawn and
C1 CCDING
S8120 ullaLlon and cureLLage, dlagnosLlc and/or LherapeuLlc (nonobsLeLrlcal)

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
113
SuC1lCn ulLA1lCn Anu Cu8L11ACL

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: lnLrauLerlne pregnancy/lncompleLe aborLlon/8eLalned producLs of
concepLlon aL x weeks gesLaLlonal age
CS1CL8A1lvL ulACnCSlS: lnLrauLerlne pregnancy/lncompleLe aborLlon/reLalned producLs
of concepLlon aL x weeks gesLaLlonal age
8CCLuu8L L8lC8MLu: SucLlon dllaLlon and cureLLage

AnLS1PLSlA: lv sedaLlon/cervlcal block wlLh (marcalne/lldocalne)
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
dllaLlon of cervlx, uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal
masses
Speclmen: roducLs of concepLlon, endomeLrlal cureLLlngs
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _____________ ls a (age) year old Cxxxxx wlLh a x week gesLaLlonal age
lnLrauLerlne pregnancy wlLh a mlssed aborLlon/lncompleLe aborLlon/reLalned producLs of
concepLlon/for volunLary LermlnaLlon of pregnancy.
and uter|ne perforat|on. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all
quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was glven lv sedaLlon. When Lhe sedaLlon was found Lo
be adequaLe, Lhe paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy
uLerus was found Lo be approxlmaLely x week slze, anLeverLed/mldposlLlon/reLroverLed. 1he
cervlx was noLed Lo be x cm dllaLed. (uescrlbe any palpable adnexal masses.) A sLralghL
caLheLer was lnserLed lnLo Lhe bladder and x mL of clear yellow urlne was obLalned.
C1 CCDING
S9840 lnduced aborLlon, by dllaLlon and cureLLage
S9812 1reaLmenL of lncompleLe aborLlon, any LrlmesLer, compleLed surglcally
S9820 1reaLmenL of mlssed aborLlon, compleLed surglcally, flrsL LrlmesLer
S9821 1reaLmenL of mlssed aborLlon, compleLed surglcally, second LrlmesLer
S9830 1reaLmenL of sepLlc aborLlon, compleLed surglcally
S9870 uLerlne evacuaLlon and cureLLage for hydaLldlform mole

!A<856B<@B4A 7;H $9C789B; ";H /=65887D5
113
ulLA1lCn Anu LvACuA1lCn

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: lnLrauLerlne pregnancy/8CM/lulu aL x weeks gesLaLlonal age
CS1CL8A1lvL ulACnCSlS: lnLrauLerlne pregnancy/8CM/lulu aL x weeks gesLaLlonal age
8CCLuu8L L8lC8MLu: ullaLlon and evacuaLlon

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
dllaLlon of cervlx, uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal
masses
Speclmen: leLus and placenLa
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _____________ ls a (age) year old Cxxxxx wlLh a x week gesLaLlonal age
lnLrauLerlne pregnancy wlLh a known feLal anomaly lnconslsLenL wlLh survlval/prevlable
8CM/a deslre for volunLary LermlnaLlon of pregnancy. (ApproxlmaLely 24 hours prlor Lo Lhe
procedure Lhe paLlenL had x lamlnary osmoLlc dllaLors placed ln Lhe cervlx.)
and uter|ne perforat|on. 1he pat|ent was counse|ed on the potent|a| need for |aparoscopy or
|aparotomy |f uter|ne perforat|on were to occur. 1he paLlenL expressed undersLandlng of Lhe
rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was glven lv sedaLlon. When Lhe sedaLlon was found Lo
be adequaLe Lhe paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy
hugger/warm blankeL was placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL
was Lhen prepped and draped ln Lhe usual sLerlle fashlon. A blmanual exam was performed
and Lhe uLerus was found Lo be approxlmaLely x week slze, anLeverLed/mldposlLlon/
reLroverLed. 1he cervlx was noLed Lo be x cm dllaLed/conLaln lamlnary osmoLlc dllaLors. A
sLralghL caLheLer was lnserLed lnLo Lhe bladder and x mL of clear yellow urlne was obLalned.

C1 CCDING
S9841 lnduced aborLlon, by dllaLlon and evacuaLlon
S9821 1reaLmenL of mlssed aborLlon, compleLed surglcally, second LrlmesLer
S9830 1reaLmenL of sepLlc aborLlon, compleLed surglcally
S9870 uLerlne evacuaLlon and cureLLage for hydaLldlform mole

$97D;B<89@ 7;H &456789:5 37476B<@B4A
117
ulACnCS1lC Anu CL8A1lvL LAA8CSCC?

1. Laparoscopy
a. ulagnosLlc Laparoscopy
b. Laparoscoplc Cvarlan CysLecLomy
c. Laser AblaLlon of LndomeLrlosls
117

118

$97D;B<89@ 7;H &456789:5 37476B<@B4A
LAA8CSCC? lC8 SuSLC1Lu LC1ClC 8LCnAnC?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: SuspecLed lefL/rlghL ecLoplc pregnancy
CS1CL8A1lvL ulACnCSlS: Conflrmed lefL/rlghL ecLoplc pregnancy
8CCLuu8L L8lC8MLu: (ullaLlon and cureLLage) and dlagnosLlc laparoscopy wlLh lefL/rlghL
salplngecLomy/salplngosLomy
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
uLerus slze, anLeverLed/mld poslLlon/reLroverLed, moblle/flxed, adnexal masses. uescrlbe
appearance of uLerus, ovarles, and falloplan Lubes. uescrlbe adheslons (locaLlon, appearance).
uescrlbe presence or absence of hemoperlLoneum.
SLClMLn: LndomeLrlal cureLLlngs. LefL/rlghL falloplan Lube wlLh suspecLed producLs of
concepLlon.
CCMLlCA1lCnS:
ulSCSl1lCn:

lnulCA1lCnS lC8 8CCLuu8L
PlS1C8?: Ms. _______ ls a (age) year old Cxxxxx who presenLed Lo Lhe emergency
deparLmenL wlLh complalnLs of abdomlnal paln accompanled by scanL vaglnal bleedlng.
CuanLlLaLlve beLa PCC was performed and noLed Lo be x. Cn ulLrasound Lhe followlng flndlngs
were noLed: (lnLrauLerlne flndlngs, adnexal flndlngs, presence of feLal hearL Lones ln Lhe
adnexal, flndlngs of free fluld ln Lhe cul de sac). 1he paLlenL was noLed Lo be hemodynamlcally
sLable/unsLable (8, hearL raLe, hemoglobln). 1he paLlenL was found Lo be an lnapproprlaLe
candldaLe for medlcal managemenL due Lo hemodynamlc lnsLablllLy/presence of feLal hearL
Lones/Lhe paLlenL's lnablllLy Lo comply wlLh sLrlcL follow up/falled medlcal Lherapy/eLc.
|aparoscopy. 1he r|sks |nc|uded, but were not ||m|ted to, b|eed|ng, |nfect|on, |n[ury to
|nterna| organs, poss|b|e b|ood transfus|on, poss|b|e hysterectomy, and poss|b|e
oophorectomy. 1he pat|ent was counse|ed on the potent|a| |oss of fert|||ty fo||ow|ng
un||atera| sa|p|ngectomy. 1he pat|ent was counse|ed on poss|b|e |aparotomy and a|| other
|nd|cated procedures. 1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons
were answered, and Lhe paLlenL consenLed Lo Lhe procedure.

C1 CCDING
S91S1 Laparoscoplc LreaLmenL of ecLoplc pregnancy, wlLh salplngecLomy
and/or oophorecLomy
S91S0 Laparoscoplc LreaLmenL of ecLoplc pregnancy, wlLhouL salplngecLomy
and/or oophorecLomy
S8673 Laparoscopy, surglcal, wlLh salplngosLomy (salplngoneosLomy)

$97D;B<89@ 7;H &456789:5 37476B<@B4A
121

LAA8CSCClC CvA8lAn C?S1LC1CM?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: LefL/rlghL ovarlan cysL
CS1CL8A1lvL ulACnCSlS: LefL/rlghL ovarlan cysL
8CCLuu8L L8lC8MLu: Laparoscoplc ovarlan cysLecLomy
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
appearance of uLerus, ovarles and falloplan Lubes. uescrlbe adheslons and evldence of
endomeLrlosls (locaLlon, appearance). uescrlbe appearance of ovarlan cysL.
Speclmen: Cvarlan cysL
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _______ ls a (age) year old Cxxxxx who presenLed wlLh complalnLs of
abdomlnal paln/lncreaslng abdomlnal glrLh/lncldenLal flndlng of an ovarlan cysL. (uescrlbe
ulLrasound flndlngs regardlng cysL lncludlng locaLlon, slze, slmple/complex, presence of
sepLaLlons, presence of Lhlck/Lhln walls, eLc.). (uescrlbe any presurglcal managemenL lncludlng
cysL changes durlng observaLlon, medlcal managemenL aLLempLed [l.e. CC] and any Lumor
marker levels LhaL were assessed.)
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of a |aparoscop|c
ovar|an cystectomy. 1he r|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to
|nterna| organs, and poss|b|e oophorectomy. at|ent was counse|ed on the potent|a| |oss of
fert|||ty fo||ow|ng un||atera| oophorectomy. 1he pat|ent was counse|ed on a poss|b|e
|aparotomy and on the potent|a| need for hysterectomy and b||atera| sa|p|ngooophorectomy
w|th stag|ng |f ma||gnancy was found. 1he paLlenL expressed undersLandlng of Lhe rlsks

on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy poslLlon wlLh Lhe legs supporLed uslng sLlrrups.
body LemperaLure. 1he paLlenL was Lhen prepped and draped ln Lhe usual sLerlle fashlon. A
blmanual exam was performed and Lhe uLerus was found Lo be small/x cm slze,
C1 CCDING
49322 Laparoscopy, surglcal, wlLh asplraLlon of cavlLy or cysL (e.g., ovarlan
cysL) (slngle or mulLlple)
S8661 Laparoscopy, surglcal, wlLh removal of adnexal sLrucLures (parLlal or
LoLal oophorecLomy and/or salplngecLomy)

$97D;B<89@ 7;H &456789:5 37476B<@B4A
123

LASL8 A8LA1lCn Cl LnuCML18lCSlS

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: Cycllc chronlc pelvlc paln wlLh suspecLed endomeLrlosls
CS1CL8A1lvL ulACnCSlS: LndomeLrlosls
8CCLuu8L L8lC8MLu: ulagnosLlc laparoscopy and laser ablaLlon of endomeLrlosls
AnLS1PLSlA: CL1A
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
appearance of uLerus, ovarles, and falloplan Lubes. uescrlbe adheslons (locaLlon, appearance).
uescrlbe ovarlan cysLs lf presenL. uescrlbe appearance and locaLlons of leslons conslsLenL wlLh
endomeLrlosls lncludlng any ovarlan endomeLrlomas.
SLClMLn: 8lopsles lf appllcable.
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _______ ls a (age) year old Cxxxxx who gave a hlsLory of chronlc pelvlc paln,
cycllc ln naLure. 1he paLlenL aLLempLed medlcal managemenL wlLh (CC, depoleupron, eLc.)
wlLh resoluLlon/lmprovemenL/no change ln Lhe sympLoms. (ulagnosLlc sLudles lncludlng
ulLrasound resulLs and laboraLory resulLs.)
|aparoscopy and |aser ab|at|on. 1he r|sks |nc|uded but were not ||m|ted to b|eed|ng,
|nfect|on, and |n[ury to |nterna| organs. 1he pat|ent was counse|ed on the h|gh ||ke||hood of
recurrence |f endometr|os|s was |dent|f|ed and ab|ated. 1he paLlenL expressed undersLandlng
of Lhe rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL consenLed Lo Lhe
procedure.

|ntravenous ant|b|ot|cs. 1he paLlenL was glven lv sedaLlon/general anesLhesla was
esLabllshed. 1he paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy
C1 CCulnC
49320 Laparoscopy, abdomen, perlLoneum, and omenLum, dlagnosLlc, wlLh or
wlLhouL collecLlon of speclmen(s) by brushlng or washlng (separaLe
procedure)
49321 Laparoscopy, surglcal, wlLh blopsy (slngle or mulLlple)
38662 Laparoscopy, surglcal, wlLh fulguraLlon or exclslon of leslons of Lhe
ovary, pelvlc vlscera, or perlLoneal surface by any meLhod

&8I56 1A;5@BCBDA
123
C1PL8 C?nLCCLCC?

1. Cervlcal ConlzaLlon
a. (LLL) Loop LlecLrosurglcal Lxclslon
rocedure
b. Cold knlfe
2. MarsuplllzaLlon of 8arbolln CysL
3. erlneorrhaphy
4. Colpoclelsls

&8I56 1A;5@BCBDA
CL8vlCAL CCnlZA1lCn
LCC LLLC18CSu8ClCAL LxClSlCn 8CCLuu8L (LLL)/llSCPL8
CCnlZA1lCn

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: Cervlcal dysplasla (Cln x)
CS1CL8A1lvL ulACnCSlS: Cervlcal dysplasla (Cln x)
8CCLuu8L L8lC8MLu: Loop elecLrosurglcal exclslon procedure/llscher conlzaLlon

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
Speclmen: Cervlcal cone blopsy and endocervlcal cureLLlng
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ________ ls a (age) year old Cxxxxx wlLh mlld/severe cervlcal dysplasla
dlagnosed on apanlcolaou smear on (daLe) wlLh Cln x dlagnosed ln colposcopy on (daLe).
SUkGICAL kISkS: 1he pat|ent was |nformed of a|| of the r|sks and benef|ts of the Loop
e|ectrosurg|ca| exc|s|on procedure]I|scher con|zat|on. k|sks |nc|uded but were not ||m|ted to
b|eed|ng, |nfect|on, |n[ury to the vu|va, vag|na, or cerv|x, uter|ne perforat|on, or negat|ve
effects on future pregnancy outcomes. 1he paLlenL expressed undersLandlng of Lhe rlsks

correcL paLlenL and correcL procedure. lv sedaLlon was admlnlsLered and found Lo be
adequaLe. 1he paLlenL was Lhen poslLloned on Lhe operaLlng Lable ln Lhe dorsal llLhoLomy
hugger/warm blankeL was placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL
was Lhen prepped and draped ln Lhe usual sLerlle fashlon. A blmanual exam was performed
and Lhe uLerus was found Lo be small/x cm slze, anLeverLed/mldllne/reLroverLed, and
moblle/lmmoblle. 1he adnexa were palpaLed bllaLerally and Lhere were no palpable adnexal
masses (lf mass ls palpable descrlbe approxlmaLe slze and moblllLy of mass). 1he bladder was
empLled wlLh a sLralghL caLheLer and x mL of clear yellow urlne was obLalned.
C1 CCDING
S7S22 ConlzaLlon of cervlx, wlLh or wlLhouL fulguraLlon, wlLh or wlLhouL
dllaLlon and cureLLage, wlLh or wlLhouL repalr, loop elecLrode exclslon
S7460 Colposcopy of Lhe cervlx lncludlng upper/ad[acenL vaglna, wlLh loop
elecLrode blopsy(s) of Lhe cervlx
S7461 Colposcopy of Lhe cervlx lncludlng upper/ad[acenL vaglna, wlLh loop
elecLrode conlzaLlon of Lhe cervlx

&8I56 1A;5@BCBDA
CCLu knllL CCnlZA1lCn

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: Cervlcal dysplasla (Cln x)
CS1CL8A1lvL ulACnCSlS: Cervlcal dysplasla (Cln x)
8CCLuu8L L8lC8MLu: Cold knlfe cone

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
Speclmen: Cervlcal cone blopsy Lagged wlLh suLure aL 12 o'clock poslLlon, endocervlcal
cureLLlng
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. __________ ls a (age) year old Cxxxxx wlLh mlld/severe cervlcal dysplasla
dlagnosed on apanlcolaou smear on (daLe) wlLh Cln x dlagnosed ln colposcopy on (daLe).
|nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vu|va, vag|na, b|adder or
cerv|x, uter|ne perforat|on, or negat|ve effects on future pregnancy outcomes. 1he paLlenL
expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons were answered, and Lhe paLlenL
consenLed Lo Lhe procedure.

correcL paLlenL and correcL procedure. lv sedaLlon was esLabllshed and found Lo be adequaLe.
Lhe legs supporLed uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger/warm
blankeL was placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was Lhen
uLerus was found Lo be small/x cm slze, anLeverLed/mldllne/reLroverLed, and
masses (lf mass ls palpable descrlbe approxlmaLe slze and moblllLy of mass). A sLralghL
caLheLer was used Lo empLy Lhe bladder and x mL of clear yellow urlne was obLalned.

CL8A1lvL 1LCPnlCuL: A blvalve/laLeral/welghLed speculum was lnserLed lnLo Lhe vaglna and
Lhe cervlx was vlsuallzed. (Local anesLhesla wlLh x lldocalne/marcalne was ln[ecLed x mL aL
Lhe x o'clock poslLlons.) Lugol's lodlne was applled Lo Lhe cervlx and non-sLalnlng areas were
noLed aL (locaLlon). x mL of vasopressln/phenylephlne/eplnephrlne (concenLraLlon) was
ln[ecLed ln Lhe cervlx aL (locaLlons) ln order Lo lnduce vasoconsLrlcLlon and lmproved
C1 CCDING
S7S20 ConlzaLlon of cervlx, wlLh or wlLhouL fulguraLlon, wlLh or wlLhouL
dllaLlon and cureLLage, wlLh or wlLhouL repalr, cold knlfe or laser

&8I56 1A;5@BCBDA
MA8SulALlZA1lCn Cl 8A81PCLln C?S1

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: LefL/8lghL 8arLholln's gland cysL
CS1CL8A1lvL ulACnCSlS: LefL/8lghL 8arLholln's gland cysL
8CCLuu8L L8lC8MLu: MarsuplallzaLlon of 8arLholln's gland cysL
ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
llnulnCS: Appearance of exLernal genlLalla, appearance of vaglna, locaLlon and slze of
barLholln cysL
SLClMLn: CysL wall from Lhe 8arLholln's gland cysL
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. ____________ ls a (age) year old Cxxxxx wlLh a hlsLory of a lefL/rlghL
barLholln's gland cysL prevlously LreaLed wlLh placemenL of a Word caLheLer wlLh subsequenL
recurrence of Lhe cysL.
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of marsup|a||zat|on of a
8artho||n cyst. k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vu|va,
vag|na, or surround|ng t|ssues and]or recurrence of the cyst. 1he paLlenL expressed
Lo Lhe procedure.

correcL paLlenL and correcL procedure. lv sedaLlon was esLabllshed and found Lo be adequaLe.
Lhe legs supporLed uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger/warm
blankeLs was/were placed Lo malnLaln conLrol of core body LemperaLure. 1he paLlenL was Lhen
uLerus was found Lo be small/x cm slze, anLeverLed/mldllne/reLroverLed, and
masses (lf mass ls palpable descrlbe approxlmaLe slze and moblllLy of mass). 1he labla were
palpaLed bllaLerally (descrlbe locaLlon and slze of 8arLholln cysL, descrlbe any eryLhema or
lnduraLlon).

CL8A1lvL 1LCPnlCuL: A x cm verLlcal lnclslon was made aL Lhe [uncLlon beLween Lhe skln
and Lhe mucosa and Lhe cysL was parLlally dlssecLed off Lhe mucosa. A crescenL-shaped
porLlon of Lhe cysL wall was Lhen exclsed and senL Lo paLhology. Cn openlng, Lhe cysL was
noLed Lo conLaln muclnous, nonpurulenL, non-malodorous maLerlal. 1he cysL wall was Lhen
suLured Lo Lhe surroundlng mucosa uslng 2-0-polygalacLln synLheLlc absorbable suLure (vlcryl)
C1 CCDING
S6440 MarsuplallzaLlon of 8arLholln's gland cysL

&8I56 1A;5@BCBDA
L8lnLC88PAP?

uA1L Cl Su8CL8?:
Su8CLCn:
ASSlS1An1:
8LCL8A1lvL ulACnCSlS: uyspareunla secondary Lo scar formaLlon (from llchen sclerosus/
chemlcal burn/laser/elecLrosurgery/Lrauma/eLc.)/excesslvely LlghL eplsloLomy repalr/
aLrophy/eLc.
8CCLuu8L L8lC8MLu: erlneorrhaphy

ln18AvLnCuS lLuluS:
u8lnL Cu1u1:
SLClMLn: erlneal Llssue
CCMLlCA1lCnS:
ulSCSl1lCn:

PlS1C8?: Ms. _________ ls a (age) year old Cxxxxx wlLh dyspareunla secondary Lo
___________. (uescrlbe any lnlLlal medlcal managemenL LhaL was aLLempLed such as Loplcal
esLrogen for aLrophy and descrlbe Lhe paLlenL's response.)
SUkGICAL kISkS: 1he pat|ent was |nformed of the r|sks and benef|ts of the per|neorrhaphy.
k|sks |nc|uded but were not ||m|ted to b|eed|ng, |nfect|on, |n[ury to the vu|va, vag|na, or
rectum. 1he pat|ent was counse|ed that per|neorrhaphy may not fu||y re||eve dyspareun|a.
1he paLlenL expressed undersLandlng of Lhe rlsks lnvolved, all quesLlons were answered, and
Lhe paLlenL consenLed Lo Lhe procedure.

uslng sLlrrups. All pressure polnLs were padded and a 8alr hugger/warm blankeL was placed Lo
usual sLerlle fashlon. (uescrlbe any scarrlng of Lhe perlneum or narrowlng of Lhe lnLrolLus
noLed on lnspecLlon.) A blmanual exam was performed and lL was noLed LhaL one/Lwo flngers
could be lnserLed easlly lnLo Lhe vaglna. 1he uLerus was found Lo be small/x cm slze,
anLeverLed/mldllne/reLroverLed, and moblle/lmmoblle. 1he adnexa were palpaLed bllaLerally
and Lhere were no palpable adnexal masses (lf mass ls palpable descrlbe approxlmaLe slze and
moblllLy of mass). A sLralghL caLheLer was used Lo empLy Lhe bladder and x mL of clear yellow
urlne was obLalned.
C1 CCDING
S7210 Colpoperlneorrhaphy, suLure of ln[ury of vaglna and/or perlneum
(nonobsLeLrlcal)
S6810 erlneoplasLy, repalr of perlneum, nonobsLeLrlcal (separaLe procedure)

&8I56 1A;5@BCBDA
A88kLVIA1ICNS

AGAk - 1he ACA8 ls a scorlng sysLem used Lo assess newborn wellbelng lmmedlaLely
followlng dellvery. 1he scorlng sysLem was developed by ur. vlrglnla Apgar, and ls a Len polnL
scorlng sysLem based on flve crlLerla (Appearance, ulse, Crlmace, AcLlvlLy, 8esplraLlons). 1he
ACA8 score ls Lyplcally assessed aL one and flve mlnuLes wlLh conLlnued assessmenL every
flve mlnuLes lf Lhe flve mlnuLe score ls less Lhan 7.

CIN - Cervlcal lnLraeplLhellal neoplasla

Cysto - CysLoscopy

D&C - ullaLlon and CureLLage

L8L - LsLlmaLed 8lood Loss

Ieta| os|t|ons:
LCA]LC]C]kCA]kC]CA]LC1]kC1 - 1erms used Lo refer Lo Lhe poslLlon of Lhe feLal verLex
relaLlve Lo Lhe maLernal pelvls:
LCA - LefL CcclpuL AnLerlor
LC - LefL CcclpuL osLerlor
C - CcclpuL osLerlor
kCA - 8lghL CcclpuL AnLerlor
kC - 8lghL CcclpuL osLerlor
CA - CcclpuL AnLerlor
LC1 - LefL CcclpuL 1ransverse
kC1 - 8lghL CcclpuL 1ransverse

Gxxxxx - Cravlda/ara
Cravlda - number of pregnancles a woman has had lncludlng Lhe currenL
pregnancy lf Lhe woman ls pregnanL
ara - 1he ouLcome of a woman's pregnancy ls classlfled ln four caLegorles
1. number of Lerm dellverles (> 37 weeks gesLaLlonal age)
2. number of preLerm dellverles (20 weeks gesLaLlonal age Lo 36
6/7 weeks gesLaLlonal age)
3. number of LermlnaLlons and mlscarrlages (< 20 weeks
gesLaLlonal age)
4. number of llvlng chlldren

GL1A - Ceneral LndoLracheal AnesLhesla

n1A]n1LA - PydroLhermal LndomeLrlal AblaLlon

IM - lnLramuscular

IUID - lnLrauLerlne leLal uemlse

IU - lnLrauLerlne regnancy

IV - lnLravenous

&8I56 1A;5@BCBDA
137

LLL - Loop LlecLrosurglcal Lxclslon rocedure

CC - Cral ConLracepLlve llls

DS - olydloxanone SuLure

kCM - remaLure reLerm 8upLure of Membranes

kCM - remaLure 8upLure of Membranes

1C1 - 1ransobLuraLor 1aplng

1V1 - 1enslon-free vaglnal 1aplng

1V1 Secure - 1ransvaglnal 1aplng Secure

US - ulLrasound
1vuS - 1ransvaglnal ulLrasound
1AuS - 1ransabdomlnal ulLrasound

V1]VI - volunLary 1ermlnaLlon of regnancy/volunLary lnLerrupLlon of regnancy

Sample Operative Dictation OBGYN

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Sample Operative Dictation OBGYN

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