How to Report on a Surgical Procedure

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STRUCTURED SURGICAL REPORT SURGERY DATE : Anatomic region code (5484) Side Resection STS resA 1 soft tissue: resection resection simple 2 muscle resection 3 vessel dissection 4 nerve dissection 5 periost resection 6 bone resection 7 vessel resection 8 nerve resection 9 MR -HIFU resB 1 bone: resection resection of bone (incl. soft tissues) resection of bone (incl. soft tissues) using 3D patient specific 2 implants 3 simple curettage 4 radiofrequency ablation (RFA); cryotherapy, MR-HIFU 5 amputation intercalary resection-replantation 6 rotationplasty 7 specific: external hemipelvectomy 8 internal hemipelvectomy 9 Tikhoff-Linberg resection Forequarter amputation with chest 10 wall Forequarter amputation without 11 chest wall 12 lower extremity 13 upper extremity resC 1 lung surgery chest wall resection 2 open thoracotomy wedge resection 3 segmental resection 4 lobectomy 5 bilobectomy / pneumonectomy 6 pleuropneumonectomy 7 thoracic wall resection /ribs 8 thoraco -endoscopic resection (VATS) 9 wedge resection lobectomy abdominal wall resD 1 resection 2 abdominal resection none 3 kidney 4 suprarenal glands 5 ureter 6 bladder 7 colon/rectum 8 bowel 9 uterus/ovaries 10 spleen 11 liver 12 pancreas 13 gall bladder 14 aorta / cava 15 other Reconstruction recA skin- / mesh-graft yes recB 1 pedicled tissue transfer rectus abdominis 2 gastrocnemius 3 latissimus dorsi 4 gracilis 5 sartorius 6 soleus 7 serratus 8 perforator flap ALT 9 other: 10 other 11 tendon transfer specify: recC 1 free tissue transfer latissimus dorsi 2 gracilis 3 perforator flap ALT 4 other 5 other: recD 1 bone: reconstruction cementation 2 ORIF 3 autograft 4 vascularized fibula autograft 5 non-vascularized fibula autograft 6 pasteurized autograft 7 allograft chips 8 bulk allograft 9 conventional prosthesis 10 modular tumor prosthesis 11 custom-made prosthesis 12 growing prosthesis 13 pedicle screws / rods 14 other recE 1 revision of tumor prosthesis recF 1 vessel reconstruction yes artery complete artery 2 patch 3 vein complete 4 vein patch 5 yes lympho-veinous 6 other recG 1 nerve reconstruction yes specify: recH 1 chest wall reconstruction abdominal recI 1 reconstruction wall 2 colon anastomosis 3 stoma 4 bladder 5 ureter 6 other Surgical complications None Hematoma Wound healing Technical failure Infection Fracture Other Surgeon’s judgement of tumor resection For bone resections: R0 / wide resection R1 / marginal resection R2 / intralesional resection For soft tissue resections: R0 / No tumor at inked margin R1 / Tumor at inked margin: -Planned close but ultimately positive around critical structure (major vessels(nerve, bone) -Positive after a tumor bed re-excision (ie. following „whoops“ procedure) -Inadvertent positive margin (IPM) R2 / grossly positive .

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