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Unlisted laparoscopy procedure, uterus

CPT4 code

Name of the Procedure:

Unlisted laparoscopy procedure, uterus

Summary

This procedure refers to any laparoscopic surgery involving the uterus that does not fall under a specific, established medical category. It uses small incisions and a camera to guide surgical tools for minimally invasive treatment.

Purpose

This procedure addresses various uterine conditions that may not be specifically classified but require surgical intervention. The goal is to diagnose and/or treat uterine problems while minimizing recovery time, pain, and scarring.

Indications

  • Unexplained pelvic pain
  • Abnormal bleeding
  • Uterine adhesions or scar tissue
  • Evaluation of endometriosis or fibroids
  • Uterine anomalies

Preparation

  • Patients are often instructed to fast for at least 8 hours before the procedure.
  • Pre-procedure assessments may include blood tests, imaging studies (ultrasounds or MRIs), and a detailed medical history.
  • Medication adjustments may be required, particularly blood thinners.

Procedure Description

  1. The patient is placed under general anesthesia.
  2. Small incisions are made in the abdomen.
  3. A laparoscope (a thin tube with a camera) is inserted to provide a visual of the uterus.
  4. Additional instruments are introduced through other small incisions as needed to perform the surgery.
  5. The surgeon may remove tissue samples, correct abnormalities, or treat conditions such as adhesions.
  6. The instruments are removed, and the incisions are closed with sutures or surgical glue.

Duration

The procedure typically takes 1 to 3 hours, depending on its complexity.

Setting

Performed in a hospital operating room or an outpatient surgical center.

Personnel

  • Surgeons specialized in gynecology or laparoscopic surgery
  • Anesthesiologists
  • Surgical nurses
  • Operating room technicians

Risks and Complications

  • Infection
  • Bleeding
  • Injury to surrounding organs such as the bowel or bladder
  • Anesthesia-related complications
  • Rare risks include deep vein thrombosis or allergic reactions

Benefits

  • Reduced recovery time compared to open surgery
  • Minimal scarring
  • Reduced postoperative pain
  • Shorter hospital stay
  • Quicker return to daily activities

Recovery

  • Monitoring in a recovery room until the effects of anesthesia wear off.
  • Pain management with prescribed medications.
  • Instructions on wound care and activity restrictions.
  • Follow-up appointments to monitor healing and address any complications.
  • Most patients can resume normal activities within 1 to 2 weeks.

Alternatives

  • Open abdominal surgery (laparotomy): involves larger incisions and longer recovery.
  • Medical management: using medications for symptom control, though it may be less effective for certain conditions.
  • Hysteroscopy: a less invasive option for some intrauterine issues but may not be suitable for those requiring extensive evaluation or treatment.

Patient Experience

Patients typically experience minimal pain during the procedure due to general anesthesia. Postoperative pain can be managed with medication. Some discomfort, such as bloating and mild cramping, is common and should subside within a few days to a week.

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