DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Oral cavity leukoplakia.
POSTOPERATIVE DIAGNOSIS:
Oral cavity leukoplakia.
PROCEDURE PERFORMED:
CO2 laser excision of alveolar ridge leukoplakia.
SURGEON: John Doe, MD
FIRST ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Zero.
SPECIMEN: Right alveolar ridge lesion.
COMPLICATIONS: None.
CONDITION: Stable.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with a history of T1N0MX squamous cell carcinoma of the floor of mouth, which was resected several months ago. The patient has new area of leukoplakia along the alveolar ridge. Decision was made to take the patient to the operating room for CO2 laser excision of alveolar ridge leukoplakia. The procedure was explained to the patient, and the patient agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient came to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, endotracheal tube was placed by the anesthesiology service without difficulty.
The table was turned. The patient was prepped and draped in the routine fashion for use of handheld CO2 laser. A dental mouth gag was used to allow visualization of the oral cavity. A sweetheart retractor was used to retract the tongue away from the right anterior alveolar ridge. The area of leukoplakia was identified, and a CO2 laser on continuous pulse with 3 watts used to excise the leukoplakia from the alveolar ridge and tooth ridge. The specimen was then sent for permanent pathology. Hemostasis was obtained with CO2 laser. After completion of removal, approximately 3 mL of 1% lidocaine with 1:100,000 epinephrine mixed 1:1 with 0.5% Marcaine was injected around the surgical site. Adrenaline-soaked pledgets were then placed onto the wound site for 5 minutes and removed. There was good hemostasis.
At that point, the procedure was completed. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition. The patient tolerated the procedure well with no apparent complications.
