Preoperative Diagnosis: Lipoma of right posterior shoulder/axilla
Case 13
Preoperative Diagnosis: Lipoma of right posterior shoulder/axilla
Postoperative Diagnosis: Same, pending pathology
Operation Performed: Excision of Lipoma of Right Posterior Shoulder/Axilla
Anesthesia: Local with intravenous sedation and monitoring
Description: With the patient in left lateral decubitus position, the right shoulder and axilla were prepared with Betadine, and draped with sterile drapes. There is a bulging mass at the posterior axillary fold. Margins of this were delineated, 1% xylocaine with epinephrine was infiltrated in the skin over the mass and at the periphery and deep to it. Later, supplementary doses were administered.
A 13 cm long incision was made obliquely from superior posterior to anterior inferior, ending at the posterior axilla. It was carried through the skin and superficial subcutaneous tissue. A multi-lobular fatty mass was encountered. It is invading the surrounding tissue and is partitioned at the periphery in multi-septal fashion. At the posterior aspect of the muscle, the surface is flat and it is the only area which has some sort of delineating capsule. Anteriorly there is a 2.5 3 3.5 cm single bulge extending in the axilla itself. This was dissected out without injuring any of the vessels. The entire lesion is about 11 3 9 cm in size. Multiple bleeders were coagulated. A Jackson Pratt drain was inserted anteriorly/inferiorly through a separate stab incision and secured with #2 silk.
A multilayer repair with interrupted 4-0 and 5-0 polysorb sutures to the subcutaneous tissue and skin, and 5-0 nylon to the superficial skin was performed. A dressing with Xeroflo, dressing sponges, and Hypafix was applied. Blood loss was minimal. Prior to the conclusion of the procedure 10 cc of 0.25% Marcaine was infiltrated in the skin and surrounding tissue for postoperative comfort.
Pathology
Tissue:
A) LIPOMA, RT POSTERIOR SHOULDER
Clinical Diagnosis And History: Lipoma, Rt Posterior Shoulder
Gross Description:
Specimen received in formalin labeled, “lipoma right shoulder” is a lobulated partially encapsulated tan to pink-red 9.5 3 6.0 3 2.5 cm portion of fibroadipose tissue. Sectioning shows a homogeneous yellow-tan lobulated and fatty cut surface. Representative sections are submitted (4 blocks).
Diagnosis:
MATURE FAT, CONSISTENT WITH LIPOMA, RIGHT POSTERIOR SHOULDER
what is ICD-10-CM Codes:
what is CPT Codes:
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