DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bilateral cervical lymphadenopathy.
POSTOPERATIVE DIAGNOSIS: Lymphoproliferative disorder.
OPERATION PERFORMED: Excisional lymph node biopsy, deep cervical node, left.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 20 mL.
SPECIMENS: Multiple left lymph nodes.
OPERATIVE FINDINGS: The patient had several necrotic nodes in the left cervical chain.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female with a history of malignant melanoma of the lower extremity. She has had a seven-month history of bilateral cervical lymphadenopathy. A fine-needle aspiration was obtained, which was nondiagnostic. Decision was made with the patient to go to the operating room for an excisional biopsy of the deep cervical node, left. The risks and benefits of the procedure were explained to the patient and the patient agreed to proceed.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. General face-mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, endotracheal tube was placed by the anesthesiology service without difficulty.
A 3 cm horizontal incision was made approximately one fingerbreadth above the clavicle on the left. This was over a palpable lymph node. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine was injected subcutaneously for decongestion. A horizontal incision was made in the skin with a #15 blade. Bovie cautery was used to expose a 2 cm lymph node in the left deep neck. This was deep to the sternocleidomastoid muscle. Lymph node was dissected free with sharp dissection and bipolar cautery. This was removed and sent for pathology. Frozen section was sent, the diagnosis of which was lymphoproliferative disease. Several other lymph nodes were noticed on the cervical chain in level IV of the neck. Two other lymph nodes were dissected free and sent for primary pathology for workup.
Hemostasis was obtained with bipolar cautery and Surgicel. The wound was thoroughly irrigated with normal saline. The wound was then closed in layered fashion. A deep reapproximation of sternocleidomastoid muscle was performed with 3-0 Vicryl. The platysma muscle was reapproximated with 3-0 Vicryl. The skin was closed with 5-0 Monocryl. Steri-Strips were placed. A rubber band drain was also placed. The patient was then woken up from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
