DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left lymphadenopathy.
POSTOPERATIVE DIAGNOSIS:
Left lymphadenopathy.
PROCEDURE PERFORMED:
Excisional biopsy of left level V lymph nodes x 3.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Zero.
SPECIMENS: Three left neck lymph nodes.
CONDITION: Stable.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old female with a history of left neck lymphadenopathy. The patient also has small lymph nodes in the right side of the neck and is complaining of possible inguinal lymph nodes. Decision was made to take the patient to the operating room for an excisional biopsy of the left neck mass to rule out lymphoma. The risks and benefits, including injury to the eleventh cranial nerve, were explained to the patient. The patient understood and agreed to proceed with the procedure.
DESCRIPTION OF PROCEDURE: The patient came to the operating room and was placed in the supine position on the operating table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty.
An incision was made in a horizontal skin crease after injecting 3 mL of 1% lidocaine with 1:100,000 epinephrine. Incision was made with a 15 blade down through the subcutaneous tissues. The deep cervical tissues were then bluntly dissected. An inferior base level V lymph node was identified. There was a second lymph node with it. These were dissected free bluntly from the surrounding tissues. The bipolar cautery was used. The eleventh nerve was identified and preserved. The more superiorly-based level V lymph node was then palpated. Blunt dissection with snap was performed over that lymph node. The lymph node was identified and retracted. It was liberated from the surrounding tissues with blunt dissection. Hemostasis was obtained with bipolar cautery. At the end of the procedure, the eleventh cranial nerve was again re-identified and was preserved.
The wound was then thoroughly irrigated with normal saline. There was no evidence of bleeding. The wound was then closed in a layered fashion with 3-0 Vicryl stitches used to reapproximate the subcutaneous tissues, 5-0 Monocryl used to reapproximate the skin. Dermabond was used for sealing of the skin edges. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.
