DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Atypia, fine-needle aspiration.
POSTOPERATIVE DIAGNOSIS: Left breast cancer.
PROCEDURES PERFORMED:
1. Left lumpectomy.
2. Left axillary lymph node sampling.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ESTIMATED BLOOD LOSS: 50 mL.
ANESTHESIA: MAC.
TUBES AND DRAINS: 10 mm Blake drain x1.
PROCEDURES PERFORMED:
1. Left lumpectomy.
2. Left axillary lymph node sampling.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the OR table in the supine position for lumpectomy and axillary lymph node sampling. Following the administration of IV sedation, the patient’s left breast was prepped with Betadine and draped in the usual sterile manner. Xylocaine 1% without epinephrine was injected overlying the mass at the 2 o’clock position at the left breast.
An elliptical incision was made overlying the mass. Dissection was carried down to the subcutaneous tissue until the mass was identified. Upon reaching the mass, the lesion was removed.
The specimen was marked with a short suture on the superior margin and a long suture on the lateral margin. The specimen was submitted to pathology and an infiltrating ductal carcinoma was identified.
Additional tissue was taken along the superior, inferior, medial, lateral, and posterior margins. The anterior margin was fully excised with the initial specimen.
Upon excising the margins, the clavipectoral fascia was then opened and a lower axillary lymph node dissection was performed removing the axillary fat between the axillary vein and chest wall and the latissimus dorsi muscle.
Vascular and lymphatic channels were clipped as they were encountered. An extensive dissection was not performed. Grossly, these nodes did appear to be negative.
A 10 mm Blake drain was placed through a separate stab incision in the anterior axillary line and anchored into place with a 2-0 silk suture.
The subcutaneous tissue was closed with interrupted 3-0 Vicryl suture and the skin closed with 4-0 Vicryl subcuticular stitch. Hemoclips were left at all margins of the lumpectomy cavity. Benzoin, Steri-Strips, dry sterile gauze and Tegaderm dressing were applied.
All needle and sponge counts were correct. The patient was returned to recovery in good condition.
