DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left palm retinacular cyst.
2. Right wrist de Quervain tenosynovitis.
POSTOPERATIVE DIAGNOSES:
1. Left palm retinacular cyst.
2. Right wrist de Quervain tenosynovitis.
OPERATION PERFORMED:
1. Excision of left palm retinacular cyst.
2. Right wrist cortisone injection.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: IV sedation with Bier block.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: This is a (XX)-year-old right-hand dominant woman who was previously evaluated and found to have a cyst in her left palm in line with her index finger. This has been present for several years and was very bothersome and painful. She also presented with signs and symptoms consistent with de Quervain tenosynovitis. After reviewing the options, the patient elected for surgical excision and at the same time an injection into her right wrist. The risks, benefits and alternatives were reviewed, and the patient provided consent.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine on the operating table. A surgical time-out was taken, and the patient’s identity, procedure laterality, and surgical plan were reviewed and confirmed. One gram of IV cefazolin was administered, and Bier block was administered to the left hand by the anesthesiologist. After IV sedation had been given, the right wrist was prepped in a standard fashion, and a cortisone injection consisting of 8 mg of dexamethasone and 1 mL of 1% Xylocaine was injected into the first dorsal compartment without complication.
Attention was then turned towards the left palm. The cyst could be felt at the level of the distal palmar flexion crease in line with the index finger. An incision was made in this crease and carefully carried down through the subcutaneous tissue, identifying both neurovascular structures. A very well-defined retinacular cyst was identified, and a square-shaped portion of the retinaculum was sharply excised, containing the entire cyst. This was sent for pathologic analysis.
The wound was thoroughly irrigated, and bipolar was used to obtain hemostasis. The wound was then reapproximated using multiple interrupted 5-0 Monocryl sutures in inverted fashion. The tourniquet for the Bier block was then let down, and bacitracin, Adaptic and a dry sterile dressing was placed. Estimated blood loss was minimal. Sponge, needle and instrument count was correct x2. The patient was then taken to the recovery room in satisfactory condition having tolerated the procedure well.
