DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pilonidal cyst.
POSTOPERATIVE DIAGNOSIS: Pilonidal cyst.
PROCEDURE PERFORMED: Pilonidal cystectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: MAC with local anesthetic.
ESTIMATED BLOOD LOSS: Minimal.
PROCEDURE FINDINGS: Pilonidal cyst.
DISPOSITION AND POSTOPERATIVE CONDITION: To PACU, in stable condition.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with complaints of posterior pain, who was found to have a pilonidal cyst that was not draining and not infected. The patient elected for its excision at this time. Preoperative risks and benefits were explained to the patient, and consent was signed for pilonidal cystectomy.
DESCRIPTION OF PROCEDURE: The patient was brought in to the operating room and laid in the prone position with arms on arm boards. MAC anesthesia was induced. Marcaine 0.5% with bicarbonate and 1% lidocaine was injected into the skin and subcutaneous tissues surrounding the pilonidal cyst. The buttocks were taped to the bed bilaterally and retracted. The buttocks were then sterilely prepped and draped in the standard fashion.
Lacrimal duct tube dilators were used to dilate the duct of the pilonidal cyst. Subsequently, methylene blue was injected into the pilonidal cyst to identify the entire cyst. A Bovie cup was used to incise an ellipse of skin incision around the pilonidal cyst. Cautery was then used to circumferentially excise the cyst from the presacral fascia. Local anesthetic was used judiciously as needed.
The patient tolerated the procedure well, and hemostasis was obtained. The entire cyst was excised as evidenced by the methylene blue. The wound was then irrigated. Closure was then commenced using 2-0 nylon in a vertical mattress fashion followed by interrupted 4-0 nylon in between. The wound was covered with bacitracin ointment and a sterile dressing. The patient tolerated the procedure well, and he was then transferred to the PACU in stable condition.
