DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Submental masses x 2.
POSTOPERATIVE DIAGNOSIS: Submental masses x 2.
PROCEDURE PERFORMED: Excisional biopsy of submental masses.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DRAINS: None.
ESTIMATED BLOOD LOSS: Less than 5 mL.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The patient was then prepped and draped in the usual sterile fashion.
Two horizontal 2 cm incisions were made through the skin into the deep subcutaneous tissue. The first lymph node, approximately in the midline, was dissected free from the underlying subcutaneous fat with mosquito forceps and Bovie cautery. Hemostasis was obtained with bipolar cautery. Attention was then turned towards the second submental mass, which was just left of midline and inferior to the previous mass.
Again, a 2 cm horizontal incision was made with the 15 blade. This was carried down into the subcutaneous fat. At that point, mosquito forceps was used to dissect the lesion from its surrounding subcutaneous fat. After removal, bipolar cautery was used for hemostasis. These specimens were then sent for permanent pathology.
The wound was then closed in layered fashion with 3-0 Vicryl stitches to reapproximate the deep tissues and 5-0 Monocryl sutures were then used to approximate the skin in a subcuticular fashion. Steri-Strips were placed. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
