0GT30ZZ
Resection Adrenal Gland, Right to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | G Endocrine System |
| Operation | T Resection |
| Body Part | 3 Adrenal Gland, Right |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection in the endocrine system means the complete surgical removal of a gland such as the thyroid, a parathyroid gland, an adrenal gland, or the pituitary, without any replacement structure put in its place. It is one of the most frequently performed procedures in endocrine surgery because so many endocrine conditions, from cancer to hormone-secreting tumors to autoimmune overactivity, are best treated by taking the entire gland out.
Common reasons include thyroid cancer or a large multinodular goiter, Graves' disease that has not responded to medication, a parathyroid adenoma causing hyperparathyroidism, an adrenal tumor such as a pheochromocytoma, or a pituitary tumor removed through the skull base. Because these glands regulate metabolism, blood pressure, calcium balance, and stress hormones, patients undergoing resection typically need lifelong hormone replacement or monitoring afterward, which their care team discusses well before surgery.
Anatomy & Axis Detail
Adrenal Gland, Right
The right adrenal gland sits atop the right kidney in close contact with the inferior vena cava, into which its short, wide central vein drains directly, making venous control the most technically demanding part of a right adrenalectomy. Indications for complete excision include pheochromocytoma, cortisol- or aldosterone-secreting adenomas, adrenocortical carcinoma, or a metastatic or indeterminate adrenal mass. Its posterior relationship to the liver and vena cava means the surgeon must mobilize hepatic attachments before safely isolating the gland, and injury to the caval junction is the principal intraoperative risk. Laparoscopic or robotic transabdominal and retroperitoneoscopic approaches are standard for most tumors, with open resection reserved for large or locally invasive disease. Coding as Resection requires removal of the entire gland rather than tumor enucleation alone.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Coding & Documentation
The operative report must confirm the entire gland was removed, not a lobe, nodule, or partial gland, since a partial removal is coded as excision instead. When a total thyroidectomy is performed in stages or as completion surgery after a prior partial removal, coders need to check whether any residual tissue remained from the earlier operation and code accordingly. A common mistake is coding bilateral adrenalectomy or parathyroidectomy as a single procedure when each gland is a separate body part value requiring its own code. Coders should also watch for cases where a resection is combined with a separate reconstructive or reconstructive-adjacent step, such as autotransplantation of a parathyroid gland fragment, which requires an additional code.