Excisional Biopsy of Posterior Neck Mass Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right posterior neck mass.
POSTOPERATIVE DIAGNOSIS: Right posterior neck mass.
OPERATION PERFORMED: Right excisional biopsy of a posterior neck mass.
SURGEON: Jane Doe, MD
ANESTHESIA: Local anesthesia with MAC.
SPECIMENS: Right posterior neck tissue.
POSTOPERATIVE CONDITION: Stable.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with a right posterior neck mass. He states that it is painful to touch. He states that it has been there for over six months. The decision was made to go to the operating room for an excisional biopsy of right posterior neck mass. The risks and benefits of the procedure, including bleeding, infection and scar, were explained to the patient and he agreed to proceed.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in the supine position on the operating room table. MAC anesthesia was given until a nice plane of anesthesia was obtained. At that point, 10 mL of 1% lidocaine mixed 1:1 with 0.25% Marcaine was injected around the right posterior neck lesion.
After allowing time for anesthesia and decongestion, a 3 cm horizontal incision was made over the neck lesion after the patient was prepped and draped in routine fashion. Dissection was carried down to the subcutaneous tissues. Posterior flaps were raised in a 360-degree fashion. Fibrofatty tissue, including lymphoid tissue, was removed from the area of the mass. No discrete large mass was identified. The patient certainly had scarring.
The wound was then thoroughly irrigated. Hemostasis was obtained with Bovie cautery. The wound was then closed in layered fashion, and 3-0 Vicryl stitches were used to reapproximate the tissues. Running 5-0 Prolene was used to reapproximate the skin. Bacitracin ointment was then placed. The patient was then awoken from MAC anesthesia and sent to the postanesthesia care unit in stable condition.
