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Operative Report Preoperative DX: 1. First trimester missed abortion: 2 Undesired fertility Postoperative DX: Same Operation: 1. Dilation and curettage with suction 2. Laparoscopic bilateral tubal ligation using Kleppinger bipolar cautery Surgeon: Oscar R. Prader, MD Assistant: None Anesthesia: General endotracheal anesthesia Findings: Pt had products of conception at the time of citation and curetage. She also had normal appearing uterus, cvartes, fallopian tubes, and liver edge Specimens: Products of conception to pathology Disposition: To PACU in stable condition Procedure: The patient was taken to the operating room, and she was placed in the dorsal supine position General endotracheal anesthesia was administered without difficulty. The patient was placed in dorsal thotomy position. She was prepped and droped in the normal sterile fashion A red rubber tip catheter was placed gently to drain the patient’s bladder. A welghted speculum was placed In the posterior vagina and Deaver retractor anteriorly. A single tooth tenaculum was placed in the anterior cervix for retraction. The uterus sounded to 9 cm. The cervix was dilated with Hanks ditators to 25 French This sufficiently passed a #7 suction curet. The Suction curet was inserted without incident, and the products of conception were gently suctioned out Good uterine cry was noted with a serrated curet. No further products were noted on suctioning. At this pointHulka tenaculum was placed in the cervix for retraction. The other instruments were removed Attention was then turned to the patient’s abdomen. A smoll vertical intraumbilical incision was made with the knife. A Veress needle was placed through that incision. Confirmation of placement into the abdominal cavity was made with instillation of normal saline without retum and a positive handing drop test. The abdomen was then insutilated with sufficient carbon dioxide gas to cause abdominal tympany. The Veress needle was removed and a 5-mm trocar was placed in the same incision. Confirmation of placement into the abdominal cavity was made with placement of the laparoscopic camera. Another trocar site was placed two fingerbreadths obove the pubic symphysis in the midline under direct visualization. The above noted intrapelvic and intraabdominal findings were seen. The patient was placed in steep trendelenburg. The follopron tubes were identified and followed out to the fimbrated ends They were then cauterized four times on either side. At this point all instruments were removed from the patient’s abdomen This was done under direct visualization during the Insulation. The skin incisions were reapproximated with 4-0 Vicryl suture. The Hulka tenaculum was removed without incident Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code/s) and external cause code(s) If appropriate. Remember, check the chapter specific sub chapter specific and category specific notations within the Tabular list
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