Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cm
CPT4 code
Name of the Procedure:
Excision, Tumor, Soft Tissue of Leg or Ankle Area, Subfascial (Intramuscular); Less than 5 cm
Summary
This procedure involves the surgical removal of a tumor located within the soft tissue under the fascia, which is a connective tissue layer, in the leg or ankle area. The tumor is less than 5 centimeters in size and may involve muscle tissue.
Purpose
This procedure aims to remove abnormal growths or tumors within the soft tissue of the leg or ankle to prevent potential malignancy or alleviate symptoms.
Indications
- Presence of a detectable soft tissue mass or tumor in the leg or ankle area.
- Symptoms such as pain, swelling, or impaired function of the leg or ankle.
- Diagnostic imaging or biopsy indicating a benign or malignant tumor.
- Failure of non-surgical treatments to manage symptoms or reduce tumor size.
Preparation
- Patient may need to fast for 8 hours prior to the procedure.
- Adjustments to current medications, particularly blood thinners, might be required.
- Pre-procedure diagnostic tests, like MRI or CT scans, to assess the tumor’s size and location.
- Blood tests to evaluate overall health and surgical readiness.
Procedure Description
- Anesthesia: Patient is given regional or general anesthesia depending on the size and depth of the tumor.
- Incision: A surgical incision is made over the tumor site.
- Exposure: The fascial layer covering the tumor is carefully opened.
- Tumor Removal: The tumor, along with a margin of surrounding tissue, is excised using surgical instruments.
- Closure: The incision is closed with sutures or staples, and a dressing is applied.
- Specimen Examination: The excised tissue may be sent for pathological examination to confirm diagnosis.
Duration
The procedure typically takes 1 to 2 hours, depending on the complexity.
Setting
It is performed in a hospital or surgical center equipped for orthopedic or soft tissue surgeries.
Personnel
- Orthopedic or general surgeon
- Surgical nurses
- Anesthesiologist
- Pathologist (for tissue examination)
Risks and Complications
- Infection at the surgical site
- Bleeding or hematoma formation
- Nerve damage leading to sensory or motor deficits
- Recurrence of the tumor
- Adverse reactions to anesthesia
Benefits
- Removal of the tumor can lead to symptom relief and prevent potential malignant transformation.
- Improvement in leg or ankle function.
- Reduced risk of future complications associated with the tumor.
Recovery
- Post-procedure pain managed with medications.
- The patient may need to limit physical activity for several weeks.
- Follow-up appointments to monitor healing and remove stitches.
- Physical therapy might be recommended to regain strength and mobility.
Alternatives
- Surveillance with regular imaging and clinical exams if the tumor is asymptomatic.
- Non-surgical treatments like radiation or chemotherapy, particularly if the tumor is malignant and less suitable for surgery.
- Minimally invasive techniques like needle biopsy but might not be curative
Patient Experience
- During the procedure, the patient will be under anesthesia and not feel pain.
- Postoperative discomfort and swelling are common, managed by pain medications and ice packs.
- Physical therapy might be required to restore full function, depending on the muscle involvement.
Pain management and comfort measures will be tailored to the individual's needs to ensure a smooth recovery process.