DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Enlarging soft tissue mass to the posterolateral aspect of the right knee.
POSTOPERATIVE DIAGNOSIS: Cystic soft tissue mass to the posterolateral aspect of the right knee.
PROCEDURE PERFORMED: Excisional biopsy of the cystic soft tissue mass to the posterolateral aspect of the right knee.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: 15 minutes.
FLUIDS: As noted in the anesthesia record.
SPECIMENS: Cystic soft tissue mass, which will be sent to Pathology for pathologic diagnosis.
CONDITION ON TRANSFER TO PAR: Good.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic female with an enlarging soft tissue mass to the posterolateral aspect of the right knee. She desires elective excision of the above. The surgical procedure including the risks, benefits, alternatives, and potential complications were discussed in detail with the patient. The patient understands the above and agrees to the above-noted procedure.
DESCRIPTION OF PROCEDURE: The patient was taken to the OR. General anesthesia was given by the anesthesiologist. She was given 1 g of intravenous Ancef prior. High-thigh tourniquet cuff was placed over the right thigh. She was placed in the prone position and prepared over her sternum and her iliac crest. The patient’s arms were positioned so there did not appear to be any tension on the brachial plexus. All pressure points were padded. The right lower extremity was prepped with DuraPrep and draped sterilely. Limb was elevated. Tourniquet was inflated to 275 mmHg.
A lazy-S incision was made in the popliteal fossa region. Dissection was carried down to the level of the fascia, which was split. Superficial vein and nerve were retracted medially. We then identified the cyst in toto, which appeared to be on the posterior surface of the lateral head of the gastrocnemius or the biceps femoris. There actually appeared to be muscle fiber that was entangled within the cyst, but we dissected the cyst out in toto as best we could keeping some of the muscle fibers with the cyst. The stalk came from distally. We placed Army-Navy retractors protecting the neurovascular bundle medially and muscle laterally. The cyst was excised in toto. There was gelatinous fluid within the body of the cyst.
We let the tourniquet down at 15 minutes to make sure there was no evidence of arterial or vascular compromise. There was no significant bleeding with letting the tourniquet down. We therefore irrigated the wound copiously with antibiotic-containing solution. Subcutaneous was closed with running 2-0 Vicryl. Skin was closed with 3-0 PDS subcuticular suture. Skin was cleansed. We infiltrated the wound margins with 0.5% Marcaine without epinephrine. Dry sterile dressing was placed followed by a knee immobilizer. The patient was reversed from anesthesia and taken to the PAR awake and stable.
The patient had a normal dorsalis pedis and posterior tibial pulse after the procedure. She was able to flex and extend her toes and ankles on the right without difficulty.
