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Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater

CPT4 code

Name of the Procedure:

Excision, Tumor, Soft Tissue of Upper Arm or Elbow Area, Subfascial (e.g., Intramuscular); 5 cm or Greater

Summary

This procedure involves the surgical removal of a tumor located within the soft tissues below the fascia (connective tissue) in the upper arm or elbow area. The excised tumor must be at least 5 cm in size. It's often performed to diagnose the nature of the tumor and prevent potential complications.

Purpose

The primary purpose of this procedure is to address and potentially cure benign or malignant tumors found within the soft tissue underneath the fascia of the upper arm or elbow area. The goals are to alleviate symptoms, prevent the spread of disease, and restore function to the affected area.

Indications

  • Presence of a palpable mass or lump in the upper arm or elbow.
  • Pain, swelling, or limited mobility in the affected area.
  • Suspected or confirmed diagnosis of a soft tissue tumor through imaging studies.
  • Rapid growth or changes in the characteristics of the tumor.

Preparation

  • Patients may need to fast for a specific period before the surgery.
  • Medications may be adjusted, particularly blood thinners or anti-inflammatory drugs.
  • Preoperative imaging studies (e.g., MRI or CT scans) to assess the tumor.
  • Blood tests and a physical examination to ensure patient readiness for surgery.

Procedure Description

  1. The patient is administered anesthesia (usually general anesthesia).
  2. The surgical site is sterilized, and an incision is made over the tumor.
  3. The surgeon carefully dissects through the layers of tissue to reach the tumor beneath the fascia.
  4. The tumor is excised along with a margin of healthy tissue to ensure complete removal.
  5. Hemostasis (stopping of bleeding) is achieved, and the incision is closed with sutures.
  6. A sterile bandage is applied to protect the site.

Duration

Typically, the procedure takes about 1 to 2 hours, depending on the complexity and size of the tumor.

Setting

The procedure is usually performed in a hospital operating room or a specialized surgical center.

Personnel

  • Surgeon (specialized in orthopedic or general surgery)
  • Surgical nurses
  • Anesthesiologist
  • Operating room technicians

Risks and Complications

  • Infection at the incision site
  • Bleeding or hematoma formation
  • Damage to surrounding muscles, nerves, or blood vessels
  • Scarring or poor wound healing
  • Potential need for additional treatment (e.g., radiation therapy or chemotherapy if the tumor is malignant)

Benefits

  • Removal of the tumor and alleviation of associated symptoms.
  • Prevention of potential complications related to tumor growth.
  • Better diagnosis which can guide further treatment if necessary.

Recovery

  • Patients may need to stay in the hospital for a short period post-surgery.
  • Pain management with prescribed medications.
  • Instructions on wound care and activity restrictions.
  • Follow-up appointments for suture removal and to monitor healing.
  • Physical therapy may be recommended to restore range of motion and strength.

Alternatives

  • Watchful waiting with regular monitoring via imaging for benign tumors.
  • Non-surgical treatments such as radiation or chemotherapy for certain types of tumors.
  • Minimal invasive procedures, though they may not be suitable for large or intrusive tumors.

Patient Experience

During the procedure, the patient will be under anesthesia and should not feel pain. Post-surgery, there may be discomfort, swelling, and a need for pain management. Recovery includes rest, gradual return to activity, and adherence to post-operative care instructions, with most patients resuming normal functions within a few weeks.

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