Question

Audit Report 5.5 Operative Report Malignant Melanoma

LOCATION: Outpatient Hospital

PATIENT: Jane Love

SURGEON: Gary Sanchez MD

PREOPERATIVE DIAGNOSIS: Large lipoma of the lower abdomen 

POSTOPERATIVE DIAGNOSIS: Malignant neurona, lower abdomen

PROCEDURE PERFORMED: Radical excision of large nest of the abdomen, which measured 9 cm x 12 cm

ANESTHESIA: General anesthesia

INDICATION: The patient has a mass in the lower back. This is becoming quite bothersome to her. We docussed treatment options of observation versus surgical excision. She wishes to have this excised. We discussed the procedure as well as the risk involved. She understands and wishes to proceed.

PROCEDURE The patient was brought to the operating room and placed in the supine position on the operating table and received general anesthetic. She was prepped and draped in sterile fashion. The area of the mass was identified and marked out. This was an ovoid lesion measuring 9 x 12 cm. This was basically between the iliac crest and lower abdomen. An incision line down the central aspect of this in universe fashion was infiltrated with 0.5% Marcaine. After waiting couple of minutes, an incision was made. Dissection was carried into the subcutaneous tissues. We then sharply circumferentially detected out a large lipomatous mass. This was quite large This was sent to pathology and came back as malignant melanoma. To minimize scarring, we did not go all the way to the end with our skin incision, however, we were able to retract this up and dissect out the lipomatous mass from under it. This was taken out all the way down to the fascia. This was then removed in total. There did not appear to be su masses there. Hemostasis was achieved. This left a 12.5 cm open wound and the subcutaneous tissues were closed with layered sutures al 3-0 Vicryl. The skin was closed with 4-0 Vicryl in running subcuticular fashion. Steri-Strips and sterile dressings, multiple Fluffs and ABDs, and then an Ace wrap were applied. The Ace wrap went around a few times across the lower abdomen and pelvic region as well as across the iliac structures to hela provide pressure to the area and to decrease the chance of developing seromas or hematomas. The patient tolerated the procedure well and went to the recovery room in stable condition.

I met with the patient's mother postoperatively and discussed the diagnosis. Discharge instructions were discussed with the patient and her mother I discussed a referral to oncology for further treatment Their questions were answered

Pathology Report Later Indicated: Malignant melanoma

One or more of the following codes are reported incorrectly for this case Indicate the incorrect code or codes.

SERVICE CODES: Excision malignant lesion, 11606

ICD-10-CM DX CODES: Malignant neoplasm of skin of trunk, C44.509

INCORRECT/MISSING CODES:

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