DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left inguinal lymphadenopathy.
POSTOPERATIVE DIAGNOSIS: Left inguinal lymphadenopathy.
OPERATION PERFORMED: Excision of left inguinal lymph node.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
DRAINS: None.
ESTIMATED BLOOD LOSS: None.
OPERATIVE FINDINGS: A left inguinal lymph node could be easily palpated, measuring approximately 2 cm. The node was not matted, and it was freely movable with no signs of fixation. There was no other lymphadenopathy within the inguinal region, just a solitary lymph node.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who has had a history of an enlarged left inguinal lymph node. The patient denies any kind of recent infections or any other constitutional symptoms. The patient has agreed to proceed with an excision of the lymph node to rule out any suspicious etiologies versus infectious causes. Operative consent was signed and placed on the chart. Preoperative antibiotics have been given.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. Bilateral lower extremity athrombics were placed. The patient’s left groin was then sterilely prepped and draped in standard surgical fashion. An Ioban was utilized.
A small transverse incision was made with a 15 blade superficial to where the left inguinal lymph node could be palpated. Bovie electrocautery was then utilized to dissect into the deep subcutaneous tissues and circumferentially around the lymph node. The feeding vessels and lymphatics into the lymph node were then ligated between hemostats and secured with 3-0 Vicryl sutures. Small lymphatic drainage areas were also ligated with the use of small hemoclips. The left inguinal lymph node was then removed. A portion of it was cut and sent off for cultures, and the remaining tissue was sent for frozen section and permanent preparation.
The wound bed was made to be hemostatic. The subcutaneous tissues were then closed with simple interrupted sutures of 3-0 Vicryl. The skin was reapproximated with a running subcuticular stitch of 4-0 Monocryl. The incision was cleaned and dried along with the application of Steri-Strips, dressing and a Tegaderm. Local was then infiltrated into the area prior to dressing change for adequate postoperative pain control. The patient was then awakened from anesthesia and transported to the recovery room in stable condition. All sponge, needle and instrument counts were correct at the end of the case.
