Reference no: EM133242572

PREOPERATIVE DIAGNOSIS: Enlarging fibroid uterus, symptomatic

POSTOPERATIVE DIAGNOSIS: 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 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 17specimen 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 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.

Question 1: The surgeon identified one of the specimens as the "uterus." In this procedure, did the surgeon mean only the uterus, or the uterus and cervix? Which documentation supports your answer?

Question 2: What code(s) should be assigned