Pre-op Diagnosis: Pelvic pain syndrome [R10.2]
Chronic salpingitis [N70.11]
Post-op Diagnosis: Same as Pre-op
Severe pelvic adhesions
Procedure(s): LAPAROSCOPIC LYSIS OF ADHESIONS – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers
CHROMOTUBATION TUBALPLASTY LAPAROSCOPIC – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers
Proc. Description(s) & CPT Code(s): LAPAROSCOPIC LYSIS OF ADHESIONS: CHROMOTUBATION TUBALPLASTY LAPAROSCOPIC
Anesthesia: General
Estimated Blood Loss: 20 mL
Quantitative Blood Loss: No data recorded
Total IV Fluids: 1000 mL
Specimens: No specimens
Implants: * No implants in log *
Complications: None
Findings: Severe pelvic adhesions, peritoneal pseudocyst adjacent to left ovary. Fallopian tubes with severe adhesions to bowel and posterior uterus. Fimbria not seen. Normal appearing ovaries. Bowel adhesions to posterior uterus and left fallopian tube.
Technique:
After the risks, benefits, indications, alternatives of the procedure were reviewed with the patient, informed consent was obtained. The patient was taken the operating room and placed under general anesthesia without difficulty. She was placed in Allen stirrups and prepped and draped in the normal sterile fashion. A Foley catheter was placed. Attention was then turned vaginally. A weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus was sounded to 8 cm. A Humi uterine manipulator was then placed through the cervix into the uterus and the balloon was inflated. Tubing was connected to the HUMI to use for chromopertubation later.
Attention was then turned to the abdomen. A 1 cm infraumbilical incision was made with a scalpel and dissected down to the underlying layer of fascia with a hemostat. The abdomen was tented up and a varies needle was inserted directly into the abdomen without difficulty. Intraperitoneal placement was confirmed with a saline-filled syringe. The abdomen was insufflated with CO2 gas. A 10 mm nonbladed trocar was then introduced at that site. Intraperitoneal placement was confirmed with the laparoscope. A 2nd 10 mm trocar was placed in the right lower quadrant under direct visualization without difficulty. A 5 mm trocar was then placed in the left lower quadrant without difficulty under direct visualization. The patient was placed in Trendelenburg. The uterine manipulator was used to mobilize the uterus. The uterus is very difficult to mobilize due to severe adhesions. There were severe adhesions along the posterior uterus to bowel, posterior cul-de-sac, ovaries, fallopian tubes. The severely limited uterine mobility. Both fallopian tubes were identified by the fimbriated end could not be seen as they were buried in the adhesions posterior to the uterus. Methylene blue mixed with saline was then injected through the uterine manipulator. Blue was visualized within both fallopian tubes but there was no spill. Fimbria were still not identified.
Patient has ultrasound indicated a possible right hydrosalpinx. Both fallopian tubes were slightly enlarged but neither appeared to be a significant hydrosalpinx could be responsible for the patient’s pelvic pain. Attention was then turned to the adhesions as this is the more likely cause of the patient’s pain. So the adhesions closest to the fundus of the uterus were addressed 1st. The LigaSure was carefully used close to the uterus to grasped cauterized and transect 15 separate adhesions along the posterior uterus. Dissection continued down the uterus towards the posterior cul-de-sac. As dissection continued, a fluid-filled structure was identified along the right posterior pelvis and mesh and adhesions. This was adjacent to the right ovary which was also behind the uterus. This was determined to be a peritoneal pseudocyst. This is likely the structure that looked like a hydrosalpinx on ultrasound. The cyst was carefully opened and clear yellow fluid was suctioned free. The remaining cyst wall was then elevated. Additional dissection was required to prevent the cyst from reaccumulating. There was a small opening in 2 the center of the cyst. The cyst wall was elevated by the assistant while a grasper was used to open the cyst wall completely. The remaining adhesions in this area were lysed to prevent cyst from forming again. Hemostasis of that area was noted. Attention was then turned to the bowel adhesions to the right posterior uterus. These were carefully taken down with blunt dissection. Cautery was avoided in this area. This allowed better assessment of the right fallopian tube. Additional dissection was done to separate the fallopian tube from surrounding structures. The tube was followed down to the posterior cul-de-sac. Fimbria were never identified. The end of the tube was not able to be seen. The end of the tube essentially disappeared into a collection of adhesion, bowel, pelvic sidewall. It was determined that additional dissection of the right fallopian tube would put patient at risk for a potential bowel injury or injury to ureter is ureters could not be seen due to the severe adhesions. At this point the majority of the adhesions on the right posterior uterus had been removed.
Attention was then turned back to the left side. They were copious bowel adhesions to the left fallopian tube. Some of these were taken down with blunt dissection. Additional sections of the tube were too densely adhered to bowel to be removed safely. The tube was followed down the posterior uterus deeper into the pelvis. Additional adhesions of the posterior uterus to the fallopian tube were identified and dissected free with sharp and blunt dissection. Hemostasis was noted. The left fallopian tube also had no visible fimbria. The end of the tube could not be seen. The tubal end disappeared into adhesion.
Saline tinted with methylene blue was was injected through the uterine manipulator again. No spill was seen from the fallopian tubes. Additional dissection of the fallopian tubes was not possible due to the other anatomy. Any additional dissection would not be likely to result in functional fallopian tubes. At that point all accessible adhesions had been removed. The posterior cul-de-sac was easily visualized and free of adhesions. This was a substantial improvement from the start of the case. The pelvis was copiously irrigated. All operative sites were inspected and noted to be hemostatic. Interceed was then placed in the posterior cul-de-sac adjacent to the right ovary to attempt to prevent future adhesion formation and future pseudocyst formation. All instruments and trocars were then removed and the abdomen was deflated. The fascia at the umbilical site was closed with a figure-of-eight suture of 0 Vicryl. The skin at all operative sites was closed with 4-0 Monocryl in a subcuticular stitch. Dermabond was placed as dressing. Attention was then turned vaginally. The uterine manipulator was removed. At that point the procedure was complete. The patient tolerated the procedure well. Sponge lap needle and instrument counts were correct x2. The patient was taken the recovery room awake and in stable condition.
CPT code 58350–Chromotubation of oviduct, including materials
ICD10 code : N70.11
R10.2