Epididymal Mass Excision Operative Sample Report

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Left epididymal mass.

POSTOPERATIVE DIAGNOSIS: Left epididymal mass.

PROCEDURE PERFORMED: Left scrotal aspiration via an inguinal approach and excision of left epididymal mass.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General.

SPECIMENS: Include the left epididymal mass.

COMPLICATIONS: None.

INDICATIONS: Refer to the preoperative history and physical.

DESCRIPTION OF PROCEDURE: The patient received clindamycin 800 mg IV piggyback on call to the operating room. The patient was brought to day surgery, to the main operating room. He was placed in the supine position. After adequate instillation of general anesthesia, the left inguinal area and scrotum were clipped preoperatively. He was prepped and draped in the usual sterile fashion.

A left inguinal incision was established and extended to the subcuticular tissue on Scarpa’s fascia with blunt and sharp dissection. The external oblique fascia was opened in the direction of its fibers from the internal and external ring. The left spermatic cord was encircled with a small Penrose drain. The left testis was delivered from the left hemiscrotum. The left testis was normal. About the tail of the left epididymis was an approximately 10 mm firm epididymal mass. The mass was bluntly and sharply excised and sent to the department of pathology for frozen and permanent section. Frozen section revealed a probable granuloma.

The left testis and epididymis were vigorously irrigated. Hemostasis was obtained. The left testis was returned to the left hemiscrotum. The patient tolerated the procedure well. The estimated blood loss was negligible. The patient received approximately 300 mL of IV fluid. The procedure was performed without transfusion. The procedure was performed without complication.

PLAN: The plan for this patient includes routine postoperative care. The patient will be seen in the office in one to two weeks for postoperative evaluation. The disposition of this patient depends on his clinical course.


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