0UTL0ZZ
Resection Vestibular Gland to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | T Resection |
| Body Part | L Vestibular Gland |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection describes the complete surgical removal of an entire female reproductive organ or defined anatomic part, without any replacement. Hysterectomy, salpingectomy, and oophorectomy are the procedures patients most commonly associate with this family, performed for conditions ranging from cancer and fibroids to endometriosis, chronic pain, or as a preventive measure against hereditary cancer risk.
Because Resection means the entire body part is taken out rather than a portion of it, the distinction from partial removal matters clinically and surgically. A total hysterectomy removes the whole uterus, while a partial or supracervical hysterectomy leaves the cervix behind, changing both the postoperative anatomy and the code assigned. The approach used, open abdominal, laparoscopic, robotic-assisted, or vaginal, also affects surgical planning and recovery but is captured separately from the root operation itself.
Anatomy & Axis Detail
Vestibular Gland
The vestibular glands, most notably the paired Bartholin glands situated at the posterior vaginal introitus, produce mucus that lubricates the vaginal opening during sexual activity. Resection of a vestibular gland is performed when recurrent Bartholin gland abscess or cyst formation has failed simpler treatments such as marsupialization or Word catheter placement, or when a gland enlargement in a woman over forty raises concern for the rare Bartholin gland carcinoma, prompting complete excision for pathologic evaluation. Because the gland lies deep to the vaginal mucosa near the vestibular bulb and can bleed briskly if incompletely dissected, full gland excision is technically more demanding than incision and drainage, and the operative note should specify which gland and side were removed.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Coding & Documentation
Coders assign Resection when the operative note confirms an entire organ or anatomically whole body part was removed, such as total hysterectomy, bilateral salpingo-oophorectomy, or complete cervical excision. The pathology report and operative note together should confirm what specifically was taken, since PCS body part values distinguish between the uterus, cervix, ovaries, and fallopian tubes as separate structures each requiring their own code when removed.
A common error is coding a single combined value when bilateral organs are removed through separate steps, or failing to code each structure that was resected individually, such as coding only the hysterectomy and overlooking a concurrent oophorectomy. Coders should also watch for cases described as "debulking" or "cytoreduction," which may include a mix of Resection and Excision depending on whether entire organs or only portions of tissue were removed.