NancyZ76
Contributor
Can anyone give any guidance for this. Thinking 19281 or 19125 or both??
Indications: This patient has a papilloma and mass of the of the right breast which was previously biopsied and requires excision.
Pre-operative Diagnosis: right breast mass and papilloma
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Post-operative Diagnosis: right breast mass and papilloma
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Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, bleeding, infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was taken to operating room identified correctly and the procedure verified as right Needle localized Breast mass Excision. A Time Out was held and the above information confirmed.
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The patient was placed prone on the stereotactic core table. The right breast clip lesion was localized stereotactically. Using standard aseptic technique and 1% Lidocaine and for local anesthetic. A 9cm Kopans needle wire device was then advanced ot the targeting coordinates. Stereotactic imaging was used to confirm appropriate localization. The wire was deployed and imaging confirmed appropriate wire placement. Sterile dressing was placed with steristrips and gauze. The patient tolerated this procedure well without complications. She was then brought to the OR.
The patient was placed supine. The breast was prepped and draped in the standard fashion. Lidocaine 0.5% with epinephrine and bicarbonate was used to anesthetize the skin over the external portion of the wire.
An curvilinear incision was created at 8-10:00 in the periareolar skin near the external wire. Dissection was carried down through the subcutaneous fat. A core of breast tissue was taken around the wire and excised. The specimen was then imaged and the clip was confirmed to be in the tissue. Hemostasis was achieved with cautery. Closure was performed in 2 layers with a 4-0 monocrylsubcuticular closure. The specimen was oriented with sutures- short superior,long lateral.
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Steri-Strips were applied. At the end of the operation all sponge, instrument and needle counts were correct. interpreted all images during the procedure.
*
Indications: This patient has a papilloma and mass of the of the right breast which was previously biopsied and requires excision.
Pre-operative Diagnosis: right breast mass and papilloma
*
Post-operative Diagnosis: right breast mass and papilloma
*
*
*
Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, bleeding, infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was taken to operating room identified correctly and the procedure verified as right Needle localized Breast mass Excision. A Time Out was held and the above information confirmed.
*
The patient was placed prone on the stereotactic core table. The right breast clip lesion was localized stereotactically. Using standard aseptic technique and 1% Lidocaine and for local anesthetic. A 9cm Kopans needle wire device was then advanced ot the targeting coordinates. Stereotactic imaging was used to confirm appropriate localization. The wire was deployed and imaging confirmed appropriate wire placement. Sterile dressing was placed with steristrips and gauze. The patient tolerated this procedure well without complications. She was then brought to the OR.
The patient was placed supine. The breast was prepped and draped in the standard fashion. Lidocaine 0.5% with epinephrine and bicarbonate was used to anesthetize the skin over the external portion of the wire.
An curvilinear incision was created at 8-10:00 in the periareolar skin near the external wire. Dissection was carried down through the subcutaneous fat. A core of breast tissue was taken around the wire and excised. The specimen was then imaged and the clip was confirmed to be in the tissue. Hemostasis was achieved with cautery. Closure was performed in 2 layers with a 4-0 monocrylsubcuticular closure. The specimen was oriented with sutures- short superior,long lateral.
*
Steri-Strips were applied. At the end of the operation all sponge, instrument and needle counts were correct. interpreted all images during the procedure.
*