DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Carcinoma of the right breast.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the right breast.
OPERATION PERFORMED: Lumpectomy, right breast.
SURGEON: John Doe, MD
INDICATIONS FOR OPERATION: This (XX)-year-old lady has a mass that is growing in the upper outer quadrant of the right breast and is penetrating through the skin. This is an obvious cancer and has tissue confirmed with needle cytology as a malignancy. The patient probably has metastatic disease on the basis of chest CT, but because of this tumor eroding through the skin now and presenting a problem of a potentially fungating-type tumor, she comes for a lumpectomy.
DESCRIPTION OF PROCEDURE: With the patient on the operating table in the supine position, sedated intravenously, the breast was sterilely prepped with Betadine and draped. An ellipse was outlined around the tumor site, oriented towards the areolar complex. Marcaine 0.5% with epinephrine was used for local anesthesia, and a generous amount was injected in the skin along the planned incision site as well as into the subcu and deeper tissues.
Then, using a #15 scalpel blade, the incision was made, and then using a cautery with a needle tip, the dissection of tissue was performed. A wedge of tissue was removed going down and encompassing the primary tumor with a generous amount of tissue around it all the way down to the chest wall. The mass was removed and oriented and then labeled with nylon suture, one strand towards the axillary end of the incision and the other towards the areolar end of the incision with two strands. This was sent as a permanent specimen.
The patient had some hard nodules in the low axillary area, and these were very accessible, so they were removed, again using electrocautery, and this was labeled as low axillary content, presumably being enlarged metastatic lymph nodes.
The wound was checked for hemostasis. Once it was felt to be dry, a Jackson-Pratt 7 mm flat drain was then brought out through her stab wound in the inframammary fold laterally and anchored to the skin with 3-0 nylon. The wound was then closed in layers with interrupted 2-0 Vicryl for the subcu and then running 3-0 nylon for the skin. The patient tolerated the procedure well. Sterile dressing with gauze was applied and bacitracin to the skin. The patient then had a sterile dressing and gauze applied and tape and was then transferred to the recovery room in stable condition. Sponge and needle counts were correct at the end of procedure. Blood loss was negligible.
