Myomectomy (Robotic / Laparoscopic)
Symptomatic uterine fibroids
Same
[Robotic-assisted laparoscopic / Laparoscopic] myomectomy with contained morcellation[, chromopertubation]
[***, MD/DO]
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old female with symptomatic uterine fibroids causing [heavy menstrual bleeding / pelvic pressure and bulk symptoms / infertility] who desires uterine preservation. Preoperative imaging showed [X] fibroids, the largest a [X]-cm [intramural / subserosal] fibroid. The risks, including bleeding, transfusion, conversion to laparotomy, hysterectomy, uterine rupture in a future pregnancy, adhesions, recurrence, and spread of an unexpected malignancy with morcellation, as well as the benefits and alternatives, were discussed, and informed consent was obtained.
The uterus was enlarged to approximately [X]-week size. [X] fibroids were removed, the largest a [X]-cm [fundal / anterior / posterior] [intramural / subserosal] fibroid. The endometrial cavity was [not entered / entered and closed]. The fallopian tubes and ovaries were [normal / ***].
The patient was placed in the dorsal lithotomy position in padded stirrups with the arms tucked. The abdomen, perineum, and vagina were prepped and draped in the usual sterile fashion. A Foley catheter and a uterine manipulator were placed. A surgical time-out was performed.
Pneumoperitoneum was established via [Veress needle / optical trocar / open Hasson] entry. [[X] 8-mm robotic ports and a [12]-mm assistant port / A [X]-mm umbilical port and three 5-mm ports] were placed under direct vision. The patient was placed in Trendelenburg [and the robot was docked].
Dilute vasopressin ([20] units in [100] mL of normal saline) was injected into the myometrium overlying the fibroid until blanching, with aspiration before injection. A [transverse / vertical] serosal incision was made over the fibroid with [monopolar scissors / a harmonic scalpel] and carried down to the fibroid. The fibroid was grasped with a [tenaculum / myoma screw] and enucleated from its pseudocapsule with traction and countertraction, using minimal energy on the myometrium. [The same technique was used to remove [X] additional fibroids.] [The endometrial cavity was entered and closed with a running [3-0 barbed] suture.]
The myometrial defect was closed in [two / three] layers with running [0 / 2-0] barbed suture to eliminate dead space, and the serosa was closed with a running [2-0 barbed / 3-0 polyglactin] suture. Hemostasis was confirmed. [An adhesion barrier was placed over the hysterotomy.]
The fibroids were placed in a containment bag and removed by contained [manual / power] morcellation through [the umbilical port site / a minilaparotomy], and the bag was removed intact. [Chromopertubation showed [bilateral tubal patency / ***].] The pelvis was irrigated, and hemostasis was confirmed under reduced insufflation pressure.
[The robot was undocked.] The ports were removed under direct vision, and the abdomen was desufflated. The fascia at port sites 10 mm or larger was closed with 0 polyglactin suture. The skin was closed with [4-0 absorbable subcuticular suture / skin adhesive]. Sponge, needle, and instrument counts were correct.
None
Fibroids ([X] in number, aggregate weight [X] g), to pathology
[X] mL
None
The patient was extubated and taken to the PACU in stable condition [for anticipated same-day discharge / for overnight observation].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Symptomatic uterine fibroids
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Robotic-assisted laparoscopic / Laparoscopic] myomectomy with contained morcellation[, chromopertubation]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: .PTAGE-year-old .PTSEX with symptomatic fibroids causing *** who desires uterine preservation. Imaging: *** fibroids, largest *** cm. Risks including bleeding, transfusion, conversion, hysterectomy, uterine rupture in future pregnancy, recurrence, and morcellation of unexpected malignancy, along with benefits and alternatives, discussed. Consent obtained.
FINDINGS: Uterus *** week size. *** fibroids removed, largest *** cm ***. Cavity [not entered / entered and closed]. Adnexa ***.
PROCEDURE:
Dorsal lithotomy, arms tucked. Prepped and draped. Foley and uterine manipulator placed. Time-out. Pneumoperitoneum via ***. Ports placed under direct vision[, robot docked]. Dilute vasopressin injected into the myometrium. *** serosal incision, fibroid enucleated from its pseudocapsule[, *** additional fibroids removed]. Myometrium closed in *** layers with barbed suture, serosa closed. Hemostasis confirmed. [Adhesion barrier placed.] Fibroids removed by contained morcellation in a bag, bag removed intact. [Chromopertubation: ***.] Irrigation, hemostasis at reduced pressure. [Robot undocked.] Ports removed, fascia closed at ports 10 mm or larger, skin closed. Counts correct.
EBL: *** mL
SPECIMENS: Fibroids (***, aggregate weight *** g) to pathology
COMPLICATIONS: None
DISPOSITION: PACU, stable.
Signed: .ME, .MYDEGREE
.TODAYVariants
Abdominal Myomectomy
The patient was placed supine. A Foley catheter was placed, the abdomen was prepped and draped in the usual sterile fashion, and a surgical time-out was performed. A [Pfannenstiel / low midline] incision was made, and the abdomen was entered. A [Balfour / Bookwalter / Alexis] retractor was placed, and the bowel was packed out of the pelvis. The uterus was delivered into the incision. [A tourniquet was placed around the lower uterine segment through windows in the broad ligaments lateral to the uterine vessels.] Dilute vasopressin was injected into the myometrium overlying the fibroids.
A [transverse / vertical] serosal incision was made over the fibroid, which was grasped with a [tenaculum / myoma screw] and enucleated from its pseudocapsule. [X] fibroids were removed [through [one / X] incisions]. [The endometrial cavity was entered and closed with a running [3-0 polyglactin] suture.] The myometrial defects were closed in [two / three] layers with [0 / 2-0 polyglactin] suture, and the serosa was closed with a running [3-0 polyglactin] suture. [The tourniquet was removed.] Hemostasis was confirmed. [An adhesion barrier was placed over the hysterotomies.]
The pelvis was irrigated, and the packs and retractor were removed. The fascia was closed with running [0 polyglactin / looped 1 polydioxanone] suture. The skin was closed with [4-0 absorbable subcuticular suture / staples]. Sponge, needle, and instrument counts were correct.
Charting Tips
- Record each fibroid's location, type (subserosal, intramural, or submucosal), and size, and state whether the endometrial cavity was entered. Cavity entry and extensive myometrial dissection are used to counsel about trial of labor versus cesarean delivery in a future pregnancy.
- Document the myometrial closure in layers. A layered closure that eliminates dead space is the record that the hysterotomy was repaired to support a future pregnancy.
- Record the vasopressin dose and concentration and that it was aspirated before injection. Intravascular injection can cause severe hypertension, bradycardia, or cardiac arrest.
- If the specimen is morcellated, document containment in a bag, the method, and that the bag was removed intact. Record the preoperative malignancy evaluation (imaging and endometrial sampling when indicated) in the indications.
- Submucosal fibroids are usually removed hysteroscopically. Use the hysteroscopy template for that procedure.
Documentation & Reimbursement Considerations
- Primary service: Report Myomectomy (Robotic / Laparoscopic) as the primary service when it is the definitive operation performed.
- Laparoscopic and robotic myomectomy are coded by intramural fibroid count and total weight. One to 4 intramural fibroids weighing 250 g or less in total, or surface fibroids only, carry 15.16 wRVU. Five or more intramural fibroids, or a total weight over 250 g, carry 19.44 wRVU. Both have a 90-day global period, and robotic assistance uses the same codes.
- Abdominal myomectomy uses the same count and weight split (15.40 vs. 19.83 wRVU, 90-day global).
- Document the number of intramural fibroids removed and the aggregate specimen weight from the OR scale or pathology. These two facts determine the code.
- Hysteroscopic resection of a submucosal fibroid is a separate procedure with its own code. Document it in a separate hysteroscopy note when both are performed.