DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Headache and vision loss.
POSTOPERATIVE DIAGNOSIS:
Headache and vision loss.
PROCEDURE PERFORMED:
Left temporal artery biopsy.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: MAC anesthesia with local, 14 mL of 1% lidocaine with 1:100,000 epinephrine.
ESTIMATED BLOOD LOSS: Less than 10 mL.
COMPLICATIONS: None.
SPECIMENS: Left superficial temporal artery, approximately 4 cm.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with a history of headaches and visual loss. The patient was referred to us for temporal artery biopsy to rule out temporal arteritis. The risks and benefits of the procedure were explained to the patient. The patient agreed to go forward with the surgery.
DESCRIPTION OF PROCEDURE: The patient came to the operating room and was placed in the supine position on the operating room table. MAC anesthesia was given until a deep plane of anesthesia was obtained. At that point, 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected in the region of the left superficial temporal artery. The length of the artery was mapped with Doppler.
After anesthesia was obtained, a vertical incision was made behind the hairline, approximately 4 cm in length. This was carried down through the superficial tissues. The superficial temporal artery was located superior to the temporalis fascia. The length of the artery was dissected free from the surrounding tissues. A mosquito clamp was used on the inferior extent to cross-clamp the artery. Another mosquito clamp was used to cross-clamp the artery superiorly. Approximately, 4.5 cm of artery was then cut from the surrounding tissue with scissors. This was sent for permanent pathology to rule out temporal arteritis. Sutures of 3-0 silk were then used to tie the distal and proximal ends of the artery.
The wound was then thoroughly irrigated. There was no further bleeding. The wound was then closed in layered fashion using 3-0 Vicryl stitches, deep. The skin edges were then reapproximated with 5-0 Monocryl. The surgery was then completed. The patient was awoken from MAC anesthesia, and the patient was then sent to the postanesthesia care unit in stable condition.
