Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure)
CPT4 code
Name of the Procedure:
Pathology Consultation During Surgery; Each Additional Tissue Block with Frozen Section(s)
Summary
During surgery, a pathologist may be called upon to examine additional tissue samples. These samples, known as tissue blocks, are quickly frozen, sectioned, and examined under a microscope to provide immediate information that can assist the surgical team in making decisions during the operation.
Purpose
This procedure helps in obtaining timely and accurate diagnoses during surgery. By examining additional frozen tissue sections, the pathologist can provide crucial information about tissue margins, presence of disease, and other critical factors, guiding the surgeon’s decisions in real-time.
Indications
- Suspected cancer or tumor requiring immediate diagnostic clarification.
- Need to evaluate tissue margins to ensure complete removal of malignant tissue.
- Unexpected findings during surgery that need further pathological assessment. Patients undergoing surgery where the nature or spread of a disease needs to be assessed immediately.
Preparation
- Patients typically follow the overall pre-operative instructions provided for the primary surgery, such as fasting or medication adjustments.
- No special preparation is needed specifically for the pathology consultation as it is part of the surgical process.
Procedure Description
- During surgery, if additional tissue samples need to be evaluated, the surgeon removes the sample and sends it to the pathology lab.
- The tissue block is quickly frozen using a cryostat machine.
- The frozen tissue is thinly sliced and placed on slides.
- The slides are stained and examined under a microscope by the pathologist.
- The pathologist communicates their findings to the surgical team, often within 15-30 minutes, guiding further surgical decisions.
Duration
Each additional tissue block examination typically takes about 15-30 minutes.
Setting
This procedure is performed within a hospital or surgical center, usually in a pathology lab that is closely integrated with the operating room.
Personnel
- Pathologist
- Surgical team (surgeon, surgical nurses)
- Laboratory technicians
Risks and Complications
- Misinterpretation of frozen section results (rare but possible).
- Handling errors that may require additional tissue samples.
Benefits
- Provides immediate diagnostic information that can impact surgical decisions.
- Helps ensure complete removal of diseased tissue, potentially reducing the need for follow-up surgeries.
- Improves surgical outcomes by allowing precise intraoperative assessments.
Recovery
- The recovery process is tied to the primary surgical procedure.
- No additional recovery steps are needed specifically for the pathology consultation.
Alternatives
- Standard post-operative pathological examination of tissues, which takes more time but does not impact immediate surgical decisions.
- Imaging techniques, although they do not provide the same level of diagnostic detail.
Patient Experience
- The patient is typically under general anesthesia and unaware of the consultation process.
- Post-operative care will follow the guidelines for the primary surgical procedure.
- Effective pain management and comfort measures are provided as part of routine surgical care.