ICD 9 CM Code

PREOPERATIVE DIAGNOSIS: Desire for sterilization
POSTOPERATIVE DIAGNOSIS: Desire for sterilization
PROCEDURE PERFORMED: Bilateral tubal ligation, modified Pomeroy technique
ANESTHESIA: General
INDICATION: The patient is a 32-year-old gravida 3, para 3, who underwent spontaneous vaginal delivery yesterday, and affirmed her request for permanent sterilization. Risks and benefits of surgery were discussed with the patient and she elected to proceed with the surgery.
TECHNIQUE: The patient was taken to the operating room where epidural anesthesia was found to be inadequate, and she was therefore given general anesthesia, prepped and draped in the normal sterile fashion. An approximately 15 mm transverse infraumbilical incision was made with the scalpel and blunt dissection to the fascia was made with Kelly clamp. The fascia was grasped between two Kocher clamps, tented up, and entered sharply. The incision was extended bilaterally for about 10 mm. Then the peritoneum was identified, grasped with two hemostats, tented up, and entered sharply to expose the uterus. Then the right fallopian tube was identified, grasped with a Babcock clamp, walked out to its fimbriated end, re-grasped approximately 3 cm from the COfneal region, and the avascular portion of the mesosalpinx was identified and perforated under the fallopian tube with a Mosquito and a length of 0 plain gut was drawn back through the proximal followed by distal ends, and an approximately 3 cm segment of tube was tied and the intervening segment of fallopian tube was excised. The luminal ends were identified and found to be hemostatic. Then a similar procedure was carried out on the left. Following this, the fascia was closed in a running fashion with 0 Vicryl, and the skin was reapproximated with 4-0 Vicryl in subcuticular stitch. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct. The patient was taken to recovery in stable condition.

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