Excisional biopsy of thigh mass

PREOPERATIVE DIAGNOSIS: Right thigh/hip mass.

POSTOPERATIVE DIAGNOSIS: Right thigh/hip mass.

PROCEDURE: Excisional biopsy of the right thigh mass.

FINDINGS: The patient had a 3 x 4-cm cystic structure consistent with an old organized hematoma from prior trauma.

ESTIMATED BLOOD LOSS: Less than 5 mL.

SPECIMEN: Cystic structure.

DESCRIPTION OF PROCEDURE: After consent was obtained for the procedure and risks and benefits described at length, the patient was taken to the operating room and placed supine on the operating room table. The patient was given IV medications by Dr. for deep sedation. The patient was then placed in the left lateral decubitus position. The patient?s right thigh was then prepped and draped in the standard surgical fashion. Local anesthetic was used directly overlying the mass. Local anesthetic consisted of 0.5% Marcaine and 1% lidocaine mixed in a 50/50 mixture.

After local anesthetic, an incision was made which was approximately 3 cm across the mass. The mass was then circumferentially dissected around with electrocautery and removed. The mass was cystic in nature with fluid being sort of a brownish serous fluid. The mass was passed off the field. Irrigation was used. Hemostasis was assured. Additional local anesthetic was then used for improved postoperative pain control.

A #10 Blake drain was placed into the space through a small separate incision given the size of the dead space left behind from the excisional biopsy. The drain was sewn in place with a 3-0 nylon suture. The excisional wound was then closed with a 3-0 Vicryl in a running fashion followed by 4-0 Monocryl in a subcuticular fashion. Steri-Strips were applied as well as a sterile dressing.

The patient was awakened and taken to the recovery room in stable condition.

codes: 
Code: 
0YB70ZX
Code Type: 
ICD-10
Code: 
?
Code Type: 
CPT