PREOPERATIVE DIAGNOSIS: Ischemic colitis.

POSTOPERATIVE DIAGNOSIS: Ischemic colitis.

PROCEDURES PERFORMED: Right hemicolectomy.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

SPECIMENS: Right hemicolon.

INDICATIONS FOR PROCEDURE: This is a gentleman who just underwent a cardiac surgery and now has distended tender abdomen. CAT scan shows a thickened colon on the right side with possible ischemia. The patient is tender on exam. We recommended exploration. Risks, benefits and alternatives have been discussed with his family, who has consented for surgery.

DETAILS OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After undergoing general anesthesia, his abdomen was prepped and draped in surgical fashion using DuraPrep.

A vertical midline incision was made. Dissection was taken down to the fascia, which was incised with a Bovie, and the peritoneum was entered. The abdomen was explored. The right colon had been ischemic and was recovering. There were some punctate hemorrhages in the right side of the transverse colon consistent with possible embolic events.

The patient also had a very distended sigmoid. Based on our concerns about ischemic colitis, we elected to do right hemicolectomy mobilizing the right colon with a Bovie, transecting it to terminal ileum as well as transverse colon just proximal to the middle colic artery with a GIA stapler. Mesentery was taken with vascular loads and stapler.

Side-to-side functional end-to-end anastomosis was created. The anastomosis was then oversewn with 3-0 silk Lembert, left the mesenteric defect open because it was fairly large and wide and it had been difficult to close.

We ran the bowel in the peritoneum and began our closure with number 1 PDS used on the fascia and staples were used to close the skin. Dressing was applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.

Right Hemicolectomy Surgery Sample #2

PREOPERATIVE DIAGNOSIS: Cecal mass.

POSTOPERATIVE DIAGNOSIS: Hepatic flexure colonic mass.

PROCEDURE PERFORMED: Right hemicolectomy.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

SPECIMEN: Right colon.

COMPLICATIONS: None.

DRAINS: A 15-French round drain placed within the gallbladder bed fossa.

FINDINGS: Upon entry into the abdominal cavity, a hepatic flexure mass could be easily palpated. Visualization revealed that the mass had extended into the fundus of the gallbladder and also into the second portion of the duodenum.

During the course of our blunt dissection, we were able to take off this area of tumor from the gallbladder bed and also from the second portion of the duodenum without injuring these structures. No other abdominal pathology was noted.

INDICATIONS FOR PROCEDURE: The patient is an (XX)-year-old male who presented to the emergency room complaining of abdominal pain and loss of appetite. On workup, his abdominal x-ray showed multiple dilated loops of small bowel and we then initially placed a nasogastric tube for decompression.

Upon questioning, the patient denied any change in his bowel habits or weight loss. Previously colonoscopy, multiple years ago, did not reveal any colonic pathology at that time and he reportedly had no family history of colon cancer. The patient also denied any history of diverticular disease.

Physical examination did not reveal any hernias, and he had a mildly tender abdomen that was quite distended. A CT of the abdomen and pelvis was then obtained, which did reveal a right-sided colonic lesion secondarily causing what looked to be a bowel obstruction. However, upon further review, the patient basically had a large bowel obstruction due to this right-sided colon lesion.

The patient was given IV fluid resuscitation, brought into the hospital and given antibiotics. The imaging findings were discussed with the patient and his family, and they were told that we would be preparing the patient for a right hemicolectomy the following day. All of the risks, benefits and alternatives to the procedure were described in detail to the patient and his family by the attending. Operative consent was signed and placed upon the chart.

DETAILS OF PROCEDURE: The patient was taken to the operating room and placed in supine position. Bilateral lower extremity athrombics were placed. A nasogastric tube along with a Foley catheter had already been placed the previous day. The patient’s abdomen was then sterilely prepped and draped in a standard surgical fashion.

A right paramedian incision was then made in a vertical fashion. The incision was extended from about 2 fingerbreadths below the costal margin to midway between the pubis and iliac crest. This incision was then deepened through the subcutaneous tissues with Bovie electrocautery. Peritoneal cavity was entered. A Bookwalter retractor device was then placed. The small bowel contents were then eviscerated. A moist towel was placed. A hepatic flexure mass was then easily palpated.

At this time, we went ahead and turned our attention at mobilizing the colon for future resection. Using electrocautery, the colon was then freed from its peritoneal attachments along the line of Toldt from the terminal ileum to just distal to the hepatic flexure. During the course of our dissection around the hepatic flexure, we noted that the tumor was eroding into a portion of the fundus of the gallbladder and also there was some tumor burden on the second portion of the duodenum. We were able to mobilize this with blunt dissection and there were no injuries noted to the duodenum or to the gallbladder fundus.

Once this was completed, the colon was then easily mobilized. Points of transection were then selected proximally and distally. The proximal resection was 5 cm from the ileocecal valve and our distal transection point was in the proximal one-third of the transverse colon. Once this was determined, the bowel was then divided with the linear cutting stapler in these two regions. The peritoneum overlying this area was then scored with electrocautery and the ileocolic artery was identified, doubly ligated with 2-0 silk sutures and transected. The main trunk to the middle colic was similarly identified and ligated. The remaining mesentery and all associated nodal tissue was then divided and swept down with the specimen.

The specimen was then removed and sent to pathology for examination. Hemostasis was checked in the operative field and shown to be intact. The two ends of the bowel were then checked and found to be viable with excellent blood supply present. At this time, we went ahead and proceeded with a staple anastomosis. The proximal and distal segments of the bowel were then brought into apposition and found to lie comfortably next to each other with no torsion.

Enterotomies were then made at the antimesenteric borders and then a linear cutting stapler was inserted and fired. Hemostasis was checked along the staple line within the lumen and shown to be intact. The enterotomies were then closed with a TA-60 stapler. The staple line was then reinforced with several interrupted 3-0 silk Lembert sutures. The anastomosis was checked and found to be intact and widely patent. The mesenteric defect was then closed with figure-of-eight 3-0 silk sutures. The abdominal cavity was then copiously irrigated with warm normal saline and hemostasis was checked.

Once this was completed, we then placed a 15-French round drain within the gallbladder bed fossa and exited in the right lower quadrant. The drain was anchored into place with a 3-0 silk suture. The peritoneum was then closed with a running stitch of 0 Vicryl. The fascia was then closed with a running 0 Prolene suture. The subcutaneous tissues were irrigated and reapproximated with running 3-0 Vicryl. The skin was reapproximated with skin staples. Iodoform wicks were placed intermittently between the staples also. Dry sterile dressing was placed and the JP drain was hooked to bulb suction. All instrument, sponge and needle counts were correct at the end of the case.

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PREOPERATIVE DIAGNOSIS: Hydrocephalus.

POSTOPERATIVE DIAGNOSIS: Hydrocephalus.

OPERATION PERFORMED:
1. Left external ventricular drain removal.
2. Right ventriculoperitoneal shunt placement in 5 kg infant.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

INDICATION FOR PROCEDURE: The patient is a (XX)-year-old boy with a complex medical history who presented with a ventriculoperitoneal shunt failure. The patient has now had more than a week of negative cultures and appropriate antibiotics.

The risks, benefits and alternatives of surgery were discussed with the family. The risks including, but not limited to, bleeding, infection, injury to the brain, injury to the peritoneal contents, allergic reaction to anesthesia or even death were discussed.

No guarantees were made or implied. Despite the above, they desired to proceed with the left external ventricular drain removal and right ventriculoperitoneal shunt placement.

FINDINGS AND PROCEDURE: The patient was brought to the operative suite and underwent general endotracheal anesthesia. The left frontal incision was then prepped, the staples removed and the external ventricular drain stay stitches cut. The external ventricular drain was removed and the exit site as well as the insertion site was oversewn using 4-0 Vicryl Rapide.

Attention was then turned to the right side of the patient. He was prepped and draped in the usual sterile fashion and his previous right frontal incision was reopened with blunt and sharp dissection down to the existing bur hole. A curette was used to widen the bur hole and Kerrison punch was used to make it larger as well. Shunt passer was then passed from the right frontal region to the right lateral cervical region just above his ECMO cutdown site. The Micro Codman shunt single pressure of 70 mmHg had the Bactiseal peritoneal catheter tied to the proximal end and been appropriately flushed.

It was then passed through the shunt passer and the shunt passer was passed from the right lateral cervical region to the right upper quadrant and the shunt again was passed likewise. The distal 20-30 cm of peritoneal catheter were cut off and discarded.

The dura was incised using monopolar electrocautery and the ventricular catheter was passed into a depth of approximately 16.5 cm. It was easily passed into the lateral ventricle with spontaneous flow of moderate pressure CSF. The ventricular catheter was then appropriately attached to the Rickham reservoir and sewn in place using 2-0 Vicryl. The valve system was appropriately seated in the scalp tissue and spontaneous flow of clear CSF was appreciated through the distal end of the peritoneal catheter.

With the assistance of anesthesia, getting a valve set up to 40, peritoneal trocar was passed in the peritoneal cavity. The distal end of the peritoneal catheter was then passed into the peritoneal cavity without difficulty.

Dr. Jane Doe had been on standby should entering the peritoneal cavity have caused any difficulty in this medically complicated patient with a history of a Nissen and G-tube.

The incisions were copiously irrigated with antibiotic irrigation and closed in anatomic layers using 4-0 Vicryl. The final layer of skin was closed using 4-0 Vicryl Rapide in the cranial incision and benzoin and Steri-Strips in the neck and abdominal incision.

The patient tolerated the left external ventricular drain removal and right ventriculoperitoneal shunt placement well and was sent to the PACU postoperatively.

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PREOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.

POSTOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.

SURGERY PERFORMED: Left breast reconstruction with placement of subpectoral implant and pocket adjustment (extensive capsular release).

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia with LMA.

COMPLICATIONS: None apparent.

ESTIMATED BLOOD LOSS: Less than 50 mL.

DRAINS AND TUBES: A 7 mm Jackson-Pratt drain.

SPECIMEN: Removed expander, discarded. Left breast implant capsule for culture and sensitivity (aerobic, anaerobic, AFB and fungal).

IMPLANT: McGhan 363LF implant with 450 cc of saline added.

INDICATIONS FOR SURGERY: The patient is a (XX)-year-old female who is status post bilateral mastectomies for cancer, reconstructed with subpectoral expanders and implants. Unfortunately, the implant on the left side had clinical infection, although no positive cultures, and had to be removed.

The tissue has now settled down and now for replantation with the major concern being additional infection and also scar. Options considered including replacement of an expander or using a Mentor adjustable implant. However, concern would be that if we do not get adequate reconstruction, the scar tissue is going to be the major limiting factor and would need additional vital tissue, latissimus flap, to permit adequate reconstruction.

Given the risk of infection, we planned to irrigate with both Ancef and kanamycin as bacitracin was not available. In addition, given preoperative Timentin, and we will use Augmentin postoperatively. A drain will be placed.

DESCRIPTION OF SURGERY: The patient was taken to the operating room for left breast reconstruction and was placed in the supine position on the operating table whereupon all appropriate monitoring equipments were attached. At this point, general anesthesia with LMA was uneventfully introduced. Timentin was given intravenously.

The patient had been marked in the preoperative holding area in a sitting position as to the planned lines of the pocket creation and these marks of course were left in place. The entire operative site was then prepped with Betadine in the usual manner, and sterile drapes were applied in the usual fashion. With excellent illumination, including lighted breast retractor and loupe magnification, the left breast reconstruction was undertaken.

The previous left lateral incision just above the inframammary fold was used, and deeper dissection was done with a Bovie cautery device maintaining meticulous hemostasis at this point and throughout the entire procedure. There was some vigorous bleeding along some of the scar tissues, but it was easily controlled with the cautery.

We did dissect underneath the pectoralis and soon came to the previous pocket. This was then enlarged to the marks coming to the lateral border of the sternum, the inframammary fold, anterior axillary line, and then superiorly as well. The periphery being well open, the overlying scar tissue of the capsule was now opened with moldable “postage stamp” dissections until by palpation it was completely released to allow good expansion over the implant.

The pocket was again examined and a portion of the lateral pocket along the chest wall was excised, cut into small sections and sent for culture. No purulence, unhealthy tissue, masses or any other abnormalities were seen beyond the scar.

The #3-0 Vicryl sutures were placed along the capsular opening at the incision and left long to tie down over the implant once placed.

The pocket was copiously irrigated with saline plus Kantrex and Ancef after a 7 mm Jackson-Pratt drain had been placed through the previous stab wound laterally inferiorly and sutured to the skin with #3-0 Vicryl.

Re-inspection was unremarkable, no active bleeding.

The implant was prepared on the back table with all air evacuated and 50 cc of saline added. The implant was now put in position and inflated up to 500 cc, the volume of the right side, and then after about 2-1/2 minutes, it was backed down to 450 cc which had been the equalizing point earlier. That seemed to give a good volume match to the right side but again concern was related to the scar and how well the tissue will re-drape to allow good breast reconstruction.

The fill valve was removed and the seal placed. The #3-0 Vicryl sutures were tied down. Additionally, a #3-0 Vicryl was placed to the subcutaneous layer and then a subcuticular #4-0 Vicryl. Steri-Strips over Mastisol completed the closure.

The entire area was cleansed and dressed with ABDs and bra. No abnormalities were seen in the skin, except for scars.

The left breast reconstruction being done, anesthesia was also ended. The patient was then escorted to the recovery area having tolerated the procedure and the anesthesia in a satisfactory condition. Written instructions were provided. She already has a prescription for Augmentin and Lortab. Followup has been arranged for next week. The patient was specifically instructed to call if there are any questions or problems.

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Percutaneous Tracheostomy Insertion Procedure Sample Report

DATE OF OPERATION:  MM/DD/YYYY

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:

Chronic renal failure.

POSTOPERATIVE DIAGNOSIS:

Chronic renal failure.

PROCEDURES PERFORMED:

1.  Insertion of left internal jugular Permacath under ultrasound and fluoroscopy guidance.

2.  Creation of right brachiocephalic fistula.

SURGEON:  John Doe, MD

CLINICAL FINDINGS AND INDICATIONS FOR PROCEDURE:  This (XX)-year-old female with chronic failure presented for insertion of acute and chronic vascular access, insertion of left internal jugular Permacath. The left internal jugular vein was accessed under ultrasound guidance and a tunneled 23 Arrow catheter was placed at the superior vena cava and right atrial junction. A right brachiocephalic fistula was created between the cephalic vein and the brachial artery.

DESCRIPTION OF PROCEDURE:  The patient’s neck was prepped and draped in the usual manner. The area was scanned with an ultrasound, and the right internal jugular vein was seen. This area was infiltrated with Carbocaine 1%. Then, under ultrasound guidance, the vein was accessed with a single percutaneous stick. A guidewire was introduced, and under fluoroscopy, a sheath and dilator were placed. A 23 Arrow catheter was placed at the superior vena cava and right atrial junction. The catheter was pulled through the anterior chest wall and transected. The attachment was placed. The catheter was sutured to the skin with 3-0 Prolene. The tunneled catheter was closed with 4-0 Maxon.

Attention was directed to the right arm, where an incision was taken down through the skin and subcutaneous tissue to the antecubital fossa, where the cephalic vein was isolated by blunt and sharp dissection.

The collaterals, including superficial cephalic and deep cephalic, were ligated with 2-0 silk and oversewn with 3-0 Prolene. This was mobilized medially and was distended with 3 and 4 mm dilator.

The brachial artery was found below the fascia proximal and distal to the brachial artery, and arteriotomy was made. End-to-side anastomosis was fashioned with continuous 6-0 Prolene suture for the posterior wall and interrupted 6-0 for anterior wall.

Upon releasing the clamps, a palpable thrill was obtained. The incision was closed in layers, subcutaneous with 2-0 PDS and subcuticular 4-0 Monocryl. Steri-Strips were applied. The patient left the OR in good condition.

Sample #2

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:

1.  Morbid obesity.

2.  Infected venous aneurysm.

3.  Left upper arm brachiocephalic fistula.

POSTOPERATIVE DIAGNOSES:

1.  Morbid obesity.

2.  Infected venous aneurysm.

3.  Left upper arm brachiocephalic fistula.

PROCEDURES PERFORMED:

1.  Closure of left brachiocephalic fistula.

2.  Excision of venous aneurysm.

3.  Insertion of left internal jugular Permacath.

SURGEON:  John Doe, MD

DESCRIPTION OF PROCEDURE:  The patient’s neck was prepped and shaved in the usual manner. The skin was infiltrated with Carbocaine 1%. The left internal jugular vein was accessed by percutaneous ultrasound. A guidewire was inserted with some difficulty in the superior vena cava, but had to be manipulated several times. Following the sheath and dilator, a 27 Arrow was placed in right atrial junction. The catheter was pulled and tunneled on the anterior chest wall. Attachment was placed. Checked for inflow and outflow and performed well. The catheter was fastened to the skin with 3-0 Prolene.

Attention was directed to the left upper arm. At this time, her arm was addressed by an incision through the skin and subcutaneous tissue to the antecubital fossa down to the anastomosis to the cephalic and brachial vein. The vein was clamped, ligated and transected, double ligated with 2-0 silk and oversewn with 5-0 Prolene. The venous aneurysm was excised by means of blunt and sharp dissection. This was a size of a lemon. The venous limb was double ligated with 2-0 silk suture and suture ligated with 4-0 nylon. Then the aneurysm was dissected first around the tissues by means of sharp dissection.

Bleeders were clamped and aneurysm was excised. The bleeding area of the aneurysm was addressed by taking an ellipse out of the perforation, which was very close to the skin. It was closed with a running locking 3-0 Prolene. The incision then was closed with vertical mattress sutures of 4-0 nylon. A pressure dressing was placed. The patient left the OR in stable condition.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:

Left index trigger finger.

POSTOPERATIVE DIAGNOSIS:

Left index trigger finger.

PROCEDURE PERFORMED:

Left index trigger finger release.

SURGEON:

John Doe, MD

ANESTHESIA:

Local.

TUBES AND DRAINS:

None.

SPECIMENS:

None.

ESTIMATED BLOOD LOSS:

Less than 10 ml.

COMPLICATIONS:

None.

INDICATIONS FOR PROCEDURE:

The patient is a (XX)-year-old gentleman with a long history of trigger finger releases in the past.  The patient has failed conservative measures for this finger and is indicated for operative release.

DESCRIPTION OF OPERATION:

The patient was brought back to the operating room after informed consent was obtained for left index trigger finger release. Preoperative antibiotics were not given. The patient was prepped and draped in the usual sterile fashion over a nonsterile forearm-based tourniquet after local anesthesia in the form of 5 mL of 0.5% Marcaine was infiltrated into the area surrounding the left index A1 pulley. A time-out was performed, and the patient’s name, operative site and procedure to be performed were verified against the consent and all were in agreement.

The incision was carried down initially through the proximal palmar crease at the level of the intersection with the index tendons. This was made sharply through the skin and then bluntly dissected down through the subcutaneous tissue until the synovium surrounding the tendon was isolated. There was an extensive amount of synovitis present, and this was debrided. The A1 pulley was then found and incised using tenotomy scissors.

Following this, range of motion was checked, and the patient was noted to be still triggering. The incision was carried further and explored more distally; however, the patient was still triggering. Thus a Bruner-type incision was made and a flap was elevated, and the dissection was carried down until the entire A1 pulley could be fully visualized. It was noted to have some marginal stenosis at the level of the A2 pulley. The A1 pulley was incised all the way to the level of the A2 pulley.

Following this, the patient’s tendon range of motion was clear. There was no triggering and no catching. Areas of scarring of the tendon were isolated and excised. The patient’s tendon was noted to be free falling into the wound. The tourniquet was let down after a total of 7 minutes, and the wounds were irrigated copiously, and hemostasis was obtained.

The wounds were suture closed with 5-0 nylon sutures in an interrupted horizontal mattress fashion. The wounds were then cleaned and covered with bacitracin, Adaptic gauze, dry gauze fluffs and a soft dressing was applied.

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PREOPERATIVE DIAGNOSES:
1. Chiari I malformation.
2. Cervical syrinx.

POSTOPERATIVE DIAGNOSES:
1. Chiari I malformation.
2. Cervical syrinx.

PROCEDURES PERFORMED:
1. Suboccipital decompression.
2. C1 laminectomy.
3. Duraplasty.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

SPECIMEN: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has a history of headaches and neck pain, particularly after strain or any type of Valsalva maneuver.

On MRI, he was found to have a Chiari I malformation with associated cervical syrinx. The patient wanted to proceed with surgery.

He understands the risk of the procedure (suboccipital decompression, C1 laminectomy, duraplasty), which mainly consists of CSF leak, hematoma, reoperation, infection, stroke, paralysis and death. The patient signed consent to proceed with surgery.

DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the prone position with his head in a Mayfield headrest. Then, midline incision was marked, and he was prepped and draped in a sterile fashion.

Incision was made with a 10-blade scalpel and Bovie coagulator and then the incision was gradually carried down from the scalp down to the midline fascia, separating the muscles.

Then, the suboccipital area was exposed along with the arch of C1 and C2. After prompt hemostasis was accomplished, the arch of C1 was completely removed posteriorly, and suboccipital craniectomy was performed with the use of the Midas Rex.

The extent of the suboccipital decompression was approximately 3 cm on each of the midline. The arch of C2 was slightly undermined and then the dura was opened in the midline, and after decompression of the cerebellar tonsils, the dura was patched with Dura-Guard, which was sutured in placed with 4-0 Nurolon.

Hemostasis was achieved. The area of the suture was reinforced with Tisseel and Duragen. Then, the incision was closed with 2-0 Vicryl, 3-0 Vicryl and 3-0 nylon for the skin.

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POSTOPERATIVE DIAGNOSIS: Left ovarian cyst.

PROCEDURE PERFORMED: Laparoscopic left ovarian cystectomy.

ANESTHESIA: General endotracheal.

SPECIMEN: Left ovarian cyst.

FINDINGS: Normal right ovary and uterus. Left ovarian cyst.

ESTIMATED BLOOD LOSS: 50 mL.

COMPLICATIONS: None.

POSTOPERATIVE CONDITION: Good condition to PACU.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room for laparoscopic left ovarian cystectomy. General endotracheal anesthesia was introduced. The patient was prepped and draped in normal sterile fashion. The bladder was catheterized.

Subsequently, the cervix was grasped with a single-toothed tenaculum, and a uterine manipulator was inserted.

Attention was turned to the laparoscopic part of the procedure. A 1 cm incision was then made below the umbilicus. A 5 mm trocar was inserted under direct visualization.

Subsequently, the abdomen was insufflated with carbon dioxide up to a pressure of 15 mmHg.

The pelvic anatomy was inspected. The uterus was normal as well as the right ovary. The left ovary had a large ovarian cyst about 6 x 4 x 4 cm.

At this point, the decision was made to proceed with a laparoscopic left ovarian cystectomy, presumed some of the normal ovarian tissue.

A 5 mm port was then placed, and under direct visualization, 2 other 5 mm ports were placed in the right lower quadrant and left lower quadrants under direct visualization.

The skin over the mucosa was injected with 10 mL of 0.5% Marcaine, incised. At this point, the ovarian cyst was grasped with a nontraumatic grasper, and laparoscope scissors were used initially when attempting to do the cystectomy.

At this point, a window was made into the left ovarian cyst. At this point, we noticed that clear follicular fluid was being extruded from the cyst, thus deflating the cyst.

At this point, we decided to remove the cyst wall from the normal ovarian tissue with the help of a ligature device.

Subsequently, the ovarian cyst wall was grasped with the ligature, cauterized and cut. This was continued until the cyst wall was freed from the normal ovarian tissue.

Hemostasis was noted over the pedicles. At this point, the endoloop device was used to remove the cyst wall. Since we had all 5 mm ports, we decided to extend the skin incision on the subumbilical port to be able to insert the 5 mm trocar. This was done under direct visualization.

The endoloop was inserted. The cyst wall was then inserted into the endoloop, which was then removed without difficulty.

The pelvis and the pedicles were irrigated with normal saline and suction was applied. Hemostasis was noted.

At this point, the procedure was deemed complete. All ports were removed and all of them under direct visualization. Carbon dioxide was removed from the abdomen. The fascia at the subumbilical port was closed with 0 Vicryl suture. The skin was approximated with 4-0 Monocryl suture. The other incisions were approximated with 4-0 Vicryl suture, and Dermabond was placed over these incisions.

Sponge, lap and needle counts were correct x3. The patient tolerated the procedure well.

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POSTOPERATIVE DIAGNOSIS: Right antecubital fossa mass.

PROCEDURE PERFORMED: Excision of right antecubital fossa mass (subfascial).

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: Local.

DISPOSITION: To home.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Minimal.

SPECIMENS: Pathology x1, right arm mass.

IMPLANTS: None.

INDICATIONS FOR PROCEDURE: The patient is known from previous consultation and previous surgery to have a right antecubital fossa mass. This is causing him discomfort. It has been previously imaged with ultrasound.

Ultimately, decision was made to perform an excision after the patient had an excision of a left arm mass, which he found to be not problematic.

Risks, benefits and alternatives were discussed, and informed consent was obtained to proceed with the procedure.

CONSENT: Prior to the procedure, the patient had ample time to ask all his questions and have these questions answered to his satisfaction. Risks discussed included but were not limited to infection, bleeding, mass recurrence, poor scarring, need for revision, need for re-removal of the mass and damage to small cutaneous branches of nerves in the area. Understanding these risks, the patient gave consent to proceed with the procedure.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating room table. The patient previously had been given a local field block with 9 cc of 1% lidocaine with epinephrine, which was well tolerated.

The patient was then placed supine on the operating room table with his right hand outstretched on the hand table. The patient’s arm was then prepped and draped in the standard sterile fashion.

After a standard operative time-out, including the patient’s input, the procedure was begun.

An incision in line with the skin fold was made, and spreading dissection was performed. Small cutaneous nerve branches were identified and protected.

Spreading dissection was performed, and the mass was palpable but was seen to be below the fascia. The fascia was then entered under direct visualization in a transverse oblique fashion.

Spreading dissection was then performed, and the mass was encountered. The mass was fatty in appearance, and dissection was performed over the top of it on all sides.

Once the mass was freed up, it was expressed out of the fascia and retracted. Dissection was then performed below it, and the mass was seen to be free. The mass was removed.

There was seen to be a small piece that had broken up and this too was dissected out and removed. These were sent to pathology as one specimen, as right arm mass.

The wound was then copiously irrigated and closures performed with 5-0 Monocryl suture in buried dermal fashion followed by a dressing of Dermabond.

At the end of the case, the counts were correct x2. The patient tolerated the procedure well and left the operating room under his own power.

Postoperative examination showed the patient ambulating comfortably, able to dress himself and move his hand with full function. Sensation testing was performed, and there was sensation intact to the volar forearm across the entire aspect of the volar forearm.

Biceps function was intact and median nerve function and sensation was intact. Discharge instructions were reinforced.

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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.

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