codeseeker
Guest
Requesting guidance - is the closure in this surgery considered an intermediate repair or complex repair? Also can someone please explain the meaning of "undermining" (described in the CPT book in the guidance preceding the repair codes, for complex repairs)?
OPERATIVE REPORT:
PREOPERATIVE DIAGNOSIS: Left shoulder mass; POSTOPERATIVE DIAGNOSIS: same
OPERATION PERFORMED: Excision of intramuscular shoulder mass with complex layer closure
COMMENTS AND FINDINGS: 5cm soft tissue mass intramuscular
DESCRIPTION OF PROCEDURE: After informed consent was obtained regarding all benefits, alternatives, risks, complications, and limitations of the procedure, the patient was taken to the operating room and was placed supine on the operating table. Following the thorough preparation of the left shoulder with Chloraprep solution, the patient was placed in lateral decubitus position, left side up. Via a curvilinear incision, we entered the subcutaneous tissue. Skin flaps were raised circumferencially with Bovie electrocautery or electrocoagulation. Muscle splitting technique was performed to identify the mass. After the tumor was circumferencially dissected out and en-bloc resection. After the mass was completely removed, it was sent to pathology. The wound was now irrigated with sterile water and it was completely hemostasized utilizing Bovie electrocautery. Local anesthesia was injected in all layers. The wound was closed in multiple layered fashion with 2-0 vicryl and 3-0 vicryl. At the conclusion of the procedure, the dermis was approximated with 3-0 vicryl in an inverted interrupted fashion, whereas the skin was approximated with subcuticular closure of 4-0 moncryl. Dermabond and SteriStrips were applied. The patient was advised no heavy lifting or strenuous activity for the next week. Patient tolerated procedure well. All instrument and gauze counts were repot by RN as correct x2. No critical events.
OPERATIVE REPORT:
PREOPERATIVE DIAGNOSIS: Left shoulder mass; POSTOPERATIVE DIAGNOSIS: same
OPERATION PERFORMED: Excision of intramuscular shoulder mass with complex layer closure
COMMENTS AND FINDINGS: 5cm soft tissue mass intramuscular
DESCRIPTION OF PROCEDURE: After informed consent was obtained regarding all benefits, alternatives, risks, complications, and limitations of the procedure, the patient was taken to the operating room and was placed supine on the operating table. Following the thorough preparation of the left shoulder with Chloraprep solution, the patient was placed in lateral decubitus position, left side up. Via a curvilinear incision, we entered the subcutaneous tissue. Skin flaps were raised circumferencially with Bovie electrocautery or electrocoagulation. Muscle splitting technique was performed to identify the mass. After the tumor was circumferencially dissected out and en-bloc resection. After the mass was completely removed, it was sent to pathology. The wound was now irrigated with sterile water and it was completely hemostasized utilizing Bovie electrocautery. Local anesthesia was injected in all layers. The wound was closed in multiple layered fashion with 2-0 vicryl and 3-0 vicryl. At the conclusion of the procedure, the dermis was approximated with 3-0 vicryl in an inverted interrupted fashion, whereas the skin was approximated with subcuticular closure of 4-0 moncryl. Dermabond and SteriStrips were applied. The patient was advised no heavy lifting or strenuous activity for the next week. Patient tolerated procedure well. All instrument and gauze counts were repot by RN as correct x2. No critical events.