EXAMPLE
Donald W. Burt, Jr., M.D.
OPERATIVE REPORT
________________________________
PREOPERATIVE DIAGNOSIS: Neoplasm of the upper back on the left
posterior aspect of the shoulder.
POSTOPERATIVE DIAGNOSES:
1. Neoplasm of the upper back on the left posterior aspect of the
shoulder.
2. Probable inclusion cyst.
PROCEDURE: Excision neoplasm of the deep subcutaneous tissue of
the posterior aspect of the left shoulder.
SURGEON: Donald W. Burt, Jr., M.D.
ASSISTANT: None.
ANESTHESIOLOGIST: Amitabh M. Mathur, M.D.
ANESTHESIA: General anesthesia via LMA.
BRIEF HISTORY: This 50-year-old male has had a growing mass on
the posterior aspect of his left shoulder for several years. It
has grown from pea size to now approximately 3 cm in diameter.
It is just above the scapula. It is distinctly formed but not
mobile. It has the appearance and feels like a lipoma. It has
begun to bother him becoming painful and irritating so he has
requested removal of the lesion at this time.
The findings, diabetes, treatment options to include doing
nothing to medical or surgical management as well as the
attendant risks, benefits, and complications of performing or not
performing any of these modalities were discussed with him and he
indicated his acceptance, understanding and desire to proceed
with surgery at this time.
FINDINGS: A 4 x 3 cm cyst containing whitish particulate matter
of the deep subcutaneous tissue of the posterior aspect of the
left shoulder above the scapula.
DESCRIPTION OF PROCEDURE: The patient was brought to the
operating room, placed on the operating room table in the dorsal
supine position and general anesthesia was begun. Once an
adequate level of anesthesia had been achieved, the patient was
rolled over to his right side and a inflatable sandbag apparatus
used to maintain him and hold him in this position. This allowed
for exposure of the posterior aspect of the left shoulder. He
was then prepped and draped in the usual aseptic manner.
At this time an incision was made in the natural skin lines over
the mass and sharp dissection carried down through the skin and
immediately apparent was a cyst underlying the skin. It tended
to want to bulge from the incision.
The skin was then retracted with skin retractors and using
Metzenbaum scissors dissection was carried around and along the
capsule of the cyst until it was removed in toto. It was found
to contain whitish particulate matter consistent with an
inclusion cyst. The wound was then thoroughly lavaged with warm
normal saline in order to remove any cyst material that may have
been left behind. The wound was then debrided with 4 x 4 gauge
for the same purpose. Hemostasis was then achieved via
electrocoagulation. The wound was then closed in multilayered
fashion using 4-0 chromic sutures and the subcutaneous tissues
reapproximated, reapproximating the skin in good fashion. The
wound was then thoroughly cleansed and dried. Dermabond placed
over the wound and a compressive dressing placed over the wound.
The procedure was terminated at this point. The patient
tolerated the procedure well and was taken to the post anesthesia
care unit in satisfactory condition.
CLOSURE: 4-0 chromic suture and Dermabond.
ESTIMATED BLOOD LOSS: Less than 5 cc.
COMPLICATIONS: None.
DRAINS AND PACKS: None used.
COUNTS: Needle and sponge count correct at the end of the
procedure.