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Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm

CPT4 code

Name of the Procedure:

Excision of Tumor, Soft Tissue of Back or Flank, Subfascial (e.g., Intramuscular); Less Than 5 cm

Summary

This surgical procedure involves removing a tumor located within the soft tissue beneath the fascia (subfascial), often embedded within the muscles of the back or flank. The tumor is less than 5 centimeters in size.

Purpose

The main goal of this procedure is to remove a tumor to prevent it from causing further health issues or discomfort. By excising the tumor, the procedure aims to alleviate pain, prevent the spread of potential cancer cells, or eliminate a benign but problematic mass.

Indications

  • Presence of a detectable soft tissue mass in the back or flank region.
  • Symptoms such as pain, swelling, or limited mobility caused by the mass.
  • Diagnostic imaging or biopsy indicating the need for tumor removal.
  • Suspected or confirmed malignancy.

Preparation

  • Follow fasting instructions as directed by the healthcare provider, usually not consuming food or drink for 8-12 hours before surgery.
  • Adjust or pause certain medications, particularly blood thinners, as advised by the doctor.
  • Undergo preoperative assessments, such as blood tests, imaging studies (e.g., MRI or CT scans), and possibly a biopsy to determine the nature of the tumor.

Procedure Description

  1. Anesthesia: The patient will be given general anesthesia to ensure they are asleep and pain-free during the procedure.
  2. Incision: The surgeon makes an incision over the site of the tumor.
  3. Exposure: The surrounding tissues are carefully retracted to expose the tumor within the muscle.
  4. Excision: The tumor is meticulously dissected and removed from the surrounding tissues while preserving as much healthy tissue as possible.
  5. Closure: The incision is closed with sutures, and a sterile bandage is applied.

Tools and equipment often include scalpels, retractors, surgical scissors, sutures, and sometimes specialized instruments like electrocautery devices.

Duration

The procedure typically takes between 1 to 2 hours, depending on the exact location and size of the tumor.

Setting

This surgery is usually performed in a hospital's operating room or a specialized surgical center.

Personnel

  • Surgeon: Performs the procedure.
  • Anesthesiologist: Administers anesthesia and monitors the patient.
  • Surgical Nurse: Assists the surgeon.
  • Operating Room Technician: Prepares and maintains the surgical equipment.

Risks and Complications

  • Common Risks: Infection, bleeding, pain at the incision site, and reactions to anesthesia.
  • Rare Risks: Damage to surrounding muscles or nerves, incomplete removal of the tumor, and recurrence of the tumor.

Benefits

  • Removal of the tumor can relieve symptoms such as pain and discomfort.
  • Prevents potential complications associated with untreated tumors, including growth and malignancy.
  • Patients generally experience these benefits shortly after recovery.

Recovery

  • Post-procedure care includes pain management, wound care instructions, and possibly physical therapy.
  • Patients may experience swelling and discomfort for a few days to a week.
  • Full recovery typically takes about 4 to 6 weeks, with specific activity restrictions to avoid strain on the surgical site.
  • Follow-up appointments are necessary to monitor healing and ensure no recurrence of the tumor.

Alternatives

  • Observation: Monitoring the tumor through regular imaging studies.
  • Radiation Therapy: May be used if the tumor is malignant and not easily accessible for surgery.
  • Chemotherapy: Might be considered for malignant tumors, especially if they are not localized.

Comparatively, surgery provides immediate removal but comes with surgical risks, while non-surgical options may have varied effectiveness and longer treatment times.

Patient Experience

During the procedure, the patient will be under general anesthesia and not feel any pain. Post-procedure, patients might experience soreness, swelling, and the need for pain relief medication. Comfort measures include prescribed medications and applying ice packs to the affected area.

Remember to follow all medical advice and attend all post-operative check-ups for optimal recovery.

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