DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left palm mass.
POSTOPERATIVE DIAGNOSIS: Left palm mass.
OPERATION PERFORMED: Excision of left palm mass.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local with IV sedation.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old right-hand dominant male who sustained a puncture injury while at work several months ago. He developed a mass over the past few months that has been painful. He has not had any drainage from the previous wounds and has had no systemic signs. Examination in the clinic revealed an approximately 2 cm mass at the level of the junction between the proximal palmar flexion crease and thenar flexion crease. After reviewing the risks, benefits and alternatives, the patient elected for and consented to operative excision.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine on the operating table. A surgical time-out was taken, at which point the patient’s identity, procedure to be performed, laterality, and surgical plan were reviewed and confirmed. IV sedation was administered and a field block was given using a combination of 1% Xylocaine and 0.5% Marcaine. A left forearm tourniquet was placed and the left upper extremity was then prepped and draped in the standard sterile surgical fashion.
The extremity was exsanguinated, and the tourniquet inflated. Skin incision in line with the thenar flexion crease was made. This was carefully carried down through the dermal layer, revealing a pearly white well-circumscribed mass. The mass was carefully dissected from the overlying tissue, taking as much of the encapsulated tissue as possible. In the deep layer, care was taken not to injure the proper digital nerves and arteries. The mass came out without significant difficulty and was sent off for pathologic analysis.
The tourniquet was then let down. The wound was thoroughly irrigated. After confirmation of hemostasis, the dermal layer was reapproximated using multiple interrupted 4-0 Monocryl sutures in an inverted subcuticular fashion.
The hand was then washed and dried. A dry sterile dressing was placed, and the patient was taken to the recovery room in satisfactory condition, having tolerated the procedure well. Estimated blood loss was minimal. Sponge, needle and instrument count was correct x2.
POSTOPERATIVE PLAN: The patient will keep the postoperative dressing on for three days, and we will plan to see him back in one week for a wound check.
