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CPC sample question # 15

Indications: Endometrial carcinoma.

Findings: At the time of entrance into the operating room, the abdomen had been previously opened. The right infundibulopelvic ligament was in the process of being skeletonized; the left was already clamped, cut, and ligated with chromic suture. The right ureter was identified, as was the left. No apparent injury was noted. The patient received Indigo Carmine intraoperatively; there was no spillage of dye. The uterus was about 8 week’s size. The tubes and ovaries appeared normal. There were dense adhesion of the colon to the rectovaginal spectrum.

Procedure: After successful anesthetic induction and prepping of the abdominal wall with Betadine solution, the patient was draped in a sterile manner and a midline incision was made. The left adnexa was taken by skeletonizing the infundibulopelvic ligament. An attempt to skeletonize the right ureter was hampered by the patient’s obesity. After a 45 minute attempt, skeletonization of the right ureter was accomplished then doubly clamped, cut, and ligated x2 with 0-silk suture the right infundibulopelvic ligament. The vesicouterine flod and rectovaginal fold were taken down with sharp dissection. The uterine vessels were taken bilaterally with Heaney clamps, cut, and ligated with 0 chromic sutures. Successive pedicles of the cardinal ligaments and uterosacral ligaments were taken with clamps and each pedicle was cut and ligated with 0 chromic suture. The angle of the vagina was taken in a similar fashion. The specimen was released and handed off the field. The cuff was then run using a 0 chromic suture in a running locking fashion. A drain was then placed. The pelvis was inspected and noted to be hemostatic, Bleeding points were taken with electrocoagulation.

The patient was markedly obese. It was difficult to identify the ureter near the bladder on the right and left side; however, at the level of the uterine vessels they were identified and there was no spillage of blue dye within the abdominal cavity. At this point, given the patient’s obesity, it was elected to conclude the procedure. Washing have been preciously obtained. An omental biopsy was also obtained. The abdomen was closed using an 0 PDS suture in a Smead-Jones fashion. The subcutaneous layer was lavaged. Bleeding points were cauterized with electrocoagulation. The skin was closed with staples. The patient was transferred to the recovery room in stable condition.

a.    58260, 58700, 58940, 58940-50, 182.0
b.    58120-50, 182.0, 198.82
c.    58150, 182.0
d.    58260, 58720-50, 195.2                    


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