CPT® Code 57556

Official Description

Excision of cervical stump, vaginal approach; with repair of enterocele

Common Language Description

The procedure described by CPT® Code 57556 involves the excision of the cervical stump through a vaginal approach, accompanied by the repair of an enterocele. This surgical intervention is typically indicated for patients who have previously undergone a sub-total hysterectomy and later develop cervical malignancy. The excision process begins with the placement of a tenaculum on the cervix, allowing for a precise incision in the upper aspect of the vaginal mucosa surrounding the cervical stump. The surgeon employs both sharp and blunt dissection techniques to carefully separate the bladder from the cervix and to release any adhesions present. Following the removal of the cervical stump, which includes adjacent parametrial tissue and a portion of the vagina, the excised tissue is sent for frozen section analysis to assess for malignancy. In addition to the cervical stump excision, the procedure includes the repair of an enterocele, which is a type of hernia that occurs when the small intestine bulges into the vaginal canal. The surgical approach involves opening the posterior vaginal mucosa to access the enterocele, excising an ellipse of skin at the junction of the vagina and perineum, and meticulously dissecting the perirectal fascia to expose the enterocele sac. The sac is then incised, allowing the small bowel to be repositioned back into the abdominal cavity, followed by closure of the sac with purse-string sutures. This comprehensive procedure not only addresses the malignancy but also corrects the enterocele, ensuring the integrity of the pelvic floor and vaginal structure.

1. Indications

The procedure described by CPT® Code 57556 is indicated for patients who have undergone a sub-total hysterectomy and subsequently develop malignancy of the cervix. Additionally, it is performed in cases where there is a need to repair an enterocele, which may occur as a complication in these patients.

Malignancy of the Cervix - The excision of the cervical stump is necessary for patients diagnosed with cervical cancer following a previous sub-total hysterectomy.
Enterocele Repair - The procedure addresses the presence of an enterocele, which is a herniation of the small intestine into the vaginal canal, requiring surgical intervention for correction.

2. Procedure

The procedure begins with the placement of a tenaculum on the cervix to stabilize it. An incision is made in the upper aspect of the vaginal mucosa around the entire cervical stump. The surgeon applies tension to the tenaculum and utilizes both sharp and blunt dissection techniques to free the bladder from the cervix and to lyse any adhesions that may be present. Once the cervical stump is adequately mobilized, it is excised along with surrounding parametrial tissue and a portion of the vagina, which is then sent for frozen section analysis to evaluate for malignancy.

Step 1: Stabilization and Incision - A tenaculum is placed on the cervix, and an incision is made in the upper vaginal mucosa surrounding the cervical stump.
Step 2: Dissection - Tension is applied to the tenaculum, and sharp and blunt dissection is performed to separate the bladder from the cervix and to lyse adhesions.
Step 3: Excision of Cervical Stump - The cervical stump, along with parametrial tissue and a portion of the vagina, is removed and sent for frozen section analysis.
Step 4: Repair of Enterocele - The posterior vaginal mucosa overlying the enterocele is opened up to the vaginal apex, and an ellipse of skin at the junction of the vagina and perineum is excised.
Step 5: Exposure and Closure of Enterocele Sac - The perirectal fascia is dissected free of the posterior vaginal mucosa to expose the enterocele sac, which is then incised. The small bowel is pushed back into the abdomen, and the sac is closed with two purse-string sutures placed around its neck. The redundant sac is excised.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any complications related to the excision and repair. Patients may experience discomfort and will require pain management. Follow-up appointments are essential to assess healing and to ensure that there are no signs of recurrence of malignancy or complications from the enterocele repair. Instructions regarding activity restrictions and signs of potential complications should be provided to the patient to facilitate a smooth recovery process.

Short Descr	REMOVE CERVIX REPAIR BOWEL
Medium Descr	EXC CRV STUMP VAG APPR W/RPR NTRCL
Long Descr	Excision of cervical stump, vaginal approach; with repair of enterocele
Status Code	Active Code
Global Days	090 - Major Surgery
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62)	1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator	Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P1G - Major procedure - Other
MUE	1
CCS Clinical Classification	129 - Repair of cystocele and rectocele, obliteration of vaginal vault

Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).