Modifying the procedure for uterovaginal prolapse
If the patient has an intact uterus and benign cervical cytology, perform supracervical hysterectomy before proceeding with Steps 1–8 above.
TIP Leaving the cervix in situ may reduce the chance of mesh erosion and provides an excellent platform for mesh attachment.
TRICK I find it most helpful to fully dissect the anterior and posterior vaginal walls before cervical amputation because upward traction on the corpus improves visualization of the surgical planes.
Once the cervix is amputated, however, effective vaginal manipulation can present a surgical challenge. Some surgeons use a tenaculum attached to the fourth arm of the robot to apply traction on the cervix, but this eliminates this arm from performing other necessary tasks. Malleable or Breisky-Navratil retractors can be used to delineate the anterior and posterior vaginal fornices, but are not always satisfactory—especially if an assistant isn’t seated between the legs.
TIP A useful and inexpensive instrument is the Colpo-Probe vaginal fornix delineator (Cooper Surgical) (FIGURE 8), which not only assists in dissecting the vagina from the bladder and rectum but also provides a stable surface during attachment of mesh.
FIGURE 8 Colpo-Probe
This device delineates the anterior and posterior vaginal fornices. It provides a stable platform against which to suture the mesh graft.
Tips and tricks for managing hemorrhage during sacrocolpopexy
Four potential areas of bleeding danger exist:
- In trying to find the sacral promontory, you risk entering the right common iliac vein if dissection is too far cephalad and lateral.
TIP I strongly advise novice robotic surgeons to try to identify the site of the promontory with a standard laparoscopic instrument with haptic feedback before moving to the surgical console.
TRICK Another trick that can help with safe identification of the promontory is mobilization of the sigmoid colon away from the sacrum by developing the retrorectal space. - During dissection of the fat pad from the promontory, you can encounter the middle sacral artery.
TRICK Spreading carefully in a caudal–cephalad direction until the level of the ligament is reached, instead of spreading in a lateral dimension, can decrease the chances of lacerating of this vessel. - A dangerous plexus of veins traverses the hollow of the sacrum. If you are trying to affix mesh at the level of S2-3, therefore, you may encounter significant bleeding.
TIP Work above the level of S1 to avoid these veins completely. - In securing the mesh to the sacral promontory, you can puncture the left common iliac vein if you are not aware of the exit point of the needle and it traverses too far medially.
TIP If you encounter bleeding, introduce a RAY-TEC sponge (Johnson & Johnson) through the accessory port. Apply manual compression for at least 5 minutes. If bleeding persists, I recommend Floseal Hemostatic Matrix (Baxter) to control hemorrhage that arises from arterial and venous sources.
TRICK As last resort, perform emergency undocking in rapid fashion while the bedside assistant maintains pressure through the accessory port.
Conclusion
The da Vinci robotic surgical system facilitates completion of sacrocolpopexy and cervicosacropexy, in a manner identical to the open technique, by surgeons who may not possess advanced laparoscopic skills. Full knowledge of the relevant anatomy is critical; there is the potential for significant morbidity during the procedure if surgical planes are created incorrectly.
Coding tips for robotic sacrocolpopexy
Robotic surgery in on the rise, but coding for robotic procedures is still limited to the basic, conventional procedure. Why? Because insurers reimburse the hospital for use of the equipment but still refuse to reimburse the surgeon any additional amount for incorporating the robot into the surgical technique.
Coding for your work when performing robotic sacrocolpopexy is straightforward: Report laparoscopic code 57425 (laparoscopy, surgical, colpopexy [suspension of vaginal apex]) for the procedure. Mesh that might be used as part of the repair is not reported separately.
Blue Cross/Blue Shield (BC/BS) added the Healthcare Common Procedure Coding System Level-II code S2900 (surgical techniques requiring use of robotic surgical system) to the national code set a few years ago. Although BC/BS and some other payers accept this code on the claim, there is no reimbursement attached: It was developed for informational purposes only.
Remember, however, that coding is complete only when you have an appropriate linking diagnosis to establish the medical necessity of laparoscopic sacrocolpopexy. Diagnostic coding options for this surgical procedure include documentation of uterovaginal prolapse (incomplete prolapse is 618.2; complete prolapse is 618.3); vaginal vault prolapse after hysterectomy (618.5); and uterine prolapse without vaginal wall prolapse (618.1).
—MELANIE WITT, RN, CPC, COBGC, MA
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