Staged Breast Reconstruction Medical Transcription Sample
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Absent left breast, status post mastectomy for cancer, staged reconstruction, expander in place.
POSTOPERATIVE DIAGNOSIS: Absent left breast, status post mastectomy for cancer, staged reconstruction, expander in place.
OPERATION PERFORMED: Staged breast reconstruction, left, with expander exchange for saline implant.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia with LMA.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 25 mL.
DRAINS AND TUBES: None.
SPECIMEN: Removed expander, discarded.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in a supine position on the operating table. All appropriate monitoring equipment was attached. At this point, general anesthesia was introduced, including LMA. Ancef 1 gram was given for prophylaxis. The entire operative site was 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 procedure was undertaken. A 15 blade was used to open up the lateral aspect of the breast incision, staying on the breast itself, just opening wide enough to allow removal of the metal fill port. Deep resection was then done with the Bovie cautery device, maintaining meticulous hemostasis.
Dissected along the pectoralis flap towards the inframammary fold, at which point, it did open to the capsule. The capsule was opened uneventfully. The expander was separated from the surrounding tissue. There was no fluid accumulation. The expander was opened, and the fluid was suctioned away. The expander was then removed uneventfully.
The pocket was examined, including bimanual palpation; this was all unremarkable. However, there was some slight cavitation of the chest wall primarily with scar buildup around the edges. We did release the capsule along the entire medial and inferior aspects and then inferiorly did make radial releases at about 1 cm intervals and then made a second incision just at about 1 cm as well, so that we could move the inframammary fold down to the desired level. Again, meticulous hemostasis was maintained. The pocket was irrigated with saline plus bacitracin. No active bleeding. A row of 3-0 Vicryl sutures was placed in the capsule opening, left long and tied down over the implant once placed.
The implant was prepared on the back table with all air evacuated and 200 mL of saline added. It was also bathed with bacitracin plus saline. All additions were done through a closed system. The implant was now put in place and inflated up to it is maximum fill volume of 475 mL. This was a larger volume than the right, and it was backed down until it seemed to be equal, which was at the 450 mL amount. The fill valve was removed and the seal was placed. The 3-0 Vicryl sutures were tied down. An additional 3-0 Vicryl was placed in the subcutaneous layer and then a subcuticular 4-0 Vicryl was put in place with Steri-Strips over Mastisol to complete this closure. All layers were cleansed and light dressing was applied using ABD and bra. Needle and sponge counts were correct. The staged breast reconstruction was ended, and the patient was escorted to the recovery area, having tolerated the procedure and the anesthesia in a satisfactory condition.
