DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Spindle cell lesion, right breast.
POSTOPERATIVE DIAGNOSIS: Spindle cell lesion, right breast.
PROCEDURE PERFORMED: Right breast wire localized lumpectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: MAC sedation as well as local anesthesia.
IV FLUIDS: 600 mL crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
URINE OUTPUT: None.
SPECIMENS: Right breast wire localized lumpectomy to Radiology and Pathology and no inferior margin to Pathology.
DRAINS: None.
COMPLICATIONS: None.
DISPOSITION: To recovery.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old woman who was recently found to have an abnormality in her right breast on mammogram. Stereotactic biopsy was performed, which demonstrated spindle cell lesion. Recommendations were made for wire localized excision.
She was referred by Radiology to our clinic and was counseled regarding risks and benefits and wished to proceed. She went to Radiology preoperatively, and a wire was placed in her breast by Dr. (XX).
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating room and placed on the operating table in the supine position for right breast wire localized lumpectomy. IV fluids, anesthesia monitoring were administered.
The right breast and the wire were prepped and draped in the usual sterile fashion. Lidocaine 1% solution was infiltrated into the skin nearby the entrance of the wire and needle into the breast.
A 15-blade was used to make an incision in this area in a circumareolar orientation in the upper-outer quadrant of the right breast continuing from an old incision, which was previously performed and has healed well. This was brought down through the subcutaneous tissue with Bovie electrocautery.
Circumferential dissection was then performed, and the tip of the wire was palpable deep within the breast tissue. Our dissection was then carried out along the length of the wire such that we encountered the mass, which was fibrous and white and nodular.
Care was taken to excise this completely. The wire was delivered into the specimen at the superior-most aspect of our incision, and the mass was completely excised. It was marked with sutures and clips for orientation, placed on a grid and sent to Radiology.
We then received word that the specimen indeed did contain the abnormality; however, the inferomedial margin was closed. Therefore, we excised more inferior medial margin and this was marked with suture for orientation.
Hemostasis was then secured, and the wound was irrigated copiously. The base of the wound was reapproximated using 3-0 Vicryl in a figure-of-eight fashion for improved cosmetic outcome.
We then closed the skin using 3-0 Vicryl in an interrupted fashion followed by 4-0 Monocryl in a running subcuticular fashion. Steri-Strips were placed, 20 mL of 0.5% Marcaine was then infiltrated into the cavity and a sterile dressing was placed.
The patient was then brought to recovery in stable condition having tolerated the procedure well. Sponge, instruments and needle counts were correct at the end of the case.
