DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right buccal space mass.
POSTOPERATIVE DIAGNOSIS: Right buccal space mass.
OPERATION PERFORMED: Transoral excision of the right buccal space mass.
SURGEON: John Doe, MD
FIRST ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Minimum.
POSTOPERATIVE CONDITION: Stable.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a pleasant (XX)-year-old Hispanic female with a history of a right buccal lesion. The lesion at times is painful and waxes and wanes in size. After discussion with the patient, the decision was made to go to the operating room for a transoral excision of a buccal lesion. The risks and benefits of the procedure, including injury to the buccal branch of the facial nerve, were explained to the patient. The patient verbalized understanding of the above and agreed to proceed with the above-mentioned procedure.
DESCRIPTION OF OPERATION: The patient was taken 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. The table was turned, and the patient was prepped and draped in the routine fashion. The surgery began with a small 1.5 cm horizontal incision at the right buccal mucosa. Superficial musculature was dissected free. This allowed visualization of the marble-sized mass, which is in the right buccal space. Sharp dissection with scissors was used to excise the attaching fascia to the lesion. The lesion was removed and sent for permanent pathology.
The wound was then thoroughly irrigated with normal saline. The wound was then closed in one layer with a 3-0 Vicryl stitch to reapproximate the buccal mucosal edges. The procedure was then terminated. The patient was awoken from general anesthesia, extubated and sent to the postanesthesia care unit in a stable condition.
