DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right neck mass.
POSTOPERATIVE DIAGNOSIS: Right neck mass.
OPERATION PERFORMED: Excisional biopsy of deep cervical lymph node, right, level II.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 75 mL.
SPECIMEN: Right neck mass.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiologist without difficulty. The table was turned. The patient’s neck was marked approximately 3 fingerbreadths below the right angle mandible. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine was injected subcutaneously. The patient was then prepped and draped in routine fashion.
A 15 blade was used to incise the skin. Approximately, 3.5 cm horizontal incision was made through the skin and subcutaneous tissues. Bovie cautery was used to excise through the platysma muscle. The right level II neck mass was immediately identified. Careful dissection around the neck mass was performed and Bovie cautery. Subsequent attention was then paid to stay around the capsule of the mass to avoid injury to the eleventh cranial nerve, the twelfth cranial nerve, and the seventh cranial nerve. The carotid artery was identified and preserved in its entire length. The jugular vein was identified. There was a small rent from the jugular vein. This was clamped and tied with 3-0 silk suture. The rest of the mass was then excised from the deep cervical space using Kitners and snap dissection with Bovie cautery. The mass was removed and sent for permanent pathology.
The wound was then thoroughly irrigated. Bipolar cautery was then used for hemostasis. Again, the wound was thoroughly irrigated with warm normal saline. There was no clear evidence of bleeding. The wound was then closed in layered fashion. The 3-0 Vicryl was used to reapproximate the platysma and 5-0 Monocryl was used to reapproximate to the skin. Dermabond was used for sealing over the cut skin edge. The procedure was then terminated, and the patient was awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
