DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Mediastinal mass.
POSTOPERATIVE DIAGNOSIS: Mediastinal mass.
PROCEDURE PERFORMED: Transcervical biopsy of mediastinal mass.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presented with left shoulder pain, and in the process of having this evaluated, was noted to have an abnormal mediastinal contour by plain films. Chest x-ray and subsequent CT scan of the chest confirmed the presence of a large anterior mediastinal mass, and the patient presents for biopsy today. The patient understands the risks and possible complications of the procedure and wishes to proceed.
OPERATIVE FINDINGS: The mass was palpable about 1 cm below the sternal notch. It was quite deep in the neck, but ultimately, it was able to be visualized after a lot of deep dissection. It was white and firm and lobulated. The frozen analysis could be consistent with an inflammatory or neoplastic process. Further specimens have been taken and sent for permanent analysis as well as flow cytometry.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced without complication. The neck and chest were prepped and draped in the usual sterile fashion.
A transverse incision was made just superior to the sternal notch and dissection down through the platysma. The strap muscles were separated in the midline, and the level of the pretracheal fascia was reached. The mass was palpable just inferior to the sternum and so further dissection was undertaken superficial to the pretracheal fascia. Multiple biopsies were taken with findings as noted above.
After assuring adequate hemostasis, the wound was closed with 3-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure. The wound was infiltrated with 1% Marcaine and then Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well without any complications. Estimated blood loss was less than 50 mL. The patient was transferred and extubated to the recovery room in stable condition. Sponge and needle count was correct at the end of the case.
