Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other than incidental Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologi
CPT4 code
Name of the Procedure:
Level III - Surgical Pathology, Gross and Microscopic Examination
Summary
This procedure involves the detailed examination of tissues removed during surgery, which includes visual inspection (gross examination) and microscopic analysis. It is used to diagnose and evaluate various conditions such as induced abortion, abscesses, aneurysms, and other abnormalities.
Purpose
The primary purpose is to determine the nature and extent of disease present in the tissue samples. The goals include diagnosing specific conditions, guiding treatment plans, and providing prognostic information.
Indications
- Symptoms suggestive of serious underlying conditions (e.g., chronic inflammation, unusual growths, suspected malignancies).
- Medical events such as induced abortion to confirm the absence of retained products of conception.
- Conditions like abscesses, aneurysms, or abnormal tissue growths that have been surgically excised.
- Evaluation of anomalies such as an anal tag, atheromatous plaque, Bartholin's gland cysts, or non-incidental appendix removal.
Preparation
- Patients usually do not require specific preparation for the pathology examination itself, as it is conducted on tissues already removed during surgery.
- Pre-surgical instructions may include fasting, medication adjustments, or laboratory tests as indicated by the underlying condition.
Procedure Description
- The surgical specimen is received by the pathology department.
- A gross examination involves visually inspecting, measuring, and photographing the tissue.
- The pathologist takes representative sections to prepare slides for microscopic examination.
- Tissue sections are stained with special dyes to highlight cellular structures.
- The pathologist examines the slides under a microscope to identify any abnormalities.
- A detailed pathological report is prepared, outlining the findings and diagnoses.
Duration
The pathology examination can take several hours to a few days, depending on the complexity and extent of tissue analysis required.
Setting
The procedure is performed in a hospital or specialized pathology laboratory.
Personnel
- Pathologist
- Laboratory technicians
- Support staff
Risks and Complications
- There are no direct risks to the patient since the procedure deals with excised tissues.
- Potential for delays in diagnosis which could impact treatment timelines.
Benefits
- Accurate diagnosis of the underlying condition.
- Informative data to guide further treatment plans.
- Prognostic information that aids in patient counseling and management.
Recovery
- Since the patient is not physically involved in this procedure, there is no recovery phase.
- Post-surgical care will be dictated by the specific surgical procedure performed prior to pathology examination.
Alternatives
- Non-invasive imaging techniques (e.g., MRI, CT scans) can provide information but may not replace the need for tissue diagnosis.
- Clinical observation and symptomatic treatment without definitive tissue diagnosis in certain benign conditions.
Patient Experience
During the procedure itself, the patient will not experience any direct effects since it is conducted on tissue samples outside the body. Postoperative care will focus on the recovery from the initial surgical procedure from which the tissue was obtained.