# excision of a pectoralis muscle



## tgenia (Jul 18, 2012)

Hi, I am pulling my hair out on this one. This procedure is done on a male for a malignant tumor on the chest wall. The closet cpt to what was performed is 19260 but the rib was not taken or use the 21557 but that indicates soft tissue. I was thinking of using 19260/52. Any Idea's? Op note attached below.

PREOPERATIVE DIAGNOSIS 
Malignant solitary fibrous tumor of the pectoralis muscle, right side.


POSTOPERATIVE DIAGNOSIS
Malignant solitary fibrous tumor of the pectoralis muscle, right side. 


PROCEDURE
Wide local excision of the pectoralis mass essentially removing 90% of the
right pectoralis muscle. 


INDICATIONS FOR PROCEDURE
This is a 68-year-old gentleman who presented with a palpable mass on his
chest wall.  Mammogram and ultrasound were performed. Ultrasound-guided
biopsy was done, which showed a sarcoma consistent with a malignant solitary
fibrous tumor. CT scan of the chest, abdomen and pelvis was performed for
staging and there was no evidence of metastatic disease and thus wide local
excision was recommended. 


ANESTHESIA
General. 


ESTIMATED BLOOD LOSS
30 cc. 


COMPLICATIONS
None. 


FINDINGS
Negative margins with no invasion past the pectoralis fascia.


DESCRIPTION OF PROCEDURE
The patient was brought to the operating room and placed in the supine
position on the operating table. After adequate sedation was given, the
patient was intubated without complication. The patient was then prepped and
draped in a standard sterile fashion. Pause for the cause was completed. The
patient had been ultrasounded preoperatively and the area had been marked
with an X.  I intraoperatively as well performed an ultrasound to help
confirm the overall borders of the mass.  To encompass the entire specimen
as well as the biopsy tract a long 12 cm elliptical incision was made.  This
was then incised using electrocautery and thick skin flaps were then created
up to the level of the clavicle and then inferiorly down to the inframammary
fold. The plane was created some mammary to allow for mobilization and
resection of the pectoralis muscle, while preserving the anterior breast
tissue. Next, the pectoralis muscle was excised off of the clavicle using the
Harmonic scalpel. Medially it was excised off of the sternum. Laterally we
took the lateral edges of the pectoralis muscle with the Harmonic scalpel
entering into the posterior plane. The posterior pectoralis fascia was
intact. The mass was not attached to this.  We then excised the pectoralis
muscle off of the intercostal muscles and ribs using electrocautery and the
Harmonic scalpel. Once we were 5 cm away inferiorly from the mass, the
pectoralis muscle was divided using the Harmonic scalpel. Again, 90% of the
pectoralis muscle was removed. I physically took the specimen to pathology
oriented it for the pathologist and the specimen was cut.  It was a very well
circumscribed mass as seen by ultrasound. The posterior margin was our
closest, but it was freely mobile intraoperatively.  At this point we felt we
had an excellent R0 resection with good margins. Clips were placed
circumferentially around the biopsy cavity and the wound was then closed in 4
layers with 2-0 Vicryl, followed by 3-0 Vicryl followed by 4-0 Monocryl in a
running subcuticular manner. Steri-Strips and a sterile dressing were placed.
A 15 round drain had also been placed in the cavity and 2-0 nylon was used to
secure the drain.  Steri-Strips and a sterile dressing were placed. The
patient was extubated and transferred back to the recovery room in stable
condition.


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## j-fowler57 (Jul 18, 2012)

How about looking into the 2155X codes. AND depending on the complexity of the closure ( he says he went 4 layers with a drain) you may need the add on codes for the additional cm. of excision closure. ( Hope I worded that correctly )


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## tgenia (Jul 26, 2012)

Thanks so much I appreciate your help


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