Excisional Biopsy (Mucosa)

Open Dropdown

Preoperative Considerations

Consent:

  • Discuss biopsy, limitations, etc.
  • TIme for diagnosis & expected follow-up
  • Damage to adjacent structures
  • Need for additional procedures

Anesthesia/Positioning:

  • Local or general anesthesia
  • If general, oral or nasal tube per Surgeon preference

Other:

  • Formalin fixative
  • Michel's medium for immunofluorescent studies

Armamentarium:

  • Local anesthesia
  • #15 blade
  • Tissue forcep
  • Tissue punch
  • Hemostatic agent like silver nitrate
  • 3-0 chromic or vicryl suture

Technique

Postoperative Considerations

Immediate:

  • None

Follow Up:

  • Approproate follow-up for biopsy result

Operative Note

Surgeon(s): ***

Assistant Surgeon(s):  ***

Preoperative Diagnosis: ***

Postoperative Diagnosis: Same

Procedure(s): Buccal nodule excision

Anesthesia: General

Implants: None

Specimen: Mucosal biopsy

Drains: None

Fluids: See anesthesia record

EBL: Minimal

Complications: None

Counts:  Correct x2

Indications: ​Mucosal lesion

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.

1% lidocaine with 1:100,000 epi was infiltrated into the surgical site. A #15 blade was used to make an elliptical incision around the specimen which was carefully excised and sent for histopathological examination. Hemostasis was achieved. The site was closed with 3-0 chromic gut.

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.

Coding

  • 11100 Biopsy soft tissue
  • 111 Biopsy soft tissue, each additional