EXAMPLE
Donald W. Burt, Jr., M.D.
OPERATIVE REPORT
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PREOPERATIVE DIAGNOSES: Thyroglossal duct cyst.
POSTOPERATIVE DIAGNOSES: Thyroglossal duct cyst.
PROCEDURE PERFORMED: Excision of thyroglossal duct cyst under
general anesthesia.
SURGEON: Donald Burt Jr., M.D.
ASSISTANT: None.
ANESTHESIOLOGIST: Mohammad Qadeer, M.D.
ANESTHESIA: General via endotracheal tube.
BRIEF HISTORY: This is a 27-year-old male who is a physician
assistant student. He has a history of a cyst of his anterior
neck for most of his life. It alternately enlarges, gets infected
and then drains. He has been treating it by open drainage. The
area over the cyst has gradually discolored and changed in
consistency. He was referred to my office by David Griffith, M.D.
for possible excision of the cyst. With this in mind, the
findings, the diagnosis, and treatment options to include doing
nothing to medical/surgical management, as well as the attendant
risks, benefits, complications of performing or not performing
any these modalities were discussed with him and he indicated his
acceptance and understanding and desire to proceed with surgery
at this time.
FINDINGS: A transverse cicatricial area of the skin in the
submental area with a fistulous opening over the area of the
hyoid bone with an underlying fibrotic reaction which by
palpation contains a cyst like structure. The cyst and fistulous
tract ran to the base of the tongue over the hyoid bone.
PROCEDURE: The patient was brought into the operating room and
placed on the operating room table in dorsal supine position.
General anesthesia via endotracheal tube was begun. Once an
adequate level of anesthesia had been achieved, the patient’s
neck was hyperextended by placing a soft roll under his shoulders
and his head and neck left in soft supportive restraints. He was
then prepped and draped in the usual aseptic manner. An
elliptical incision was then designed around the area of the cyst
and cicatricial formation of the neck and this was then sharply
incised. Sharp dissection was carried down through the
subcutaneous tissues. Hemostasis was the electrocoagulation. The
cyst and skin was then grasped with an Allis forceps. Dissection
was then carried down around the cyst removing the fibrotic
reactive tissue along with the cyst using electrocautery.
Dissection was carried down until the hyoid bone was identified.
The tract itself seemed to run over the top of the hyoid bone to
the base of the tongue. Dissection was carried to the base of the
tongue and a small portion of the tongue muscle was taken as
well. The area over the hyoid was cauterized. This was then set
aside for later examination by the pathologist.
At this time the wound was closed in multiple layer fashion using
4-0 chromic sutures beginning with the deep tissues and
progressing through soft tissue to the subcutaneous tissues where
the skin was reapproximated using interrupted 4-0 chromic
sutures. Appearance was good. The wound was then thoroughly
cleansed and dried and Dermabond placed. A sterile dressing was
then placed over the area using a 4 x 4 and tape. The procedure
was terminated at this point. The patient tolerated the procedure
well and taken the postanesthesia care unit in satisfactory
condition
CLOSURE: 4-0 chromic suture.
ESTIMATED BLOOD LOSS: Approximately 25 mL.
COMPLICATIONS: None.
DRAINS AND PACKS: None used.
NEEDLE AND SPONGE COUNT: Correct at the end of the procedure.