Hysterectomy (Total Laparoscopic / Robotic)
58570
-
58571— Laparoscopic hysterectomy with bilateral salpingectomy -
58572— Laparoscopic hysterectomy with bilateral salpingo-oophorectomy -
58150— Total abdominal hysterectomy, open (corpus and cervix) -
58180— Supracervical abdominal hysterectomy, open -
58260— Vaginal hysterectomy, ≤250 g uterus -
58290— Vaginal hysterectomy, >250 g uterus
[Uterine fibroids / abnormal uterine bleeding / adenomyosis / endometrial cancer / cervical dysplasia], symptomatic, not responsive to medical management
Same
Total laparoscopic hysterectomy (TLH) [with bilateral salpingectomy / bilateral salpingo-oophorectomy]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [female] with [symptomatic uterine fibroids / abnormal uterine bleeding unresponsive to medical management / adenomyosis / endometrial carcinoma]. [The uterus was [X]-cm / enlarged on imaging.] Hysterectomy was recommended. The risks, benefits, and alternatives including UAE, endometrial ablation, myomectomy were discussed and informed consent was obtained.
The uterus was [normal / enlarged, [X]-cm, with [fibroids / adenomyotic changes]]. The bilateral fallopian tubes and ovaries were [normal / with [right adnexal cyst / endometrioma / adhesions]]. The cul-de-sac was [free / with endometriosis implants]. The ureters were identified bilaterally throughout the case.
The patient was positioned in the dorsal lithotomy position with the legs in Allen stirrups. A [uterine manipulator (RUMI / VCare)] was placed. A [12-mm] umbilical port was placed via [Veress needle / optical trocar / Hasson open technique]. The abdomen was insufflated with CO₂ to [15 mmHg]. Three additional [5-mm] ports were placed under direct vision.
The round ligaments were desiccated and divided bilaterally. The broad ligaments were opened anteriorly and posteriorly. [Bilateral salpingo-oophorectomy: The infundibulopelvic ligaments were coagulated and divided bilaterally.] [Bilateral salpingectomy: The utero-ovarian ligaments were coagulated and the fallopian tubes divided with the coagulating shears.] The vesicouterine peritoneum was incised and the bladder was dissected off the lower uterine segment and cervix.
The uterine arteries were skeletonized and coagulated/desiccated at the uterine isthmus bilaterally. The cardinal and uterosacral ligaments were divided. The colpotomy was performed circumferentially at the [cervico-vaginal junction] using [monopolar scissors / harmonic scalpel] with the manipulator cup as guidance. The uterus [and cervix] was removed vaginally.
The vaginal cuff was closed with [running 0-Vicryl] suture incorporating the uterosacral ligaments for apical support. Cuff closure was confirmed laparoscopically and was hemostatic and intact.
Port sites were closed with [0-Vicryl] fascial closure at the 12-mm site.
None
Uterus [and cervix], sent to pathology. [Bilateral tubes / ovaries, sent separately.]
[X] mL
None
The patient was taken to the PACU in stable condition. A [Foley catheter] was removed [in the PACU / on postoperative day 1]. Diet was advanced as tolerated. Ambulation was initiated on postoperative day 1.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***, symptomatic, medical management failed
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: TLH [with bilateral salpingectomy/BSO]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General
INDICATIONS: .PTAGE-year-old .PTSEX with ***. Uterus *** cm. Consent obtained.
FINDINGS: Uterus *** cm, ***. Tubes/ovaries ***. Cul-de-sac ***. Ureters identified bilaterally.
PROCEDURE:
Dorsal lithotomy, Allen stirrups. Uterine manipulator placed. 12 mm umbilical port [Veress needle / optical trocar / Hasson]. Insufflated to 15 mmHg. *** additional ports. Round ligaments divided. Broad ligament opened. [BSO: IP ligaments desiccated/divided.] [Salpingectomy: utero-ovarian ligaments desiccated, tubes divided.] Vesicouterine peritoneum incised, bladder mobilized. Uterine arteries skeletonized, coagulated at isthmus. Cardinal/uterosacral divided. Colpotomy circumferential at CVJ. Uterus removed vaginally. Vaginal cuff closed running 0-Vicryl with uterosacral ligaments. Cuff hemostatic, confirmed laparoscopic. Port sites closed.
EBL: *** mL
SPECIMENS: Uterus ± tubes/ovaries to pathology
COMPLICATIONS: None
DISPOSITION: PACU. Foley out POD 1. Ambulate POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
Total Abdominal Hysterectomy (TAH)
A total abdominal hysterectomy was performed via [Pfannenstiel / midline] incision for [markedly enlarged uterus / prior abdominal surgery / morbid obesity limiting laparoscopy / oncologic case requiring pelvic lymphadenectomy]. The pelvic anatomy was exposed with a self-retaining retractor. The round ligaments were ligated and divided. The broad ligament was opened. The uterine vessels were clamped, divided, and suture-ligated bilaterally. The cervix was removed by circumferential incision at the vaginal cuff. The vaginal cuff was closed with [0-Vicryl] figure-of-eight sutures. Open approach is appropriate when laparoscopic access is limited or contraindicated.
Charting Tips
- Document ureter identification. Ureteral injury is the most feared complication of hysterectomy (0.1–1%). Document bilateral ureter identification at the pelvic brim, at the crossing over the uterine artery, and at the level of the bladder. 'Ureters were identified and protected throughout' is the minimum required documentation.
- Document vaginal cuff closure including apical suspension. Cuff dehiscence occurs in ~0.3% of laparoscopic hysterectomies. Document the suture used, number of layers, and that the uterosacral ligaments were incorporated for apical support. Apical suspension prevents cuff prolapse.
- For endometrial cancer cases, document lymph node dissection template and sentinel node procedure if performed. Lymph node assessment is required for staging and treatment planning. Document which dissection was performed (sentinel mapping, pelvic LND, para-aortic LND) and the node count from each region.
Billing Tips
- Bill 58150 for total abdominal hysterectomy (TAH, 16.88 wRVU, 90-day global). Bill 58180 for supracervical abdominal hysterectomy (16.19 wRVU). Document whether the cervix is preserved or removed, as this determines the code.
- Bill 58260 for vaginal hysterectomy, uterus under 250g (13.80 wRVU). Bill 58291 for vaginal hysterectomy with removal of tube(s) and/or ovary(ies) (21.51 wRVU). Bill 58552 for laparoscopic-assisted vaginal hysterectomy (LAVH, 16.49 wRVU).
- Bilateral salpingo-oophorectomy (BSO) at the time of abdominal hysterectomy: 58152 includes TAH + BSO (21.31 wRVU). If BSO is added to a vaginal hysterectomy, use 58291 or 58292. Do not separately bill oophorectomy codes when included in the hysterectomy code.
- 90-day global period: drain removal, wound checks, vaginal cuff inspection, and routine follow-up are bundled. Vaginal cuff dehiscence requiring OR repair within the global period uses modifier -78.
- For malignant indication, node dissection is separately billable. Pelvic lymph node dissection (38770, 10.43 wRVU) and para-aortic node dissection (38780) with modifier -51. Document the surgical staging performed.