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CPC sample question # 10

Preoperative Diagnosis: Pelvic mass, probable ovarian neoplasm.

Postoperative Diagnosis: Neurofibroma of the retroperitoneum.

Anesthesia: General.

Findings: Uterus, tubes, and ovaries were unremarkable bilaterally; however, the ureters were adherent to the bladder base and upper rectum; very large retroperitoneal mass extending to the pelvic brim. Estimated  Blood  Loss: 500 cc.

Indications: Pelvic pain.

Description of procedure: The patient was taken to the operating room and intubated under general tracheal anesthesia. Her abdomen was prepped and draped in the usual sterile manner. A Foley catheter was placed in the bladder under sterile conditions. A vertical midline skin incision was made with the knife. The abdomen was opened in layers. After entry into the peritioneal cavity, washings were taken from all quadrants of the abdomen and pelvis and sent for peritoneal cytology. 

Exploration of the abdomen revealed a smooth liver edge and the kidneys were bilaterally present and normal. The periaortic area palpated normal and there were no enlarged lymph nodes in this area. The patient was noted to have a totally normal uterus, bilateral tube and ovaries.

A very large retroperitoneal mass that extended to the pelvic was noted. It measured 7.5 cm and extended posterior to the external iliac artery and vein and down into the hollow of the sacrum. The ureter was draped over it and it was densely adherent to the bladder base as well as the paravaginal area and the upper rectum posteriorly.

The retroperitoneal space was opened and the pelvis vessels were identified. The ureter was noted to be coursing over the mass. The ureter was dissected free with sharp dissection. Sharp and blunt dissection was then used to shell out the mass. Which was extremly difficult.

The patient had many small vessels leading to the mass, both coming from the erea of her bladder base and the right pelvic sidewell as well as the sacral hollow. Hemoclips were used for hemostasis as well as 2-0 silk ties. The dissection was quite difficult and tedious and continued down to the final attachment with the proximal rectum and paravaginal area. It was dissected off using sharp dissection. There were several bleeding areas that were controlled using pressure, silk ties, and Avitene.

There was an oozing tumor bed where this tumor had enveloped the area. This, again, was controlled using mostly Avitene and pressure. The frozen section returned as benigh neurofibroma.

The pelvis was checked for bleeding. It was felt to be hemostatic. The uterus, tubes, and ovaries were placed back in normal position. The colon was inspected and felt to be uninjured. The bladde base was rather friable secondary to the dissection and there was hematuria. The base of the bladder was inspected and there was no evidence of any direct injury. The urete was dissected out were it had draped over the colon down to the base of the bladder. It also appeared uninjured. The other ureter was checked and felt to be normal on the left side. The abdomen was then closed using 0 Vicryl interrupted mattress closure. The skin was closed using a running subcuticular suture of 3-0 Vicryl.

The patient left the operating room in stable condition. She was awake and extubated. The sponge, needle, and instrument counts were correct at the case. She had slightly bloody urine at the complection of the procedure. Blood loss was 500 cc.

a.    49204, 211.8
b.    49203, 237.70, 239.5
c.    49204-22, 233.9, 237.71
d.    19329, 239.5, 237.72


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