DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Airway compromise.
2. Squamous cell carcinoma of the larynx.
POSTOPERATIVE DIAGNOSES:
1. Airway compromise.
2. Pathology confirms squamous cell carcinoma of the larynx.
PROCEDURES PERFORMED:
1. Direct laryngoscopy with biopsy.
2. Tracheotomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 20 mL.
SPECIMENS: Left glottis and subglottis.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The patient had a large obstructing mass of the left glottis and subglottis. Frozen section biopsies were consistent with squamous cell carcinoma.
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, we placed an endotracheal tube through the Dedo laryngoscope without difficulty.
After a deep plane of anesthesia was obtained, a direct laryngoscopy was performed. There were no lesions or masses noted in the base of the tongue, vallecula, epiglottis, piriform sinuses or aryepiglottic folds. The right vocal fold appeared free of tumor. The left false vocal fold appeared free of tumor. There was a large obstructing lesion involving the inferior portion of the left vocal fold and subglottis. Biopsies were taken and sent for frozen section. The frozen section diagnosis came back as squamous cell carcinoma.
Decision was then made to perform a tracheostomy. The patient was prepped and draped in a sterile fashion. A horizontal incision was made approximately two fingerbreadths above the clavicle. This was made with Bovie cautery. This was carried down to the superficial tissues deep to the platysmal muscle. At that point, a vertical incision was made between the strap muscles. This was carried down to the trachea. An incision was made between the second and third tracheal ring. This allowed access to the airway. A #8 Shiley cuffed tracheostomy tube was then placed into the area without difficulty. This was connected to the gas anesthesia with good CO2 return.
Hemostasis was obtained with Bovie cautery. Tracheostomy tube was then sewn to the anterior neck with 3-0 Prolene stitches. A Velcro soft collar was placed around the neck. This completed the surgery. The patient was then awakened from general anesthesia and sent to the postanesthesia care unit in stable condition.
