Not quite sure how this should end up being billed. Hoping for other thoughts (even if they are only regarding part of the op report). I know there is not nearly enough info for the excisions. They are driving me crazy! I have the pathology to work from (it follows the scrubbed op report), but ugh. Thanks.


PREOPERATIVE DIAGNOSIS
Ventral hernia, symptomatic. History of multiple lesions on the back. History of Muir Torres syndrome.

OPERATION PERFORMED
Exploratory laparotomy with reduction of ventral hernia with omentectomy, laparoscopic with open repair with 14 x 18 cm Bard mesh.

DESCRIPTION OF PROCEDURE
The patient was taken to the operating room after induction of adequate anesthesia, the patient was turned in a right lateral position. The multiple lesions had been marked over the left and right back. The lesions numbered a total of 11. The area was well prepped and draped. Transverse incisions were made for most of the lesions, carried down through subcutaneous tissue. Fatty appearing tumors were noted in most of the lesions noted inferiorly. In the right upper back a lesion with some associated scarring and substance was appreciated, and this was resected with wider margins. An additional lesion that appeared to be some sort of sebaceous or epithelial cyst concerning for the Muir Torres Syndrome was noted in the upper back superiorly. It was the most cephalad of all the lesions. The lesions were all well excised, passed off as specimen. Hemostasis was achieved with electrocautery. The wounds were then closed with 3-0 Vicryl to the subcutaneous tissue. Clips were applied to the skin. Tegaderm dressings were applied to all these lesions. With this completed, the patient was then placed in a supine position. Curvilinear incision was made with a #15 blade over the significantly enlarged umbilicus. The patient was noted to have a significant amount of omental fat. This was freed from surrounding tissue. The fascial defect was enlarged slightly to allow access to the abdominal cavity. Once this was well freed, attempt was made to reduce the herniated tissue and this was not possible. Ultimately resection of the omentum was performed and tissue was passed off as specimen. Hemostasis was achieved. All residual tissue was then reduced. The Bard Kugel mesh was then inserted. It was tacked at one end with 2-0 Prolene suture. The laparoscopic instrumentation had been placed under direct vision. Once this was done, the peritoneum was loosely closed with Allis clamps and the abdomen was insufflated. Then, utilizing the ProTack the mesh was applied circumferentially to the abdominal wall. The 2-0 Prolene sutures were utilized on the mesh attaching it to fascia. With all this completed, residual umbilical tissue was then draped over the mesh. The wound was thoroughly irrigated with antibiotic solution. It was then closed in layers utilizing 2-0 Vicryl to the deep tissue and 3-0 Vicryl to the subcutaneous tissue. Clips were applied to the skin. Again the abdomen was well insufflated, and circumferential view of the mesh noted to lie in good position with no bulges. The tacks were all well in place. The patient tolerated the procedure.

Pathology:
A. SOFT TISSUE, "SUBMITTED AS MULTIPLE MASSES OF THE BACK":

MULTIPLE FRAGMENTS OF BENIGN ADIPOSE TISSUES, CONSISTENT WITH FRAGMENTS OF TISSUES FROM LIPOMAS.

SEVERAL FRAGMENTS OF TISSUE HAVE FEATURES SUGGESTIVE OF ANGIOLIPOMA.

B. SKIN AND SUBCUTANEOUS TISSUE, "SUBMITTED AS RIGHT UPPER MID BACK MASS":

BENIGN SKIN AND SUBCUTANEOUS TISSUES WITH A BENIGN EPIDERMAL INCLUSION CYST IDENTIFIED IN SUBCUTANEOUS TISSUES. THE LESION IS BORDERED BY FIBROTIC DERMAL CONNECTIVE TISSUES.

C. SKIN AND SUBCUTANEOUS TISSUE, "SEBACEOUS CYST, UPPER BACK":

BENIGN SKIN AND SUBCUTANEOUS TISSUES WITH A BENIGN EPIDERMAL INCLUSION CYST IDENTIFIED IN SUBCUTANEOUS TISSUES. THE LESION IS BORDERED BY FIBROTIC DERMAL CONNECTIVE TISSUES.

Specimen(s) Received
A. MULTIPLE MASSES OF THE BACK
B. RIGHT UPPER MID BACK MASS
C. SEBACEOUS CYST, UPPER BACK

Specimen is received in five parts and all fixed in formalin.

A. multiple masses, back and consists of thirteen, lobulated to fragmented appearing pieces of yellow-tan fibroadipose tissue, with sizes ranging from 0.5x0.5x0.4 cm to the largest measuring 2x2x1 cm. Sections of all specimens reveal firm, lobulated, yellow-tan fibroadipose tissues. Random and representative sections are submitted in five cassettes. 5 C F, P.E.

B. right upper mid back mass and consists of an ellipse of wrinkled, pink-tan skin and underlying lobulated, firm, yellow-tan fibroadipose tissue, measuring overall 2.5x2x2.5 cm. The surface of the specimen is marked with black ink prior to sectioning. On sectioning the specimen, underlying elements of firm, tan, subcutaneous tissues are noted. Centrally, there is a 1 cm area of a cystic lesion identified, containing white-tan, cheesy material. Bordering elements of lobulated appearing, yellow-tan fibroadipose tissues are seen. Random cross sections are submitted in two cassettes. 2 C 2, P.E.

C. sebaceous cyst, upper back and consists of a lobulated to fragmented appearing, ellipse-like piece of grey-tan skin and underlying, lobulated to fragmented, yellow-tan soft tissue, measuring 2.5x2x2.4 cm. The surface of the specimen is marked with black ink prior to sectioning. Sections of the specimen reveal underlying elements of firm, tan connective tissue. A disrupted cystic lesion is noted at one edge, measuring 1 cm in maximum dimension, containing white-tan, cheesy material. Representative cross sections are submitted in two cassettes. 2 C 3, P.E.