OPERATIVE REPORT: Total laparoscopic hysterectomy using daVinci
®
robotic equipment.
The abdomen and vagina were prepped and draped in the normal sterile fashion. A Foley catheter was inserted.
A long weighted speculum was placed into the vagina, and an anterior wall retractor was placed into the vagina.
The cervix was grasped with a single-tooth tenaculum and the uterus was sounded to 7.5 cm and was anterior.
The balloon manipulator was then properly placed. The balloon was filled to approximately 3 cc of saline. The
cervical cup was placed around the cervix. A sterile glove filled with a lap pad was then placed inside the
vagina to help with pneumoperitoneum. An 11 mm port was placed in the left upper quadrant just under the
inferior costal margin. Adequate pneumoperitoneum was obtained. A 12 mm port was placed supraumbilically
and the 12 mm trocar was placed through that port. The daVinci camera was then placed supraumbilically.
Three more ports were then placed. The 11 mm port was then placed in the left upper quadrant, and there were
two 8 mm ports that were placed 10 cm laterally to the umbilicus and 2 cm inferiorly. The daVinci robot was
then docked in the normal fashion. The patient was placed in steep Trendelenburg positioning.
Inspection of the pelvis showed a normal uterus, ovaries, and tubes. The right fallopian tube was cauterized
using the PK bipolar cautery and was ligated using the hot shears. The utero-ovarian ligament was also
coagulated and cut. The round ligament was coagulated and cut. A bladder flap was created with the hot shears
and the bladder was dissected down from the cervix.
This entire procedure was then repeated on the left side. The blue balloon cuff was then identified and an
incision was made in the cervicovaginal junction on top of the vaginal cuff. This was also repeated posteriorly.
The incision was extended laterally, freeing the uterus from the surrounding vagina. The uterus was then
delivered posteriorly through the vagina using the robotic assistant. The vaginal cuff was closed with four
figure-of-eight sutures of 0 Vicryl. The ureters were identified bilaterally. The entire pelvis was hemostatic. The
supraumbilical site was closed with a suture of 0 Vicryl. The skin was closed with 4-0 Monocryl using
subcuticular stitches. Steri-Strips were placed. The final needle, sponge, and instrument count was correct. The
patient tolerated the procedure well. Patient to the recovery room in good condition.
Coding this scenario
Report the following codes for this procedure:
• 68.41 (laparoscopic total abdominal hysterectomy)
• 17.42 (laparoscopic robotic assisted procedure)
Final diagnosis: Uterine carcinoma (malignant) with pelvic pain
Report the following codes:
• 179 (malignant neoplasm of uterus, part unspecified)
• 625.9 (unspecified symptom associated with female genital organs)