Can you please tell me if I am using the correct codes for this Op Report. I will try to condense the report.
Procedure: Mandibulotomy w/ wide resection of LT base of tongue caner, LT. modified radical neck dissection, Lt. Pectoralis major regional flap and complex closure.
DX: Left base of tongue cancer
Specimens: left base of tongue frozen sections, LT modified radical neck dissection, level 1-5.
Incision was demarcated using a lip splitting incision extending down along the chin onto the neck and then curving into a transverse fashion.
Started out with a tracheotomy incision. A window was removed from the anterior tracheal wall. Backed out the endotracheal tube and placed the tracheotomy.
Next was the radical neck dissection. Accessory nerve was identified within level 2 and preserved. The hypoglossal nerve was identified and traced through its course from level 2 to level 1. The mylohyoid was retracted. Dissected levels 2-5. Level 2B dissected out and fibro fatty tissues from levels 2-5. Sensory cervical plexus branches were transected.
Attention was turned to primary tumor. Performing the lip splitting incision and dissecting into the gingival labial sulcus. Soft tissue from the anterior portions of the mandible were freed up. Stair stepped mandibulotomy incision was demarcated. Sagittal saw was used. Extended the incision from the gingival labial sulcus down into the floor of mouth. Transected the mylohyoid and then the digastric muscle, back to the palate. A 3-demensional resection of the left base of tongue tumor. It was very large. It extended all the way into the anterior aspect of the tongue. The posterior margin required removal of the mucosa off of the lingual aspect of the epiglottis. Dissection extended onto the soft palate and mandible. The tumor was fully resected. Deep and superficial margins were obtained. Also, lateral margin at the level of the palate was obtained.
Next the pectoralis major regional flap was obtained. Tunnel was developed from the chest up into the neck.
Then sewing the flap to the epiglottis, base of the tongue, oral tongue, palate and floor of the mouth mucosa. The lower lip mucosa was reapproximated again. The majority of the hypoglossal nerve had to be transected as this nerve was diving directly into the tumor. Drain was placed. Trach was sewn in.
I came up with 41135, 31502, and 15732. Am I missing something??
Thanks for your help, I know this is a long one!!!
Next the radical neck dissection was done. Acessory nerve was identified within level 2 and preserved. the mylohyoid was retracted. lingual nerver preserved freeing up the remainder of level 1 contents. Dissected levels 2 through 5. note, there was extensive amount of scar tissue likely whre there was a prior tumor in the distal portion of the accessory nerve.
Performing the lip splitting incision and dissecting inot the gingival labial portions of the mandible. A stari stepped mandibulotomy was incision was demarcated. When the plates were removed I performed the mandibulotomy with a sagittal saw. Then extended the incision from the gingival labial sulcus down inot the floor of mouth.,transected the mylohyoid and then the digastric muscle back to the palate.
The performed a 3 dimensional resection of the lt base of tongue tumor. it was large. removed the mucosa off of the lingual aspect of the epiglottis, to the soft palate and mandible. crossed over the midline and the tongue base. deep and superficial margins were obrtained. they were deep medial and superficial posterior margins. Margins at the level of the palate were also obtained.
next was the lt pectoralis major regional flap w/complex closure.
Next was closure of the pharyngeal and oral cavity defect.Sewing the pec flap to the epiglottis, base of tongue, oral tongue, palate and floor or mouth mucosa.The more anterior protion of the dissection was sewn primarly. the flap was sewn into postions. the lower lip mucosa was reapproximated again. the majority of the hypoglossal nerve had to be transected as theis nerve was diving directly inot the tumor. drain was placed.