Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity, disarticulation Fetus,
CPT4 code
Name of the Procedure:
Level VI - Surgical Pathology, Gross and Microscopic Examination: Bone Resection, Breast Mastectomy with Regional Lymph Nodes, Colon Segmental Resection for Tumor, Colon Total Resection, Esophagus Partial/Total Resection, Extremity Disarticulation, Fetus Examination
Summary
This procedure involves the surgical removal and detailed examination of various tissues, including bones, breast tissue with lymph nodes, segments of the colon, the entire colon, the esophagus, extremities, and fetal tissue. Pathologists perform both a gross (visual) and microscopic analysis to diagnose and understand diseases or conditions present in the resected tissues.
Purpose
The purpose is to diagnose diseases like cancer or to understand particular conditions of the resected tissues, thereby guiding further treatment. The goal is to obtain detailed pathological information to aid in patient management.
Indications
- Presence of tumors or masses.
- Suspicion of cancer.
- Chronic conditions such as Crohn's disease or ulcerative colitis.
- Severe trauma or non-functional extremities.
- Complications in fetal development.
Preparation
- Fasting may be required if the resection involves the digestive tract.
- Medication adjustments, particularly if blood thinners are used.
- Preoperative diagnostic tests like imaging studies (CT, MRI).
- Blood tests to assess overall health and readiness for surgery.
Procedure Description
- Bone Resection: Removal of a bone segment, cleaned and examined visually, then prepared for microscopic examination.
- Breast Mastectomy with Lymph Node Removal: Complete removal of breast tissue along with nearby lymph nodes; tissues are examined for cancer cells.
- Colon Resection for Tumor/Total Resection: Removal of the diseased portion or entire colon; tissues are then sampled for pathology.
- Esophagus Resection: Partial or total removal of the esophagus; the tissue is analyzed for malignancies or other conditions.
- Extremity Disarticulation: Removal of a limb; examination focuses on potential malignancies or severe infections.
- Fetus Examination: Detailed examination of fetal tissue, often in cases of miscarriage to understand the cause.
Tools and Technology: Scalpels, forceps, microscopes, histopathology equipment. Anesthesia: General anesthesia is typically required.
Duration
The duration varies, generally between 1-6 hours depending on the complexity of the resection.
Setting
Performed in a specialized surgical pathology laboratory within a hospital.
Personnel
- Surgeon.
- Surgical Nurses.
- Pathologist.
- Anesthesiologist.
Risks and Complications
- Infection.
- Bleeding.
- Anesthetic complications.
- Specific complications related to the type of resection, such as leakage in gastrointestinal surgeries.
Benefits
Provides crucial diagnostic information to guide treatment. Allows for assessment of the disease spread. Benefits are usually realized shortly after the pathology report is available, typically within a few days.
Recovery
- Postoperative care varies by resection type; may include wound care, antibiotics, pain management.
- Recovery time ranges from a few weeks to several months.
- Follow-up appointments are necessary to discuss pathology results and further treatment.
Alternatives
- Imaging studies (e.g., MRI, CT scans), which can be less accurate.
- Biopsies that are less invasive but may not provide as comprehensive information.
- Watchful waiting in certain non-aggressive conditions.
Patient Experience
Patients will generally experience anesthesia and will be unconscious during the procedure. Postoperative discomfort varies with the type of resection but can usually be managed with pain medications and supportive care.