op report
Please see the below op report - the mass did involve the bone. The code chosen is a 20240- still not sure if this is correct. Can someone please give their opinion? Thank you !!!
PREOPERATIVE DIAGNOSIS: Right parietal subgaleal mass.
POSTOPERATIVE DIAGNOSIS: Right parietal subgaleal mass.
OPERATION PERFORMED: Right parietal scalp incision for excisional biopsy of a subgaleal
tumor.
SURGEON:
ANESTHESIA: Local using 1% lidocaine with 1:100,000 dilution of epinephrine; used a total
of 5 mL and then IV sedation by Anesthesia.
PREOPERATIVE MEDICATION: Cefazolin 2 grams IV on induction.
PREOPERATIVE SUMMARY: The patient is a 76-year-old white male, initially presented several
weeks ago with a spell, thought he was having a stroke. Subsequently, MRI scan was
obtained, which showed a fairly large left paramedian tumor growing from the falx cerebri,
measured approximately 2.5 x 1.5 x 1 cm in size and was definitely displacing the medial
portion of the left frontal lobe laterally. He was started on Decadron. I planned to bring
him to surgery for excision of the tumor. On the morning of the surgery, a preoperative
Stealth stereotactic MRI scan was obtained, which showed that the tumor had basically nearly
completely disappeared, only some enhancement of the falx cerebral. Based on this, I did
cancel the surgery and felt the most likely diagnosis was an intracranial lymphoma because
of its response to the steroids. I did send the patient down for a spinal tap that very
day. We did do flow cytometry and looked for abnormal cells, but nothing conclusive was
found from the spinal fluid. Based on the lack of a diagnosis, I did recommend a biopsy of
a right-sided subgaleal mass, which I felt was probably the same type of tumor as the one
intracranially. I discussed it with Dr., the patient's oncologist, and he agreed
that he would prefer to have diagnostic tissue. Today, we are coming in to do the
excisional biopsy of this tumor. From the preoperative MRI scan, no evidence of any
involvement of the underlying skull. I did explain the surgery to the patient and his wife.
I was planning a scalp incision and then to remove this subgaleal tumor. I did discuss the
rationale for surgery, including potential benefits and risks, including the potential risks
of potential CSF leak, postoperative wound hematoma, the possibility of the tumor recurring
in the future, the possibility of some involvement and invasion of the underlying skull,
requiring some drilling away of the tissue, the possibility of infection, and the risks of
local anesthesia, including the possibility of death. The patient understood these risks,
and he did consent to the surgery.
OPERATIVE SUMMARY: The patient was brought to the operating room, laid on the operative
table in the supine position where he was given some mild IV sedation. He was positioned on
a gel donut such that the area of the biopsy of the patient's right medial parietal scalp
was exposed. This was shaved with clippers and then prepped and draped off in a sterile
manner using a double-glove technique. I planned an incision in the coronal plane to
preserve blood flow in the scalp, and then hemostasis was carried out along the edge of the
scalp, and a self-retaining retractor was placed. An obvious mass was identified. I worked
circumferentially around it, and then using monopolar cautery divided the galea and
periosteum in a circumference all the way around the tumor. Then using a curved periosteal
elevator, I gradually peeled the tumor back away from the skull, and despite the lack of
evidence on the MRI scan, there was some invasion into the superficial portion of the skull.
The tumor mass was removed, placed in a specimen cup, and sent to Pathology for gross and
microscopic pathological diagnosis. Because of some invasion of the superficial scalp, I
did use a Midas Rex dissecting tool to drill away much of this outer layer of the skull
until I was sure that I had drilled away all of the soft tissue as well as a margin of bone
underneath it to remove, if possible, all of the invading tumor. Once this was
accomplished, I did use FloSeal over the skull and then a piece of Gelfoam and then applied
pressure to obtain hemostasis. After holding pressure for approximately 4 minutes, this was
removed area. The extra FloSeal was irrigated away, and then the scalp incision was closed
in 2 layers in usual fashion with the skin being closed with skin staples. The incision was
then dressed with a bacitracin ointment, Telfa, sterile 4 x 4's, which were taped to the
patient's scalp. The patient then underwent successful reversal of the IV sedation, was
moving both upper and lower extremities well at the end of the procedure, and left the
operating room in stable condition.
This procedure was done with the aid of my physician assistant, who was
invaluable in maintaining retraction, suctioning, and otherwise assisting in the operation
to make it safer and more efficacious for the patient.
ESTIMATED BLOOD LOSS: For the procedure was 5 mL.
COMPLICATIONS: None.