Thumb Soft Tissue Mass Excision Sample Report

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Left thumb soft tissue mass.

POSTOPERATIVE DIAGNOSIS: Left thumb soft tissue mass.

PROCEDURE PERFORMED: Excision of left thumb soft tissue mass.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA-C

ANESTHESIA: Digital block with IV sedation.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old right-hand dominant female who initially cut her finger approximately eight weeks ago. She kept it wrapped and let it heal on its own. She has developed increasing sensitivity and swelling over the area that has not resolved. She presents today for excision of the underlying mass. We discussed the procedure, postoperative protocol, and all the risks and benefits which include but are not limited to infection, wound dehiscence, neurovascular damage, tendinous damage, recurrence of the mass, and even loss of life or limb. The patient understands all this and agrees to proceed.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the operating table. IV sedation was administered to make the patient comfortable under the direction of the anesthesiologist. The correct digit was identified, it was marked preoperatively in conjunction with the patient, and confirmed by OR consent and then time-out prior to procedure.

The left upper extremity was prepped with ChloraPrep and then draped down in the usual sterile fashion. The mass was present along the ulnar aspect of the left thumb at the IP joint. The hand was elevated and then a thumb Tourni-Cot applied.

A transverse incision was made in line with the thumb crease over the mass. Incision was carried down through the skin only. Tenotomy scissors were used to divide the underlying subcutaneous tissue, and several little white nodules were expressed. These were sent off to pathology. Clinically, they appeared like epidermal inclusion cysts. The skin was undermined and further soft tissue debrided as needed.

The wound was irrigated with antibiotic solution and then two simple stitches were placed to reapproximate the edges. The procedure was done under a digital block using 0.5% Marcaine at the ulnar base of the thumb. The incision was covered with Betadine-soaked Adaptic, a 4 x 4, 1 inch Kling, and 1 inch Coban. The patient tolerated the procedure well. The patient was awoken from anesthesia and brought straight back to Day Surgery in stable condition.


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