Axillary Lymph Node Biopsy Procedure Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Lymphadenopathy.
POSTOPERATIVE DIAGNOSIS: Lymphadenopathy.
PROCEDURE PERFORMED: Left axillary lymph node biopsy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Monitored anesthesia care with local anesthetic.
ESTIMATED BLOOD LOSS: None.
DRAINS: None.
SPECIMEN: Left axillary lymph node.
COMPLICATIONS: None.
CONDITION: Good.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has been seen for complaints of fatigue and weight loss. During his evaluation, he was noticed to have significant lymphadenopathy present with an area obvious in the left axilla. The patient was consulted for lymph node biopsy. The above-mentioned procedure was advised, and the patient is aware of the procedure, alternatives, risks and benefits. Consent was signed and placed in the chart.
DESCRIPTION OF PROCEDURE: The patient was transported from his hospital room to the operating suite and placed on the operating table in a supine position. The patient’s arms were placed on the arm board perpendicularly and secured comfortably. Monitored anesthesia care was induced in the standard anesthesia protocol. Lap belt was placed over his lap. The left axilla was shaved, prepped, and draped in the usual sterile fashion.
A transverse axillary incision was then made directly over a palpable lymph node. Dissection was carried down using Bovie cautery. Lymph node was identified and dissected free using Bovie cautery. This was done without difficulty. The lymph node was handed off for a fresh specimen and sent to Pathology. The wound was irrigated. Hemostasis was obtained using Bovie cautery.
The wound was closed in two layers, closing the clavipectoral fascia with 3-0 Vicryl interrupted suture, and the skin was reapproximated with 4-0 Monocryl running subcuticular stitch. Steri-Strips, gauze and Tegaderm dressings were applied. The patient was awakened from monitored anesthesia care and transported to the recovery room in satisfactory, stable condition. The patient will be readmitted for treatment evaluation.
