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#1
06-29-2012, 09:39 AM
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Local advancement flap
Can someone help me with the following please?
1. Wide local excision of the right helix and lobule. 2. Closure of irregular defect with local advancement flaps. 3. Sentinel lymph node biopsy using lymphoscintigraphy and Lymphazurin lymphatic dye. wide local excision and sentinel lymph node biopsy. Review of the images was undertaken prior to entering the OR. The patient localized well to two sites in the right neck, one in level 2A and the other in 5B. These sites were marked on the neck. The patient was brought to the operating facility after correct identification. Operative time-out was performed. The patient was then prepped and draped in the usual sterile fashion. Prior to prepping and draping 1 mL of Lymphazurin dye was injected into the helix in the region of the melanoma excision around the circumferential area. Following prepping and draping a wide local excision in the form of wedge resection of the helix and superior lobule was undertaken. This was closed primarily by advancing the lobule and the helical segments with closure with deep 3-0 Vicryl followed by a running 5-0 plain gut stitch. Following this attention was turned to the two sites marked status post lymphoscintigraphy. Baseline radioactivity was measured with the Geiger counter. Of note, prior to excision of the primary background was 40 and the primary site measure 4300. Prior to incising sentinel lymph node biopsy site 1 the baseline was 1200. Blunt dissection was used since this was in the region of the marginal mandibular nerve in level 2A to take every precaution and using nerve safe dissection techniques. Burlisher as well as Bovie cautery was used to dissect. Dissection was carried through the incision site down to the level of the retromandibular vein. At this point Lymphazurin dye was readily visible. Specimen was removed. Ex vivo measurement with a Geiger counter revealed an activity of 9800 of the ex vivo specimen. The excisional site dropped in activity from 1200 at baseline to 500 status post removal of the specimen. There was a superficial specimen that was removed and placed in a separate specimen cup prior to the Lymphazurin and positive double collection. This extra sentinel lymph node segment measured a total of 40. Following this attention was turned to the second sentinel lymph node site. Baseline for this site was 2200. Again dissection was carried down using Burlisher and Bovie cautery. A Weitlaner was used for retraction as well as a Cummings retractor for exposure. The specimen was removed which we felt was a good cluster of benign-appearing lymph nodes. The ex vivo measurement was 1900. Following this the sentinel node site was measured and the baseline of 2200 had dropped to 10 which we were satisfied with. Closure of the two sentinel lymph node sites was performed with interrupted Vicryl and running subcuticular Monocryl. The patient tolerated the procedure very 
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#2
06-29-2012, 12:42 PM
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a little confused. This is an excision of a melanoma? If so it is missing the size of the lesion. Going on that thought I would say something from the 11620 range depending on size and an intermediate closure along with either 38500 for superficial lymph node or 38510 for deep lymph node and 38900 for the injection of the dye and I am supposing the radioactive tracer injection was performed by someone other that the surgeon in radiology.
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