VASECTOMY PROCEDURE NOTE

PROCEDURE: Elective Bilateral Vasectomy -CPT 55250

PRE-OP DIAGNOSIS:
FINDINGS:

POST-OP DIAGNOSIS:

ANESTHESIA: . Total amount used: ml.

INDICATIONS/COUNSELING:
-Patient desires elective sterilization.
-Confirmed that Patient was counseled regarding the risks, alternatives, and benefits of male sterilization by vasectomy.
-Confirmed that patient was informed of the risks of the procedure, including but not limited to failure of the procedure to produce sterility, the risks of bleeding, infection, chronic testicular pain, and injury to scrotal contents.
-Confirmed that all questions were answered in the pre-vasectomy counseling visit. No guarantees were given or implied.
-Verified that the consent form was signed prior to patient taking preprocedural medication(s).
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record to include ensuring: only select what's applicable

PHYSICAL EXAM:
Inspection/Palpation of the genitalia: choose one

PROCEDURE
-The patient was laid supine on the procedure table.
-He was prepped and draped in the usual fashion using and allowing proper dry time per manufacturer and infection control recommendations.
-After identifying the vasa bilaterally, the left vas was grasped using the three-finger technique.
-Using a 27g needle, a 1-2 cm wheal was made at the 1 cm distal to the base of the penis with anesthetic agent to provide local skin anesthesia.
-The needle was then advanced through the wheal and adjacent to the Vas Deferens.
-After gentle aspiration, anesthetic agent was injected into the to achieve regional vasal block.
-The VasSide Vas Deferens was maneuvered to the desired incision site, and was used to make a 1-2 cm incision.
-The soft tissue was then bluntly dissected with fine cured hemostats.
-The VasSide Vas Deferens was grasped and elevated through the incision and exposed using vas fixing forceps. Perivas tissue was bluntly dissected away using .
-Once it was decided that sufficient perivas tissue had been dissected away and risk of superimposed vascular tissue over the vas deferens was low, a 1cm section of vas deferens was isolated using vas fixing forceps to grasp distal and proximal ends.
- were used to secure testicular and prostatic ends of vas deferens prior to transection.
-The 1cm segment of vas deferens was transected/excised using and this 1cm section was sent for pathologic examination/review.
-cautery was applied to length of the lumen of of the Vas Deferens until blanching occurred.
only check if applicable-The area of remaining Vas Deferens and perivas tissue exposed through the incision was inspected thoroughly.
- before the remaining Vas Deferens was reduced back into the scrotum.
-These procedural steps described were repeated on the Right Vas Deferens.
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-For closure, scrotal fascia/skin was
.
-Skin was dressed with sterile gauze.

DISPOSITION

-Patient was reminded of post-procedural instructions including:
-Gave patient return precautions to include: .
-Patient left in stable condition.
-Followup plan:
.

Result - Copy and paste this output: