NAME: Chantelle Murphy-Brown
Date of Surgery: 6/24/202x
Surgeon: Sheila Jackson-Lewis, MD
Preoperative Dx: Undesired fertility, multiparity
Postop Dx: SAME
Operation: Laparoscopic bilateral tubal cauterization using Kleppingers
PROCEDURE: The patient was taken to the OR, was placed in the dorsal lithotomy position, and was
prepped and draped in a sterile manner. A speculum was inserted into the vagina and a single-tooth
tenaculum used to grasp the anterior lip of the cervix. A Hulka tenaculum was used to grasp the cervical
lip and manipulate the uterus. Once this was done, an infraumbilical incision was made with the knife
and a Veress needle inserted through the incision site. CO2 gas was instilled after saline via syringe was
checked for position. CO2 gas, approximately 2 L, was instilled into the abdominal cavity. Once this was
done, the Veress was removed, and a 5-mm trocar was inserted through the incision site. The
laparoscopic camera was then placed through the sleeve.
Under direct visualization and transillumination, after Trendelenburg position, a second incision site was
made with the knife suprapubically in the midline, and a 5-mm trocar was inserted through the incision
site. First, a blunt probe was used to identify the fallopian tubes. They were easily visible, so the
Kleppingers were then used to cauterize full thickness burns on each fallopian tube approximately five
to six adjacent times until good cautery was achieved; using the monitor. Once this was finished and
thought to be satisfactory, the instruments were removed. The CO2 gas was allowed to passively
escape. The incision sites were closed with 4-0 Vicryl in an interrupted manner. Approximately 10 cc
total of 1.25% Marcaine was injected subcutaneously for pain relief. The Hulka tenaculum was
removed, and a silver nitrate stick was used to cauterize one of the puncture sites on the cervix. This
was the end of the procedure. The patient tolerated it well and went to the recovery room in good
condition.
Assign the Surgical CPT Code(s) and modifier(s) if applicable _______________________________