Surgical Terminology

Question 1

Approaches: Open

Answer 1

through skin/ mucous membrane/ other body layers to get to procedure site; ex. abdominal hysterectomy

Question 2

Approaches: percutaneous

Answer 2

Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure

ex. needle biopsy of the liver, liposuction

Question 3

Approaches: percutaneous endoscopic

Answer 3

Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure

Ex. Arthroscopy or laparoscopic cholecystectomy

Question 4

Approaches: via natural or artificial opening

Answer 4

entry through natural or artificial external opening; ex. Foley catheter placement

Question 5

Approaches: via natural or artificial opening endoscopic

Answer 5

endoscope used through natural or artificial external opening to reach and visualize site of procedure; ex. transurethral cystoscopy with removal of a bladder stone

Question 6

Approaches: via natural or artificial opening with percutaneous endoscopic assistance

Answer 6

entry through natural or artificial external opening AND entry to the site made by puncture or natural incision with use of endoscope; ex. laparoscopic-assisted vaginal hysterectomy (LAVH)

Question 7

Approaches: external

Answer 7

performed on the integument or mucous membrane and procedures performed inderectly by the application of external force through the skin or mucous membrane; ex. closed reduction of a fracture, resection of the tonsils

Question 8

destruction

Answer 8

Physical eradication of all or a portion of a body part by the direct use of energy, force or a
destructive agent

ex. dermabrasion, ablation of a lung tumor, fulguration of rectal polyp, cautery of skin lesions

Question 9

replacement

Answer 9

always involves a device that is put in or on to physically take the place or function of all or part of a body part; device must remain in place after procedure is completed; ex. skin graft

Question 10

dilation

Answer 10

expands an orifice or lumen of a tubular body part

ex. endoscopic stent, dilation of the esophagus, percutaneous transluminal angioplasty, pyloromyotomy

Question 11

restriction

Answer 11

partially closing an orifice or lumen of a tubular body part

ex. gastroesophageal fundoplication, laparoscopic gastric banding, cervical cerclage

Question 12

drainage

Answer 12

taking or letting out of fluids and/or gases from a body part; ex. thoracentesis

Question 13

excision

Answer 13

cuts off our out a portion of a body part without replacement; ex. lumpectomy

Question 14

resection

Answer 14

cuts off or out all of a body part without replacement; ex. removing entire lymph node chain, total nephrectomy, total lobectomy of lung

Question 15

extraction

Answer 15

Definition: Pulling or stripping out or off all or a portion of a body part by the use of force

Explanation: The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies

Examples: Dilation and curettage, vein stripping

Question 16

division

Answer 16

cutting into a body part without drawing fluids and or gases in order to SEPARATE or transect a body part; ex. osteotomy and spinal cordotomy

Question 17

release

Answer 17

freeing a body part from an abnormal physical constraint by cutting or by the use of force

ex. carpal tunnel release procedure, adhesiolysis

Question 18

detachment

Answer 18

cutting off all or part of the upper or lower extremities without replacement; ex. above-knee amputation of distal femur, fifth toe ray amputation and above-elbow amputation

Question 19

fusion

Answer 19

joining articular body parts together to make the body part immobile, using a fixation device, bone graft, or other means

ex. spinal fusions and ankle arthrodesis

Question 20

reattachment

Answer 20

putting back in or on all or a portion of a separated body part to its normal location or other suitable location; ex reattaching an avulsed ear or an amputated finger

Question 21

reposition

Answer 21

move all or a portion of a body part to its normal location or other suitable location. The body part may or may not be cut out or off
to be moved to the new location

ex. orchiopexy, fracture reduction

Question 22

change

Answer 22

taking out or off a device form a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane; ex. urinary catheter change

Question 23

fragmentation

Answer 23

breaking solid matter in a body part to pieces; physical force is applied directly or indirectly; ex. extracorporeal shockwave lithotripsy (ESWL) and transurethral lithotripsy

Question 24

inspection

Answer 24

visually and/or manually exploring a body part; ex. digital rectal examination (DRE)

Question 25

alteration

Answer 25

modifying the natural anatomic structure of a body part without affecting the function; to improve appearance; ex. breast augmentation, face lift, abdominoplasty, rhinoplasty

Question 26

creation

Answer 26

defined as making a new genital structure that does not physically take place of the body part; ex. penis creation for FTM

Question 27

occlusion

Answer 27

completely closing an orifice or the lumen of a tubular body part. The orifice can be a natural orifice or an artificially created orifice ex. fallopian tube ligation, ligation of inferior vena cava

Question 28

transfer

Answer 28

defined as moving without taking out, all, or a portion of a body part to another location to take over the function of all or a portion of a body part; ex. transverse rectus abdominis muscle (TRAM) flap reconstruction

Question 29

extirpation

Answer 29

taking or cutting out solid matter within a body part; used when there is a substance contained within a small area that can be scooped out without removing the entire body part; ex. thrombectomy

Question 30

removal

Answer 30

removing, or taking out a device in or on a body part. If a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation CHANGE. ex. removal of pancreatic drain

Question 31

repair

Answer 31

restoring the body part to its normal structure. Used only when the method to accomplish the repair is not one of the other root operations ex. thymoplasty, colostomy takedown, suture of laceration

Question 32

transplantation

Answer 32

puts in a living body part from a person or animal into another person; ex. kidney transplant

Question 33

control

Answer 33

ex. control bleeding

Question 34

bypass

Answer 34

altering the route of passage of the contents of a tubular body part; ex. coronary artery bypass graft (CABG)

Question 35

mapping

Answer 35

locating the route of passage of electrical impulses and/or locating functional areas in a body part. Applicable only to the cardiac conduction mechanism and the central nervous system ex. cardiac mapping, cortical mapping, cardiac electrophysiological study, and intraoperative cardiac mapping

Question 36

supplement

Answer 36

putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part; ex. HELEX septal occluder

Question 37

insertion

Answer 37

putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part; ex. insertion of pacemakers, radioactive implants, or central venous catheters

Question 38

revision

Answer 38

correcting, to the extent possible, a malfunctioning or displaced device ex. adjustment of the position of the pacemaker lead, recementing of hip prosthesis