DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Supraglottic mass.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the supraglottis, T3 N0 MX.
PROCEDURE PERFORMED:
1. Awake tracheostomy.
2. Direct laryngoscopy with biopsy.
3. Esophagoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 10 mL.
SPECIMEN: Supraglottic mass.
PROCEDURE FINDINGS: The patient had a large obstructing supraglottic mass. Frozen sections were sent to pathology and showed a squamous cell carcinoma.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating table. Appropriately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected subcutaneously over the region of the cricoid cartilage. After allowing time for anesthesia and decongestion, awake tracheostomy was performed.
An incision was made with a 15 blade in the skin and the subcutaneous fat. The subcutaneous fat was then dissected in a horizontal fashion down through the platysmal muscle. At that point, a vertical incision was carried down between the strap muscles to visualize the cricoid cartilage and trachea. At that point, the space between the second and third tracheal ring was identified, and a horizontal incision was made between the second and third tracheal ring. A # 6 cuff Shiley was then placed without difficulty. At that point, general anesthesia was given to the patient through gas anesthetics and IV.
Once a deep plane of anesthesia was obtained, diagnostic laparoscopy was performed with the Dedo laryngoscope. There were no lesions or masses noted in the base of tongue or vallecula. A large mass was involving the laryngeal surface of the epiglottis and epiglottic fold. There were no lesions or masses noted in the pyriform sinus or true vocal folds bilaterally. The Dedo laryngoscope was then removed. The esophagoscope was then passed posteriorly into the hypopharynx. The cricopharyngeal muscle was identified. The esophagus was then identified anteriorly and followed down inferiorly. There were no lesions or masses noted in the entire extent of the esophagus.
The esophagoscope was then removed. At that point, the patient was awakened from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.
