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Biopsy, soft tissue of pelvis and hip area; superficial

CPT4 code

Name of the Procedure:

Biopsy, soft tissue of pelvis and hip area; superficial

Summary

A superficial soft tissue biopsy in the pelvis and hip area involves removing a small sample of tissue from just beneath the skin. This sample is then analyzed to diagnose or monitor medical conditions affecting that region.

Purpose

This procedure is used to diagnose or evaluate conditions such as infections, tumors, or other abnormalities in the soft tissues of the pelvis and hip. The main goal is to provide a definitive diagnosis, which can guide treatment decisions.

Indications

  • Unexplained lumps or masses.
  • Persistent pain or swelling in the hip or pelvis area.
  • Suspicion of infection or abscess.
  • Abnormal imaging results requiring tissue analysis.

Preparation

  • The patient may need to fast for a few hours before the procedure.
  • Certain medications, especially blood thinners, may need to be adjusted.
  • Diagnostic imaging, such as an MRI or CT scan, may be performed prior to the biopsy to locate the exact area of concern.

Procedure Description

  1. The patient lies on an examination table.
  2. The area of the biopsy is cleaned and sterilized.
  3. A local anesthetic is injected to numb the area.
  4. A small incision is made in the skin.
  5. A biopsy needle or surgical instrument is used to remove a tissue sample.
  6. The incision is closed with sutures or adhesive strips if necessary.
  7. The tissue sample is sent to a laboratory for analysis.

Tools and Equipment Used:

  • Sterile gloves and drapes.
  • Local anesthetic (e.g., lidocaine).
  • Biopsy needle or surgical scalpel.
  • Sutures or adhesive strips.

Duration

The procedure typically takes between 15 to 30 minutes.

Setting

This procedure is usually performed in an outpatient clinic, hospital, or surgical center.

Personnel

  • A surgeon or interventional radiologist performs the biopsy.
  • A nurse assists with preparation and post-procedure care.
  • An anesthesiologist may be involved if sedation is required.

Risks and Complications

  • Common risks: Infection, bleeding, or bruising at the biopsy site.
  • Rare risks: Damage to surrounding structures, allergic reaction to anesthetic, or inadequate tissue sample requiring a repeat biopsy.
  • Complications are managed by appropriate post-procedure care and follow-up.

Benefits

  • Accurate diagnosis of underlying conditions.
  • Helps guide appropriate treatment plans.
  • Non-invasive compared to deeper tissue biopsies.

Recovery

  • Patients can typically go home the same day.
  • Keep the biopsy site clean and dry.
  • Pain at the site can be managed with over-the-counter pain relievers.
  • Avoid strenuous activity for a few days.
  • Follow-up appointments may be needed to discuss biopsy results and next steps.

Alternatives

  • Imaging studies alone (e.g., MRI, CT scan) for non-invasive diagnosis.
  • Aspiration biopsy for fluid-filled masses.
  • Surgical biopsy for deeper or more complex tissues.

    Pros and Cons:

  • Imaging is less invasive but may not provide a definitive diagnosis.
  • Aspiration biopsy is less invasive but may not be suitable for all types of tissue.
  • Surgical biopsy provides a larger sample but is more invasive.

Patient Experience

  • Patients will feel a pinch or sting from the local anesthetic injection.
  • Most patients report minimal discomfort during the procedure due to the local anesthetic.
  • Post-procedure soreness or mild pain at the biopsy site is common and usually resolves within a few days.
  • Anxiety about awaiting results can be managed with the support of healthcare professionals.

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