DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Adenocarcinoma of the right alveolar ridge, retromolar trigone.
POSTOPERATIVE DIAGNOSIS: Adenocarcinoma of the right alveolar ridge, retromolar trigone.
PROCEDURE PERFORMED: Excision of right retromolar trigone, alveolar ridge adenocarcinoma with shaving of the mandible.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 30 mL.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The patient had a surgical healing site from the previous operation, but no palpable mass was noted. Frozen sections were sent to pathology, which were negative at the new margins.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with a history of a right retromolar trigone, alveolar ridge mass, which was excised by an oral surgeon. The pathology came back as an adenocarcinoma. The pathological specimen had a positive margin. The margin was not defined. The decision was made to go back for re-excision of right alveolar ridge, retromolar trigone adenocarcinoma. The risks and benefits were explained to the patient, and the patient agreed to go ahead with the procedure.
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. The anesthesiology service was unable to place an endotracheal tube. The otolaryngology service placed an endotracheal tube over a stylet. The table was then turned. A self-retracting mouth gag was used to visualize the right retromolar trigone and alveolar ridge. The incision site was well identified from the previous surgery.
A new margin of approximately 1 cm was taken anteriorly, mediolaterally, and posteriorly en bloc. This was carried down with Bovie cautery to the mandible. The specimen was approximately 4 x 2 cm in dimension. The depth of the resection was approximately 7.5 mm. The new margins were sent for frozen pathology. A 3 mm cutting bur was then used to shave down the alveolar ridge for new marginal purposes. The wound was then thoroughly irrigated.
Hemostasis was obtained with Bovie cautery. The wound was then reapproximated with 3-0 Vicryl stitches in a horizontal mattress fashion. A small cut was visualized on the tongue, which was reapproximated with a 3-0 Vicryl in a simple manner. The wound was then thoroughly irrigated. There was no evidence of bleeding. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
