CPT® Code 58294

1. Indications

The procedure described by CPT® Code 58294 is indicated for patients presenting with a significantly enlarged uterus, specifically one that weighs more than 250 grams. This condition may be associated with various symptoms or conditions, including but not limited to:

• Uterine Fibroids: Noncancerous growths in the uterus that can lead to an increase in size and weight.
• Endometrial Hyperplasia: A condition characterized by the thickening of the uterine lining, which can contribute to an enlarged uterus.
• Uterine Prolapse: A condition where the uterus descends into the vaginal canal, often requiring surgical intervention.
• Abnormal Uterine Bleeding: Heavy or irregular bleeding that may necessitate the removal of the uterus to alleviate symptoms.

2. Procedure

The procedure for CPT® Code 58294 involves several detailed steps to ensure the successful removal of the enlarged uterus and repair of the enterocele:

• Step 1: The procedure begins with the placement of tenacula on the cervix to provide traction, allowing for better access to the surgical site.
• Step 2: The vaginal mucosa is incised around the entire cervix, creating an opening to access the uterus.
• Step 3: Blunt and sharp dissection techniques are employed to separate the bladder from the uterus, ensuring that the bladder is not damaged during the procedure.
• Step 4: The bladder is elevated to expose the peritoneal vesicouterine fold, which is then incised to further access the surgical area.
• Step 5: The cul-de-sac is exposed, and the peritoneum is incised to allow for the ligation of the uterine vessels.
• Step 6: One of the morcellization techniques—hemisection, intramyometrial coring, or wedge resection—is employed to remove the uterus as its 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.
• Step 8: The cardinal ligaments are clamped at the lower uterine segment, incised, and suture ligated to secure the area.
• Step 9: The lower portion of the broad ligament is clamped and divided at its attachment to the lower uterine segment.
• Step 10: The tubo-ovarian round ligaments are exposed, clamped, and incised close to the uterine fundus bilaterally, followed by the transection of the fallopian tubes.
• Step 11: The tubo-ovarian round ligaments are doubly ligated, and the entire morcellized uterus is removed from the surgical site.
• Step 12: If the tubes and ovaries are to be removed, the round ligament is cut and tied bilaterally, and tension is applied to the infundibulopelvic ligament, which is then cut to allow for the delivery of the tubes and ovaries along with the morcellized uterus.
• Step 13: The anterior vaginal wall is elevated, and the entire length of the broad ligament is exposed to control any bleeding.
• Step 14: The peritoneum is closed, and the vaginal cuff is left open to allow for drainage of the pelvis.
• Step 15: To repair the enterocele, the vaginal mucosa overlying the enterocele is opened, and the perirectal fascia is dissected free of the posterior vaginal mucosa to expose the enterocele sac.
• Step 16: The enterocele sac is incised, and the small bowel is pushed back into the abdomen. The sac is then closed with two purse-string sutures placed around the neck of the enterocele, and any redundant sac is excised.

3. Post-Procedure

Post-procedure care following a vaginal hysterectomy with enterocele repair includes monitoring for any signs of complications such as excessive bleeding, infection, or urinary issues. Patients are typically advised to rest and avoid strenuous activities for a specified period to promote healing. Follow-up appointments are essential to assess recovery and ensure that the surgical site is healing properly. Additionally, patients may receive instructions regarding pain management and any necessary lifestyle modifications to support recovery.