T5-1B OPERATIVE REPORT, EXCISIONAL BIOPSY

Essay

T5-1B OPERATIVE REPORT, EXCISIONAL BIOPSY
PREOPERATIVE DIAGNOSIS: Two separate lesions found on ultrasound felt to be solid masses at 12 o'clock and 3 o'clock
POSTOPERATIVE DIAGNOSIS: Two separate lesions found on ultrasound felt to be solid masses at 12 o'clock and 3 o'clock
PROCEDURE PERFORMED: Excisional biopsy times two after needle localization times two, left breast (the radiologist placed the markers and reported the placement service, so you do not need to report the placement service).
ANESTHESIA: 40 cc of Marcaine with sedation
SPECIMENS: Two separate biopsy specimens were sent along with accompanying fragments. These were exactly where they were described by the radiologist after placing the guidewires. They felt firm and rubbery, consistent with fibrosis. There was no other tissue in the area to be biopsied. The rest was normal breast tissue. Radiology did not, however, confirm the presence of the lesions in the specimen. The patient will follow up with an ultrasound in 3 months to confirm that they have been resected. I am very confident this whole area was removed, and there is no suspicious tissue left behind.
ESTIMATED BLOOD LOSS: Less than 50 cc (cubic centimeter)
PROCEDURE IN DETAIL: After good sedation, a total of 40 cc of Marcaine was infiltrated into the proposed incision. The incision was made between both guidewires. First the 3 o'clock lesion was resected and submitted to Radiology. After this, incision was extended north and the 12 o'clock lesion was resected. The 12 o'clock lesion was said to be just below the tip of the guidewire; however, it was separated from the specimen at the time of resection. There was no palpable abnormality in this area whatsoever after the two specimens were delivered. The wound was irrigated. Hemostasis was obtained with electrocautery. The wound was closed with two intramammary stitches in a running subcuticular skin stitch. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was returned to the recovery room in good condition.
PATHOLOGY REPORT LATER INDICATED: Benign breast tissue
T5-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________