DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ductal carcinoma in situ, left breast.
POSTOPERATIVE DIAGNOSIS: Ductal carcinoma in situ, left breast.
PROCEDURE PERFORMED: Ultrasound localization and lumpectomy, left breast.
SURGEON: John Doe, MD
ANESTHESIA: Local with sedation.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old female who recently underwent a stereotactic core biopsy for calcifications in the medial left breast, and she was found to have atypical ductal hyperplasia with focal DCIS. Lumpectomy was recommended.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. After satisfactory administration of IV sedation, the stereotactic core biopsy site was examined sonographically, and it was noted to be very superficial in the upper inner left breast.
It was not felt necessary to place a wire since it was so superficial. It was easily seen sonographically, and using the ultrasound for guidance, the skin was marked for the exact location of the core biopsy site. The markings were left in place, and the breast was then prepped with Betadine and draped in a sterile fashion.
Using the preplaced markings, the incision was then drawn on the skin encompassing the prior core biopsy site in an elliptical fashion orienting the incision in a radial fashion. Lidocaine 1% with epinephrine mixed with 0.5% Marcaine was then injected into the anticipated skin incision, as well as into the deeper breast tissue.
Incision was then made with a 15 scalpel blade and carried through the skin and subcutaneous fat. Hemostasis was secured with cautery. Using appropriate retraction, the dissection was then carried wide on all sides of the prior biopsy site. It was taken down a sufficient distance into the breast tissue. It was not taken down to the chest wall due to the superficial nature of the core biopsy site. It was taken for a distance of approximately 3 to 4 cm deep into the breast when it was excised posteriorly.
Dissection was done with cautery and Metzenbaum scissors since predominance of the breast tissue was mostly fatty. Specimen with the overlying skin ellipse was completely freed up. The prior core biopsy site was not transected during the dissection. It was oriented for the pathologist with sutures and sent for permanent section.
The wound was thoroughly irrigated with sterile water. Hemostasis was secured meticulously with cautery. Subcutaneous tissue was then closed with interrupted 4-0 Vicryl. The skin was closed with a running subcuticular suture of 5-0 Vicryl. Benzoin and Steri-Strips were applied lengthwise. A 4 x 4 gauze was then placed and a 6-inch Ace bandage was then wrapped around the chest. Estimated blood loss was 20 mL. Counts were correct. The patient tolerated the procedure well and was taken to the recovery room in good condition.
