DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Soft tissue subcutaneous mass of the right scalp.
2. Skin nodule of the right scalp.
POSTOPERATIVE DIAGNOSES:
1. Soft tissue subcutaneous mass of the right scalp.
2. Skin nodule of the right scalp.
OPERATION PERFORMED: Excision of soft tissue mass and skin nodule of the right scalp.
SURGEON: John Doe, MD
ANESTHESIA: Local, using 1% lidocaine solution and intervenous Versed sedation.
ESTIMATED BLOOD LOSS: 15 mL.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This patient, who is status post prior cardiac transplantation, now presents with a slowly enlarging soft tissue mass along the right scalp as well as a persistent small skin nodule. The patient is status post prior excision of a soft tissue lipoma with atypia along the scalp and will now undergo excision of this new soft tissue mass as well as the skin nodule.
DESCRIPTION OF OPERATION: The patient was transported to the operating room and placed supine on the operating table. Following administration of intravenous Versed sedation to achieve a satisfactory level of anesthesia, the right temporal region of the scalp was prepped and draped in the customary fashion using Betadine solution and sterile towels and sheets.
The site of the planned skin incisions, overlying the soft tissue mass as well as surrounding the skin nodule, were thoroughly infiltrated with 1% lidocaine solution with epinephrine and the skin incisions made. The dissection was carried into the subcutaneous tissue, and all bleeding points were controlled with Bovie electrocautery as appropriate. The soft tissue mass was identified and appeared to be a well-encapsulated lipoma.
Using careful sharp and blunt dissection, the mass was completely excised from the surrounding soft tissue of the scalp with care being taken to ensure that the capsule was not violated and then a margin of normal-appearing fatty tissue was included surrounding the mass. The mass was then delivered for permanent pathological examination.
The area of dissection was thoroughly irrigated with Kantrex solution and checked for hemostasis. The subcutaneous tissue was closed with interrupted 3-0 Vicryl sutures and the skin reapproximated with interrupted vertical mattress 3-0 nylon sutures.
In a similar fashion, an elliptical skin incision was made surrounding the skin nodule with care being taken to ensure that a margin of normal-appearing skin was included. The dissection was carried to the subcutaneous tissue and the mass completely excised.
All bleeding points were controlled with Bovie electrocautery. The incision was irrigated with Kantrex solution and the skin reapproximated with interrupted 3-0 nylon vertical mattress sutures. Collodion was placed over the incisions, and the patient transported to the same-day surgery area in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.
