# lap: pelvic mass



## daniel (Jan 20, 2014)

Hi All

Are we using unlisted for this service?


POSTOPERATIVE DIAGNOSIS:  Pelvic mass consistent with hemangioma.


OPERATION PERFORMED:  Resection of pelvic mass.


FINDINGS:  The patient had a left-sided pelvic mass approximately 4 cm adjacent to the left seminal vesicle identified on CT scan.  The patient needed to have the mass removed to be an eligible transplant recipient.  Mass was in left pelvis adjacent to left SV, left ureter, was identified and preserved, left vas deferens was preserved.  The mass was completely resected.


PROCEDURE IN DETAIL:  The patient is a 35-year-old male who presented to Urology Clinic for renal transplant clearance, with an incidental finding of a left pelvic mass.  The patient has a history of having a nephrectomy for hemorrhagic cyst, and also has end-stage renal disease since he was a child from lupus.  The patient's pelvic mass had unclear etiology, so it was decided to excise it to determine pathologic significance.   


The patient was brought to the operating room.  He consented to the risks and benefits of the surgery, which included but were not limited to bleeding, infection, need for further surgeries should the mass be malignant, the risk of anesthesia which included heart attack, stroke, and death, as well as requiring need for tissue adjacent to the mass to be resected as well.  The patient agreed to the risks and benefits and wished to proceed as planned.   


Upon entering the operating room, he was positioned in lithotomy with all pressure points padded.  He had had general anesthesia with an ET tube placed.  He received preoperative antibiotics.  He was then prepped and draped in the usual fashion.  He was in low lithotomy for robot positioning.  We began with placing a Veress needle in the midline abdomen.  Care was taken to avoid damage to any intraabdominal structures.  The abdomen was insufflated, and a 12 mm port was placed supraumbilical.  Once this was placed, the camera was then placed into the abdomen.  There were found to be minimal adhesions.  Then, four additional ports were placed, three robotic arms placed and one assistant port was placed.  The robot ports were all 8 mm, and the assistant port was 10 mm.  We then docked the robot adequately, attached all the arms, and began the intraabdominal dissection with the robotic assistance.  Upon examining the pelvis, a vascular lesion was noted at the left pelvis.  As we proceeded toward it, we identified the ureter, which was easy to identify and avoided.  We then also identified the ampulla.  Using the preoperative imaging to guide us, we traced the ampulla down to the left seminal vesicle, and were able to completely excise and dissect the mass free from the seminal vesicle.  It did not appear to be attached or invading any of the surrounding structures.  Once this mass was dissected free, it was removed and sent for frozen section which was found to be a hemangioma.  Also, a slightly abnormal appearance was on the peritoneum, which had been overlying and abutting the vascular tissue in question.  This was also sampled and taken for permanent specimen as well as frozen, the frozen being benign.  Once this was completed, we irrigated the pelvis.  Good hemostasis was achieved.  This completed this part of the case.  We then undocked the robot and proceeded to close the abdomen.  We used a Carter-Thomason device to close the 10 mm midline port.  We then removed all the other laparoscopic ports under direct vision.  There was no bleeding seen.  The abdomen was desufflated.  Also, a JP drain was left in the pelvis and secured with nylon sutures to the right lower quadrant laparoscopic port.  The four other incisions were then closed with a subcutaneous layer of Vicryl, skin with Monocryl, and covered with Dermabond.  The JP drain was dressed in gauze, thus completing the procedure.


RAPID FROZEN SECTION TELEPHONE DIAGNOSIS:  Benign hemangioma.


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## lizard (Jan 23, 2014)

because it was done with the laparoscope there isn't really a code. I would use the unlisted abdomen laparoscopic code for the excision of the hemangioma and 49321 for the bx of the peritoneum.


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## daniel (Jan 23, 2014)

Thank You!


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