OPERATIVE DIAGNOSIS: Left chest wall mass and ovarian cancer
POSTOPERATIVE DIAGNOSIS: Left chest wall mass of unknown behavior and ovarian cancer
PROCEDURES: Diagnostic bronchoscopy with evaluation of the bronchial tree tube, a left video assisted thoracoscopy, and a resection of the anterior chest wall mass with some resection of the pleura. (Determine if the word resection really means resection. Remember that resection in documentation just means removal and you have to determine was a whole or parital body part removed.)
PROCEDURE NOTE: General sedation was administered by oral endotracheal tube. The bronchoscope was inserted. The right upper lobe, middle lob, and lower lobe were normal. No endobronchial lesions were seen. The scope was inserted in the left upper lingual lobe and segments were normal.
The left chest was prepped and draped in normal sterile fashion. An incision was made and the thoracoscope was inserted. Under direct vision, additional lateral port was placed. Dissection was then carried down. The mass was identified within the chest wall. It was confine to the pleura. This appeared to be a large plaque, approximately 10x4cm. A separate satellite mass was present. Using the Bovie electrocautery, the pleura was then dissected from the chest wall. The entire chest wall mass was resected including the pleural lesion.
It was then placed in the EndoCath and removed and sent to pathology for evaluation. No other areas were seen in the pleura. Hemostasis was obtained. A chest tube was placed to the apex and anchored with heavy silk. The lung was re-expanded with no significant air leak. The wound was then closed in layers with absorbable sutures. The patient tolerated the procedure well with no complications. (Use your guidelines for accurate coding. This started as a diagnostic procedure and ended up removing two masses.)