I have a physician that did a axillary dissection with excision of nodule, right axilla. I'm not sure if I should code this as a excision breast nodule or axillary nodule.
Procedure details: The patient was brought to the operating room. Under general anesthesia, the right axillary area was prepped and draped in the usual manner. A marking pen was used to mark a line of excision of the accessory tissue in the right axilla. An incision was made along the skin line in elliptical fashion. Underlying dissection of subcutaneous tissue was then performed. Hemostasis was achieved using electrocautery and ties of 4-0 Vicryl where indicated.
The nodular tissue at the base of the mass was identified and excised along with the excessive overlying tissue. When this was complete, markings were made. Two sutures were placed at the area of the nodule and the superior edge of the skin was marked.
Following this, frozen section report was of inflammatory tissue. Next, the subcutaneous tissue was approximated using interrupted sutures of 4-0 Vicryl. Skin edge was then approximated using wide skin staples. A dressing was applied over this area. The patient was returned to the recovery area in good condition.
Pathology results benign breast with acute and chronic mastitis.
Procedure details: The patient was brought to the operating room. Under general anesthesia, the right axillary area was prepped and draped in the usual manner. A marking pen was used to mark a line of excision of the accessory tissue in the right axilla. An incision was made along the skin line in elliptical fashion. Underlying dissection of subcutaneous tissue was then performed. Hemostasis was achieved using electrocautery and ties of 4-0 Vicryl where indicated.
The nodular tissue at the base of the mass was identified and excised along with the excessive overlying tissue. When this was complete, markings were made. Two sutures were placed at the area of the nodule and the superior edge of the skin was marked.
Following this, frozen section report was of inflammatory tissue. Next, the subcutaneous tissue was approximated using interrupted sutures of 4-0 Vicryl. Skin edge was then approximated using wide skin staples. A dressing was applied over this area. The patient was returned to the recovery area in good condition.
Pathology results benign breast with acute and chronic mastitis.