DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Stage IV breast cancer with left breast mass.
POSTOPERATIVE DIAGNOSIS: Stage IV breast cancer with left breast mass.
PROCEDURE PERFORMED: Left lumpectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal and local anesthetic consisting of 0.5% Marcaine with epinephrine.
ESTIMATED BLOOD LOSS: Less than 25 mL.
DRAINS: None.
DESCRIPTION OF PROCEDURE: The patient was brought into the operative room and placed on the operative table in the supine position. General endotracheal anesthesia was administered, and the patient was prepped and draped in the usual sterile fashion. A skin incision was made in the superior portion of the breast for a mass located at the 12 o’clock position deep to the upper portion of the areola. Dissection continued down with electrocautery. A large lumpectomy was performed around the palpable mass extending down to the level of the muscle. The specimen was oriented with a single long suture lateral, double long suture anterior, and single short suture superiorly, sent to pathology in a routine fashion. Hemostasis was achieved with electrocautery. Local anesthetic was injected into the wound for a total of 30 mL of 0.5% Marcaine with epinephrine. The wound was then closed in two layers approximating the deep dermal layer with 3-0 Vicryl and the skin with 4-0 Monocryl. Steri-Strips and dressings were applied. The patient was extubated and transported to the recovery area in stable condition.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: History of right breast cancer, mammographic abnormality.
POSTOPERATIVE DIAGNOSIS: History of right breast cancer, mammographic abnormality.
PROCEDURE PERFORMED: Right breast wire localized lumpectomy.
SURGEON: John Doe, MD
ANESTHESIA: MAC sedation with local anesthesia.
IV FLUIDS: 500 mL of crystalloids.
ESTIMATED BLOOD LOSS: Minimal.
URINE OUTPUT: None.
SPECIMENS: Right breast mass to pathology.
DRAINS: None.
COMPLICATIONS: None.
DISPOSITION: To recovery.
INDICATION FOR PROCEDURE: This is an (XX)-year-old woman with a remote history of right breast cancer treated with breast conservation. She was on tamoxifen for five years and has undergone followup mammography, which demonstrated a spiculated lesion near her previous lumpectomy site. An ultrasound-guided core biopsy was performed in this area, and although fibrocystic changes were seen, this was considered to be discordant. Therefore, surgical excision was recommended. A wire was placed into the right breast preoperatively by Radiology.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating room and placed on the operating table in the supine position. IV fluids, anesthesia, and monitoring were administered. Her right breast was prepped and draped in the usual sterile fashion. Then, 1% lidocaine solution was infiltrated into the skin of her right breast at her previous lumpectomy site.
An incision was made in this area in a circumareolar fashion and carried through the subcutaneous tissue. Bovie electrocautery was then used to secure hemostasis and dissect circumferentially, keeping the tip of our wire at the center of our specimen. Once this was adequately performed, the wire was delivered into the wound, and the specimen was completely excised. It was marked with sutures and clips for orientation and placed on a grid. It was then sent to Radiology for specimen radiograph.
Attention was returned to the wound where hemostasis was secured. The wound was copiously irrigated. Clips were placed in all aspects of the cavity. Once this was adequately accomplished, we received word from Radiology that the specimen contained the spiculated density and the clip.
The wound was then closed using 3-0 Vicryl in an interrupted fashion followed by 4-0 Monocryl in a running subcuticular fashion. Steri-Strips were placed and cavity was infiltrated with 0.25% Marcaine solution. The patient was then brought to recovery in stable condition, having tolerated the procedure well after a sterile dressing was placed in this area. Sponge, instrument, and needle counts were correct at the end of the case.
