DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Substernal thyroid goiter.
POSTOPERATIVE DIAGNOSIS: Substernal thyroid goiter.
OPERATION PERFORMED: Incisional biopsy of the thyroid.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None acute.
SPECIMENS: Biopsy of thyroid tissue.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with a history of a thyroid mass and substernal thyroid goiter as seen per CAT scan. The patient was having a biopsy for establishment of diagnosis.
DESCRIPTION OF OPERATION: The patient was brought back to the operating room and placed in the supine position. Anesthesia was obtained. After the patient was intubated, landmarks were identified, 1:100,000 epinephrine plus 1% lidocaine was used to inject the area of the incision in the neck. The patient was then prepped and draped in the standard sterile fashion.
A 15 blade was used to incise the skin after which a Bovie cautery was used to further dissect the tissue planes. Subplatysmal flaps were elevated superiorly and inferiorly. After the strap muscles were identified, a midline incision was extended between the strap muscles to the level of the thyroid gland. Once the thyroid was identified, the 15 blade was taken again, and incision was made into the substance of the thyroid gland. Biopsy samples were then removed.
Surgicel packing was then used to pack the wound created. Appropriate hemostasis was obtained with the electrocautery device. After bleeding had stopped, a JP drain was placed. The incision was irrigated and suctioned. Hemostasis was confirmed. The strap muscles were then closed in a layered fashion with 3-0 Vicryl. The subcutaneous tissue of the skin was also closed with Vicryl sutures, and the skin was closed with a running Prolene suture, and bacitracin ointment was applied to the wound. The patient was extubated uneventfully and transferred in stable condition to the PACU.
