AN2114
Guru
I have the op report below. Is the information enough to be considered a hemiglossectomy or just code a removal of tongue lesion? It doesn't say that a portion of the tongue was removed but I want another opinion in case I'm missing something.
Procedure: Hemiglossectomy with removal of lesion 4cm x 4cm with primary complex closure.
Procedure details: The patient was brought to the operating room, was placed in supine position. A timeout was called indicating the correct patient and procedure. General anesthesia was begun via face mask technique and patient intubated without complication.
Patient was prepped and draped in the normal sterile fashion. 2cc of 1% xylocaine with epi was injected into the incision site. A Jennings retractor was placed in the mouth and the oral cavity was opened. A 3-0 silk suture was placed in the anterior tongue surface to assist with tongue manipulation. Using a 15 blade a 4 cm mucosal incision was made along the ventral surface of the tongue. Using a combination of pickups with curved iris scissor the cystic lesion within the tongue was carefully dissected and the entire cystic capsule was removed. The defect size was approximately 4x4cm in size. Hemostasis was achieved with bovi cautery and three 3-0 vicryl sutures were placed deep within the tongue to approximate the remaining tissue. Four mucosal interrupted sutures were placed to approximate the tongue superficial surface. The retractor was removed and stomach contents suctioned. Care of patient returned to the anesthesia team.
Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.
Procedure: Hemiglossectomy with removal of lesion 4cm x 4cm with primary complex closure.
Procedure details: The patient was brought to the operating room, was placed in supine position. A timeout was called indicating the correct patient and procedure. General anesthesia was begun via face mask technique and patient intubated without complication.
Patient was prepped and draped in the normal sterile fashion. 2cc of 1% xylocaine with epi was injected into the incision site. A Jennings retractor was placed in the mouth and the oral cavity was opened. A 3-0 silk suture was placed in the anterior tongue surface to assist with tongue manipulation. Using a 15 blade a 4 cm mucosal incision was made along the ventral surface of the tongue. Using a combination of pickups with curved iris scissor the cystic lesion within the tongue was carefully dissected and the entire cystic capsule was removed. The defect size was approximately 4x4cm in size. Hemostasis was achieved with bovi cautery and three 3-0 vicryl sutures were placed deep within the tongue to approximate the remaining tissue. Four mucosal interrupted sutures were placed to approximate the tongue superficial surface. The retractor was removed and stomach contents suctioned. Care of patient returned to the anesthesia team.
Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.