Surgeon(s): ***
Assistant Surgeon(s): ***
Preoperative Diagnosis: ***
Postoperative Diagnosis: Same
Procedure(s): ***
Anesthesia: General
Implants: None
Specimen:***
Drains: None
Fluids: See anesthesia record
EBL: Minimal
Complications: None
Counts: Correct x2
Indications: ***
Findings: As expected
Procedure in Detail:
The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail. The patient was transferred to the operating room by the anesthesia team. The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures. A time-out was performed and the procedure began.
The mouth was opened with a mouth gag, and the tongue was retracted laterally. A midline incision was made from the tip of the tongue to the base, exposing the tumor. Subsequently, using a Bovie electrocautery device, partial glossectomy was performed, meticulously excising the tumor with 1cm margins from visible tumor. The specimen was sent for histopathological examination. Frozen margins were negative. Hemostasis was achieved using the Bovie electrocautery, ensuring optimal control of bleeding throughout the procedure. The wound bed was irrigated with saline solution to remove any debris or residual tissue. Closure of the surgical site was meticulously performed using absorbable sutures, ensuring proper approximation of the tongue tissues without tension.
The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.
ICD-10-CM (Diagnosis) Code:
CPT (Procedure) Code:
CDT (Dental) Code: