DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Soft tissue mass, left heel, possible ganglion cyst.
POSTOPERATIVE DIAGNOSIS: Soft tissue mass, left heel, possible ganglion cyst.
PROCEDURE PERFORMED: Excision of soft tissue mass, 2 x 2 cm lesion, left heel, under local monitored anesthesia care.
SURGEON: John Doe, MD
SEDATION: LMAC.
INDICATIONS FOR OPERATION: This is a healthy (XX)-year-old female who presented with a continuing painful enlarging mass in her left heel. Radiographs and MRI demonstrate possible fluid-filled area consistent with ganglion cyst. Two in-office aspirations have not provided any relief, and we discussed in detail with the patient a more sophisticated, aggressive excision of this lesion and sending it to Pathology for both gross and microscopic examination. We discussed in detail with the patient risks, complications, outcomes, and expectations involved. The patient understood and signed the consent form.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position and transferred to the operating table in the same supine position. Her left foot was dressed and draped in appropriate aseptic technique, and approximately 22 mL of 0.5% Marcaine plain was used to anesthetize her left lower extremity. An ankle tourniquet set at 250 mmHg was placed on her left ankle and inflated, and the patient also received 1 gram Ancef IV piggyback prior to the procedure for antibiotic prophylaxis.
An incision, approximately 3-4 cm long, was placed over her left heel, and this was carefully deepened to the level of the subcutaneous tissue. Immediately, we noticed the large soft tissue mass consistent with a neuroma-type tissue, and this was carefully excised using both sharp and blunt dissection. The mass itself measured 2 x 2 cm, and this was sent to Pathology for both gross and microscopic examination.
The surgical area was then thoroughly examined, and any further pathologic tissue was debrided. The area was thoroughly rinsed and irrigated with kanamycin-type solution. The deep tissue was then reapproximated using 3-0 Vicryl suture and the epidermal tissue reapproximated using 3-0 nylon suture in a horizontal mattress-type fashion.
A sterile compressive dressing was placed on the patient’s foot, and the tourniquet was let down. All digits, including the fifth digit, became pink and warm with good capillary refill times. The patient left the OR in good condition and will follow up with us in approximately 7-10 days.
