1. A small uterus on exam under anesthesia with no adnexal masses. 2. Cervical stenosis precluding hysteroscopy or sampling with an endometrial
biopsy Pipelle.
STATEMENT OF MEDICAL NECESSITY: This is a 45-year-old, G-1, P-0, A-1 female with no pertinent medical history, who initially presented to clinic with a diagnosis of postmenopausal bleeding, however, upon laboratory review, FSH levels are more consistent with perimenopausal bleeding. The patient also has a thickened endometrial stripe and inability to obtain sufficient tissue sample on endometrial biopsies in clinic. The sonogram also revealed a 1.6 cm polyp versus submucosal fibroid within the endometrium. The plan was for a diagnostic hysteroscopy with a possible polypectomy and D and C. The procedural risks, benefits, alternatives, and indications were reviewed with the patient.
*
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was established. The patient was placed in dorsal lithotomy position using Allen stirrups, ensuring proper positioning and cushioning to avoid nerve injury. Exam under anesthesia was performed with the findings noted above. Straight catheterization of the bladder was removed. The patient was prepped and draped in the usual sterile fashion. A weighted speculum was inserted into the posterior vaginal fornix and anterior right angle retractor was used to expose the cervix. A single tooth tenaculum was attached to the anterior lip of the cervix to assist with insertion of the hysteroscope. In preparation for hysteroscopy, normal saline was chosen as the distention medium and the pressure setting was set to 66 mmHg based on the patient’s mean arterial pressure. The hysteroscope was primed with the chosen media and focus obtained. Attempted cervical dilation began using the Hagar dilator, however, dilation was not able to be obtained with this method and we then used uterine dressing forceps to attempt cervical dilation. Given the extent of cervical stenosis, we then attempted using a lacrimal duct dilator, however, again, due to the cervical stenosis, it was felt that we were unable to sufficiently dilate the cervix to the point that we could insert the hysteroscope or/and endometrial biopsy Pipelle. The surgery was stopped at this point and the tenaculum was removed from the cervix, the weighted speculum was removed, and the patient was returned to the supine position. There was no fluid deficit due to the hysteroscope not being inserted into the uterus due to the cervical stenosis. The patient was extubated without difficulty and transferred to the recovery room in good condition. There were no
anesthetic or surgical complications. Sponge and instruments were correct.

Opinions on what to bill for please & thank you!

Marylou