DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Large 14 x 10 cm superficial soft tissue mass at the posterior cervical neck region.
POSTOPERATIVE DIAGNOSIS: Large 14 x 10 cm lipoma from posterior cervical neck region.
OPERATION PERFORMED: Excision of large 14 x 10 cm lipoma from posterior cervical neck region.
SURGEON: John Doe, MD
ASSISTANT: None
ANESTHESIA: General endotracheal anesthesia.
SPECIMEN: A 14 x 10 cm lipoma removed in its entirety.
ESTIMATED BLOOD LOSS: Minimal.
TRANSFUSIONS: None.
DRAINS: One 15-French Blake drain.
INDICATIONS FOR OPERATION: The patient is a very pleasant (XX)-year-old female with known history of lump in the posterior cervical neck region for quite some time but most recently increasing in size, becoming more worrisome, and causing more symptoms. This had been attempted to be removed in the office, but this was too large. On examination in the office, she was found to have a very large 14 x 10 cm mobile mass. Most likely, this was a lipoma for which excision was then recommended.
The procedure, risks and complications, which include but are not limited to bleeding, infection, and possibility of recurrence of this mass, and of course the possibility of recurrence despite the use of a drain were quite thoroughly explained to the patient, and she agreed to proceed.
DESCRIPTION OF OPERATION: With the patient in the main operating room under adequate general endotracheal anesthesia, she was placed in prone position with all pressure points adequately padded. She was placed in slight reverse Trendelenburg position.
At this point, attention was then directed to this large soft tissue along the posterior cervical neck region. She already had a transverse incision, which had been used for attempted previous removal. At this point, the site of the incision was marked, edge encompassed the previous incision. This entire area was prepped with iodoform and draped in the usual sterile fashion.
Incision was made to encompass previous incision. Dissection was then carried through the subcutaneous tissue, and at this point, a large lipoma was encountered. Superficial planes were established to separate the lipoma from the subcutaneous tissue. Dissection was then carried circumferentially down to the muscle of this entire lipoma where she also had multiple other small lipomas. It was subsequently removed in its entirety and sent to pathology. At this point, the rest of the wound was thoroughly checked, and we did not see any other abnormalities. A nice deep field block was then obtained using 0.25% plain Marcaine.
Next, a 15-French Blake drain was placed along the depth of the wound and secured to the skin using 0 Prolene. The subcutaneous tissue was approximated using interrupted 3-0 Vicryl. The skin was then approximated using wide staples along with antibiotic ointment with sterile dressing, and the Blake drain was placed to bulb suction.
The estimated blood loss was minimal. None was transfused. A 15-French Blake drain was placed. Sponge and instrument counts were correct x3. The patient subsequently tolerated the procedure well, and she was then returned to the recovery room in very stable condition.
