sdunaway1
Guru
Would this be coded as a skull based tumor? Cannot find a proper code. The path report states - Calvaria lesion, right, resection: - Cavernous hemangioma.
61781,61304(?)
diagnosis: Expansile right calvarial lesion
Procedures:
- Craniotomy for excision of right calvarial lesion
- stereotactic navigation, necessary for incision planning, craniotomy planning, and ensuring maximal safe extent of resection while protecting sensitive neurological structures and cerebral vasculature
Surgeons:
Surgeons and Role:
*
--An assist was needed throughout the entirety of the procedure to assist with patient transport, positioning, and retraction of soft tissue and neurologic structures, and assisting under the microscope.
Indications: 57 year old male who presented with severe refractory lancinating pain in the skull and scalp on the right side over many years. Patient had previously been found to have a hypodense "punched" out appearing lesion in his skull. He was evaluated by multiple other surgeons who indicated to him that excision was not necessary. Given the growth of the lesion (double over the course of 2 years) and the refractory pain, decision was made to attempt excision and send for biopsy. The risks, benefits, and alternatives of the above procedure were discussed with the patient, they verbalized understanding and elected to proceed.
Procedure in detail:
The patient was transported to the operating room on a gurney and general endotracheal anesthesia was smoothly induced by the anesthesia team. Eyes were taped shut to prevent corneal abrasion. We placed the the patient in a mayfield horseshoe head holder after transitioning the patient to the OR table in supine position with a shoulder bump to facilitate easier access to the location of the lesion. All pressure points padded, a lower body warmer was placed. The scalp was scrubbed, washed, and dried. We then registered the stealth navigation system using electromagnetic navigation with a forehead external array to better than 2mm accuracy and this was double checked against anatomic landmarks. Next the hair was clipped and planned out a curvilinear incision. The scalp was then prepped with chloraprep which was allowed to dry before sterile draping. A timeout was held. We injected local anesthetic with epinephrine along our incision. We double checked the stealth navigation and found it remained accurate
We opened our incision with 10 blade scalpel, obtained hemostasis and using a self retaining retractor to mobilize the scalp. The scalp flap was mobilized with periosteal elevator. We located the area of the lesion which was partially recognizable by the abnormal discolored appearance of the outer cortex using the stealth EM navigation system. After defining the boders of the lesion, a high speed drill was used to gently perforate the outer cortex of the bone overlying the calvarial lesion at it's superior aspect. A well circumscribed, dusky mottled and pink lesion was immediately appreciated inside the bone, with good margins. The rest of the overlying thinned outer cortex was removed with the use of #3 and 4 kerrison rongeurs until the lesion was visualized circumferentially. Once it was fully exposed the entire lesion was removed en bloc with a penfiled one and handed off to the back table for pathology. The inside of the bony cavity was then debrided aggressively with a penfield 1 to ensure no residual lesion was present and the margins were drilled approximately 1 mm in each direction to ensure supramarginal resection. No residual gross tumor was identified.
For closure, we filled the bony cavity with dry gelfoam and placed a contoured trimmed mesh just slightly larger than the calvarial cavity and secured with 4 mm cranial plating screws. We copiously irrigated the site with irricept. We closed the scalp flap with interrupted 2-0 vicryl sutures, then running 4-0 monocryl. The wound was cleaned, dried, and dressed with bacitracin and telfa. All counts were correct x2, the drapes were taken down. The patient's head was then removed from the head holder and he was turned back to the supine position on a gurney. Patient was extubated and transferred to PACU ins table condition with anticipated DC home if pain was well controlled. There were no complications.
61781,61304(?)
diagnosis: Expansile right calvarial lesion
Procedures:
- Craniotomy for excision of right calvarial lesion
- stereotactic navigation, necessary for incision planning, craniotomy planning, and ensuring maximal safe extent of resection while protecting sensitive neurological structures and cerebral vasculature
Surgeons:
Surgeons and Role:
*
--An assist was needed throughout the entirety of the procedure to assist with patient transport, positioning, and retraction of soft tissue and neurologic structures, and assisting under the microscope.
Indications: 57 year old male who presented with severe refractory lancinating pain in the skull and scalp on the right side over many years. Patient had previously been found to have a hypodense "punched" out appearing lesion in his skull. He was evaluated by multiple other surgeons who indicated to him that excision was not necessary. Given the growth of the lesion (double over the course of 2 years) and the refractory pain, decision was made to attempt excision and send for biopsy. The risks, benefits, and alternatives of the above procedure were discussed with the patient, they verbalized understanding and elected to proceed.
Procedure in detail:
The patient was transported to the operating room on a gurney and general endotracheal anesthesia was smoothly induced by the anesthesia team. Eyes were taped shut to prevent corneal abrasion. We placed the the patient in a mayfield horseshoe head holder after transitioning the patient to the OR table in supine position with a shoulder bump to facilitate easier access to the location of the lesion. All pressure points padded, a lower body warmer was placed. The scalp was scrubbed, washed, and dried. We then registered the stealth navigation system using electromagnetic navigation with a forehead external array to better than 2mm accuracy and this was double checked against anatomic landmarks. Next the hair was clipped and planned out a curvilinear incision. The scalp was then prepped with chloraprep which was allowed to dry before sterile draping. A timeout was held. We injected local anesthetic with epinephrine along our incision. We double checked the stealth navigation and found it remained accurate
We opened our incision with 10 blade scalpel, obtained hemostasis and using a self retaining retractor to mobilize the scalp. The scalp flap was mobilized with periosteal elevator. We located the area of the lesion which was partially recognizable by the abnormal discolored appearance of the outer cortex using the stealth EM navigation system. After defining the boders of the lesion, a high speed drill was used to gently perforate the outer cortex of the bone overlying the calvarial lesion at it's superior aspect. A well circumscribed, dusky mottled and pink lesion was immediately appreciated inside the bone, with good margins. The rest of the overlying thinned outer cortex was removed with the use of #3 and 4 kerrison rongeurs until the lesion was visualized circumferentially. Once it was fully exposed the entire lesion was removed en bloc with a penfiled one and handed off to the back table for pathology. The inside of the bony cavity was then debrided aggressively with a penfield 1 to ensure no residual lesion was present and the margins were drilled approximately 1 mm in each direction to ensure supramarginal resection. No residual gross tumor was identified.
For closure, we filled the bony cavity with dry gelfoam and placed a contoured trimmed mesh just slightly larger than the calvarial cavity and secured with 4 mm cranial plating screws. We copiously irrigated the site with irricept. We closed the scalp flap with interrupted 2-0 vicryl sutures, then running 4-0 monocryl. The wound was cleaned, dried, and dressed with bacitracin and telfa. All counts were correct x2, the drapes were taken down. The patient's head was then removed from the head holder and he was turned back to the supine position on a gurney. Patient was extubated and transferred to PACU ins table condition with anticipated DC home if pain was well controlled. There were no complications.