CPT® Code 58290

1. Indications

The vaginal hysterectomy coded as CPT® 58290 is indicated for the removal of an enlarged uterus, specifically when the uterus weighs greater than 250 grams. This procedure is typically performed in cases where the patient presents with symptoms related to uterine enlargement, which may include:

• Uterine Fibroids: Noncancerous growths in the uterus that can cause pain, heavy bleeding, or pressure symptoms.
• Abnormal Uterine Bleeding: Heavy or irregular menstrual bleeding that may not respond to other treatments.
• Pelvic Pain: Chronic pain in the pelvic region that may be attributed to an enlarged uterus.
• Prolapse: A condition where the uterus descends into the vaginal canal, often requiring surgical intervention.

2. Procedure

The procedure for a vaginal hysterectomy coded as CPT® 58290 involves several detailed steps to ensure the safe and effective removal of the enlarged uterus:

• Step 1: The procedure begins with the placement of tenacula on the cervix to provide traction during the surgery. This is crucial for stabilizing the cervix and allowing better access to the uterus.
• Step 2: The vaginal mucosa is incised around the entire cervix, creating an opening that allows for further dissection and access to the underlying structures.
• Step 3: Traction is applied to the tenacula, and the bladder is carefully separated from the uterus using both blunt and sharp dissection techniques. This step is vital to prevent injury to the bladder during the procedure.
• Step 4: The bladder is elevated to expose the peritoneal vesicouterine fold, which is then incised to facilitate access to the pelvic cavity.
• Step 5: The cul-de-sac is exposed, and the peritoneum is incised to allow for the identification and ligation of the uterine vessels, which supply blood to the uterus.
• Step 6: One of the morcellation techniques, such as hemisection, intramyometrial coring, or wedge resection, is employed to remove the uterus in smaller pieces as the uterine attachments are severed.
• Step 7: As portions of the uterus are exteriorized and removed, the broad ligament is exposed, and the uterosacral ligaments are clamped and divided to facilitate complete removal.
• Step 8: The cardinal ligaments are clamped at the lower uterine segment, incised, and suture ligated to ensure that all supporting structures are adequately addressed.
• Step 9: The lower portion of the broad ligament is clamped and divided at its attachment to the lower uterine segment, further aiding in the removal process.
• Step 10: The tubo-ovarian round ligaments are exposed, clamped, and incised close to the uterine fundus bilaterally, allowing for the removal of the uterus.
• Step 11: The fallopian tubes are transected, and the tubo-ovarian round ligaments are doubly ligated to secure the structures before removal.
• Step 12: The entire uterus is removed, and if the tubes and ovaries are also to be excised, the round ligament is cut and tied bilaterally.
• Step 13: Tension is applied to the infundibulopelvic ligament, which is cut, allowing for the delivery of the tubes and ovaries along with the morcellized uterus into the vagina for removal.
• Step 14: The anterior vaginal wall is elevated, and the entire length of the broad ligament is exposed to control any bleeding that may occur during the procedure.
• Step 15: Finally, the peritoneum is closed, and the vaginal cuff is left open to allow for drainage of the pelvis, which is an important consideration for post-operative care.

3. Post-Procedure

After the completion of the vaginal hysterectomy, the patient will typically be monitored for any immediate complications. The vaginal cuff is intentionally left open to facilitate drainage, which helps prevent fluid accumulation and potential infection in the pelvic area. Patients may experience some discomfort and bleeding post-operatively, which is expected. Recovery time can vary, but patients are generally advised to avoid heavy lifting and strenuous activities for several weeks to allow for proper healing. Follow-up appointments are essential to monitor the recovery process and address any concerns that may arise during the healing period.