Could you please advise cpt’s on this op report:
The left groin was assessed by way of a wedge biopsy at the inferior limit of the lesion to potentially rule in malignancy. Frozen section was performed. During the time the frozen section was performed, we proceeded forth with the excision of a right groin condyloma. We marked out 1 mm from the condylomatous change for fear that the lesion would have benign characteristics but direct extension into the soft tissue. We then used a combination of cold knife excision and electrocautery to excise the full thickness of the lesion and the associated dermis due to bulk. The excision was carried down to the subcutaneous tissue. The overall excision site was 8 cm in diameter and this achieved complete excision of this lesion in the right of midline at the mons pubis.
We then moved on to treat the left groin. I elected to change gloves and place a Foley catheter. The nurses could not identify the penis so I elevated a bulk of condylomatous change presuming it was the penis. I used a ring forceps to retrieve the glans penis from a foreskin that was heavily burdened with condylomatous change. I inserted the Foley catheter after complementing the prep with more iodine paint. The catheter was inserted with ease into the bladder. Urine was obtained and sent for pathologic evaluation by way of urinalysis under microscopy. The Foley was passed off to the anesthesia staff for the purposes of monitoring urine output.
We then turned our attention to excision of the left groin lesion and debridement of the devitalized tissue. We marked out a border around the lesion that was 1 cm away from the gross change. We then used a combination of electrocautery and harmonic scalpel transection once the skin was incised with a 10 blade. We circumnavigated the process into the subcutaneous tissue. There was hypervascularity and edema in the soft tissue. Once we circumnavigated the process, we sent margins at the skin level for the purposes of frozen section to assure against a positive margin. The medial margin, inferomedial margin, and inferolateral margin were all assessed for these were the at risk margins. These all returned negative on frozen section.
We then dissected into the soft tissue all the way down to the femoral triangle. The inguinal canal was exposed first by way of dissection to the inguinal ligament. We then moved out laterally to identify the fascia lata on the patient’s left. We then incised from a lateral to medial direction with a combination of electrocautery and harmonic shears. When we got to the sartorius muscle, it was densely adherent to the lesion in question. I was concerned that it was directly invaded so we excised the sartorius muscle across the course of its path along the femoral triangle. As we progressed more medially, we identified that there was a deep abscess in this leg. Pus evolved and this was cultured. We then excised the necrotic medial aspects of the sartorius and a bit of the adductor itself. This achieved excision of necrotic muscle across the course of 8 x 10 cm.
We then irrigated with copious amounts of crystalloid solution until it returned clear and progressed on. In the femoral triangle, it was worrisome that the artery and vein would be involved in the process. Therefore, we opened the external ring cephalad to the inguinal ligament. We incised it in an oblique fashion and this allowed us to palpate through the abdominal wall to feel the femoral artery and vein as it transitioned from its named component of the external iliac artery and vein. This would allow for direct compression should we encounter any violation to these large structures. We then incised from medial to lateral. The scrotal skin had previously been incised with a cold knife, and we took this dissection over across the adductor of the left leg and deep into the femoral triangle taking care to preserve the integrity of the nerve, artery, vein, and lymphatics. Fortunately, we were able to elevate the lesion off of the femoral artery and vein. We did not have to dissect into the femoral triangle to disturb the lymphatics in this region. There was subcutaneous change on the inferior limit of the lesion consistent with lymphedema already present and we did not want to worsen such if not necessary.
We then identified a branch off of the femoral artery that projected cephalad as though this was a low takeoff for an inferior epigastric artery. We isolated it in vessel loops and then very carefully removed it from the tumor feeling that we did not compromise any oncologic principles at this time. We then had to address the vein. The vein was tethered to the lesion by way of a direct branch off of the common femoral vein that was transected with cold technique and then sutured closed with 6-0 Prolene. This allowed for complete extirpation of the lesion. The specimen was oriented with a long suture lateral and a short suture superolateral. This was given to the pathologist and transferred to their department.
We then irrigated with copious amount of crystalloid solution which returned clear and performed a local field blockade utilizing a combination of Exparel, injectable saline, and 0.5% Marcaine without epinephrine.
We then debrided a bit more soft tissue in the depths of the femoral triangle. There was a cavity where the purulence had dissected just medial to the adductor and down the femoral canal. We excised this capsule and sent it for separate pathologic evaluation because of the diagnosis of squamous cell carcinoma with associated abscess. We were worried that there could be perforation, but I think that this is probably obstructed lymphatic channels that have become abscessed. I checked the specimen after excision and found no full-thickness defect in the specimen itself.
We then once again irrigated and debated our plan for closure. Because of the infected space in the left leg, we elected to leave the right-sided excision open in its entirety. Silvadene was placed atop this area and an ABD pad would be utilized. The femoral vein and artery were exposed in the left dissection which was now measuring 35 cm in oblique orientation parallel to the inguinal ligament and 18 cm in craniocaudal orientation; 80 cm of the defect required excision of muscle. The remaining aspects of the defect were made up of excision of necrotic skin and soft tissue in association with a neglected necrotic squamous cell carcinoma of the left groin.
Because we had excised the sartorius muscle to preserve oncologic principles and to remove all devitalized muscle, we were unable to perform this rotation flap. We were not prepped for the purposes of a gracilis flap, but I did have the plastic surgeon come to the room and take a look. He agreed that a gracilis flap would be a good option. He was heavily engaged in another case and I felt that the patient had been asleep long enough for this operation. We would be best served with recovery from the operation, nutritional supplementation, and potential promotion of improved wound healing. Therefore, we placed Adaptic in the base of the wound and then laid moist gauze atop the Adaptic to fill the void. We then would close the area off from external elements by way of a quilting of ABD pads.
I should mention as well that prior to doing this we did close the fascia of the external ring. Specifically, we closed the aponeurosis of the external abdominal oblique with a combination of running and interrupted sutures of absorbable type.
Thank You
Kalpana