Level II - Surgical pathology, gross and microscopic examination Appendix, incidental Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglio
CPT4 code
Name of the Procedure:
Level II - Surgical pathology, gross and microscopic examination
Common Names: Pathologic examination, Gross and microscopic analysis
Summary
This procedure involves a detailed examination of surgically removed tissues to diagnose diseases. Samples from the appendix, incidental findings in the Fallopian tubes, traumatic amputations of fingers or toes, newborn foreskin, hernia sacs, hydrocele sacs, nerves, skin, and sympathetic ganglia are analyzed both visually (gross examination) and under a microscope (microscopic examination).
Purpose
The procedure diagnoses or rules out medical conditions like infections, cancers, tissue abnormalities, or congenital issues by examining the tissue samples.
Indications
- Unexplained pain or swelling in organs
- Traumatic injury resulting in amputation of fingers or toes
- Newborn circumcision
- Hernias or hydroceles needing surgical intervention
- Abnormalities in nerves or skin requiring plastic repair
Assessment of sympathetic ganglia for neurologic conditions
Preparation
- In most cases, no specific preparation is required for the pathology itself, as the focus is on the surgical collection of samples.
- Preoperative tests and clearances relevant to the surgical part of the procedure are conducted.
Procedure Description
- Sample Collection: Tissue samples are collected during surgery from the respective areas (e.g., appendix, Fallopian tubes, etc.).
- Gross Examination: The pathologist inspects the samples visually, noting abnormalities in size, shape, texture, and color.
- Fixation: Samples are preserved in formalin to prevent decay.
- Microscopic Examination: Thin sections of the sample are sliced, stained, and examined under a microscope for cellular abnormalities.
Tools and Equipment:
- Surgical instruments for tissue extraction
- Formalin for fixation
- Microtome for slicing tissue sections
- Microscope for cellular examination
Anesthesia or Sedation:
- Depends on the surgical procedure for tissue collection (e.g., general anesthesia for major surgeries, local anesthesia for minor procedures).
Duration
The pathology examination itself can take several hours to days, depending on the complexity of the sample analysis. Each tissue extraction surgery varies in time.
Setting
- Samples are collected in surgical settings such as hospitals or surgical centers.
- Pathological examination is performed in a pathology lab.
Personnel
- Surgeons perform the extraction of tissue samples.
- Pathologists conduct the gross and microscopic examination.
- Nurses and lab technicians assist in both settings.
Risks and Complications
- Minimal risks from the pathology aspect; risks are related more to the surgical extraction process.
- Rare complications might include insufficient tissue sampling or need for further surgery if initial samples are inconclusive.
Benefits
- Accurate diagnosis of medical conditions leading to targeted treatment.
- Early detection of serious conditions like cancer can significantly improve outcomes.
Recovery
- Recovery pertains mainly to the surgical procedure for obtaining tissue samples and follows standard post-operative care protocols.
- Follow-up consultations to discuss pathology results and further treatment plans.
Alternatives
- Non-invasive diagnostic imaging (e.g., MRI, CT scans), although these might not provide the same detailed cellular-level information.
- Fine needle aspiration (FNA) for cytologic studies (less invasive but may be less comprehensive).
Patient Experience
- Experience during pathology collection varies by the surgical procedure performed for sample extraction.
- Post-operation, patients may experience routine surgical recovery sensations including soreness, swelling, or mild pain, managed with prescribed medications.
By adhering to these guidelines, patients can ensure they are well-prepared for the procedure and understand its scope, benefits, and recovery process.