Finger Mass Excisional Biopsy Operative Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right ring finger mass.
POSTOPERATIVE DIAGNOSIS: Right ring finger mass.
PROCEDURE PERFORMED: Excisional biopsy of right ring finger mass.
SURGEON: John Doe, MD
ANESTHESIA: Local/monitored anesthesia care.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMEN: A 2.5 x 2 cm tannish firm mass to pathology, appearance clinically akin to a giant cell tumor.
COMPLICATIONS: None noted.
DISPOSITION: Stable to postanesthesia care unit.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old right-hand dominant male who has had a mass on his right ring finger for approximately 1-1/2 years. It is along the ulnar border of the middle phalanx and had been increasing in size. Although it was nontender, the concerns in the increase in size did warrant recommendation for an excisional biopsy of this mass. Risks, including damage to neurovascular structures and infections as well as recurrence, were discussed with the patient in the office, and an informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room and placed on the operating room table in the supine position with his right arm extended on the hand table. After satisfactory sedation was provided per Anesthesia, a metacarpal block of the right ring finger was performed using 1% lidocaine 0.5% Marcaine mix. A well-padded tourniquet was applied to the right forearm. The right arm was then prepped and draped in the usual sterile manner. A time-out was performed to confirm the patient’s site of surgery and type of surgery to be performed.
A longitudinal incision was made slightly volar to an axial incision of the middle phalanx directly overlying this mass with a 260 degrees lens on both the proximal and distal end of this longitudinal incision. The total incisional length was the span of the middle phalanx. A transverse incision was also made extending dorsally at approximately the middle aspect of the incision. The skin incisions were made using a #15 scalpel.
A blunt dissection was performed of the subcutaneous layer and this tannish, well-circumscribed firm mass was easily identified in the subcutaneous tissue along the ulnar border of the middle phalanx. Providing retraction along the mass itself, a meticulous dissection was performed taking special care with a Beaver blade to dissect medially adjacent to the mass. Tenotomy scissors were utilized to identify the digital nerve and vessel prior to proceeding with further excisional biopsy.
Once the digital nerve and vessel were identified, they were preserved well meticulously dissecting medially along the border of the mass using this Beaver blade. The mass was completely excised from the underlying soft tissue. It was noted that there were two small punctate lesions that were also tattooed into the dorsal distal aspect of the subcutaneous tissue. Therefore, the dorsal distal flap was excised to remove any of these lesions. There were no further satellite lesions that were present. It was noted that the mass was tannish in color and had an appearance very similar to a giant cell tumor.
The incision was copiously irrigated with sterile saline, and the incision was closed with 5-0 nylon horizontal mattress in cosmetic manner. The tourniquet was let down, and hemostasis was obtained with pressure and with a low set electrocautery. Hemostasis was obtained prior to repairing the skin. The incisions were then dressed with a sterile dressing consisting of bacitracin, Adaptic, dry gauze, sterile Kling and Coban. The patient tolerated the procedure well. There was good perfusion of the digit after excision of this mass.
