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Resection Epididymis, Right to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | V Male Reproductive System |
| Operation | T Resection |
| Body Part | J Epididymis, 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 procedures remove an entire body part of the male reproductive system without replacing it with other material. Orchiectomy - removal of one or both testes - is the most common example, performed for testicular cancer, as part of treatment for advanced prostate cancer, for severe trauma, or occasionally for chronic pain or infection unresponsive to other treatment. Other resection procedures in this family include removal of the entire epididymis or complete removal of the prostate and seminal vesicles.
These are typically definitive procedures aimed at eliminating diseased or damaged tissue rather than preserving it. Because the organ is removed in full, resection often has permanent effects on fertility and hormone production, which is part of why patients considering these procedures discuss options like sperm banking or hormone replacement beforehand.
Anatomy & Axis Detail
Epididymis, Right
The right epididymis is the coiled duct lying along the posterior surface of the right testis where sperm mature and are stored before passage into the vas deferens. Resection of this structure removes it entirely and is done for epididymal tumors, chronic refractory epididymitis, large epididymal cysts, or as an isolated procedure when the testis itself is preserved and only the duct and its surrounding tissue require excision. Because the epididymis sits closely against the testis, the operative note must distinguish an epididymectomy limited to the duct from any concurrent orchiectomy, since removing the testis along with it would require coding an additional or different body part rather than epididymis 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
Coders assigning Resection need pathology or operative documentation confirming the entire organ was removed, not just a portion. A frequent error is coding Resection when only a partial excision was performed, such as a partial orchiectomy for a small testicular mass with preservation of remaining tissue - that scenario belongs under Excision instead. Laterality also matters: unilateral versus bilateral orchiectomy uses different body part values, and the note should state clearly whether one or both testes were removed.