Code Following Preoperative Explained for Students (Easy Guide)

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code the following Preoperative Diagnoses: Enlarging fibroid uterus, symptomatic Postoperative Diagnoses: Enlarging fibroid uterus, symptomatic Procedures Performed: Exploratory laparotomy, Supracervical abdominal hysterectomy, bilateral salpingo-oophorectomy Specimens: Ovaries, fallopian tubes and uterus Description of Procedure: The patient was taken to the operating room and placed under general anesthesia. She was prepped and draped in the normal sterile fashion. A Foley was placed. Using her prior C-section incision, a Pfannenstiel skin incision was made and carried through the underlying layer of fascia. The rectus muscles were elevated and split in the midline. The peritoneum was identified, elevated, entered and stretched laterally. The uterus revealed the enlarged uterine fibroids consistent with her preoperative exam and ultrasound. The ovaries and fallopian tubes were normal and consistent with menopause. The round ligaments were ligated, cut and held. The ureters were identified bilaterally and protected. The ovarian pedicles were free tied and stitched for excellent hemostasis. The uterine arteries were skeletonized, clamped, transected and suture ligated. The cardinal ligament was clamped, transected and suture ligated. The patient identified the desire to retain her cervix. The cervix was amputated from the uterine specimen and the specimen was handed off the table. V-lock suture was used to oversew the cervix. The entire pelvic cavity was copiously irrigated and explored. The ureters were re-examined and were normal. The ovarian pedicles and cervical stump were dry. The peritoneum was closed with 3-0 Vicryl. The rectus muscles were brought together with a #1 interrupted and the skin was then closed in layers.

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