EXAMPLE OF OPERATIVE NOTE
PT NAME MR # XXXXXX
PREOPERATIVE DIAGNOSIS: Malignant melanoma, left neck.
POSTOPERATIVE DIAGNOSIS: Malignant melanoma, left neck.
PROCEDURE PERFORMED: Left neck complete lymph node dissection.
ATTENDING SURGEON: C. Wayne Cruse, M.D.
ASSISTANT: XXX, M.D.
INDICATIONS: This 56-year-old white male had a 1.7 mm malignant melanoma on the left superior helical rim treated in January 20xx with excision, flap closure, lymphatic mapping and sentinel node removal. One neck lymph node was removed, which was negative for tumor.
The patient did well until recently when there was noted to be an abnormality on a PET/CT scan and 2 hypermetabolic lymph nodes were identified in the left neck. A fine needle aspiration of this left neck site revealed malignant melanoma.
The patient was then seen by me and we recommended a left neck complete lymph node dissection.
Preoperatively we talked to the patient about the risk and possible complications including infection, bleeding, scar, hematoma, nerve dysfunction, chyle leak, concavities, and deformities and he wants us to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to operating room where in the supine position, general anesthesia was obtained by the anesthesiologist. A catheter was introduced into the bladder and the patient's back and head was elevated. The patient's surgical site was then injected with Marcaine with epinephrine and the left face, neck and chest was then prepped and draped in a sterile manner.
The patient had a previous cervical curvilinear incision in place in the superior neck. There were no other skin abnormalities noted. The ear primary site showed no evidence of recurrent disease.
We made an upper neck transverse incision and a mid neck zigzag incision. We excised the previous scar with these incisions. Initially, we raised subplatysmal flaps superiorly onto the face and parotid gland. We then raised an anterior flap in the subplatysmal plane to the strap muscles medially. . We raised a subplatysmal flap onto the clavicle inferiorly and a subplatysmal flap to the trapezius muscle posteriorly.
Throughout the case, hemostasis was obtained with cautery and with large metallic clips on the specimen and ties of silk and Vicryl on the patient. We also used smaller metallic clips for hemostasis and lymphostasis.
We used pickups and scissors in the subplatysmal area to dissect on the submandibular gland and identified the marginal mandibular branch of the facial nerve. It was spared from the dissection. The facial artery and vein were noted and ligated. The facial artery and vein ties were reflected superiorly to protect the marginal mandibular branch of the facial nerve.
The submandibular gland was dissected free from the mandible and its attachments were divided. The mylohyoid muscle was identified and retracted superiorly and the lingual nerve was identified. The nerve branch to the submandibular gland was divided. The submandibular gland duct was ligated. The hyoid bone was identified and dissection was then carried from an anterior to posterior direction on the posterior belly of the digastric muscle.
We identified the anterior border of sternocleidomastoid muscle superiorly at the mastoid process, dissected in front of the sternocleidomastoid muscle and identified the posterior belly of the digastric muscle. The dissection was then carried anteriorly and the posterior facial vein was ligated. The posterior belly of digastric was then dissected free from hyoid bone to mastoid process.
The cautery was used to divide the fascia overlying the strap muscles anteriorly. The origin of the omohyoid muscle was divided. Dissection was then carried on to the clavicle and the fascia over the clavicle was divided and reflected superiorly into the neck specimen.
We identified the internal jugular vein, behind the omohyoid muscle and dissection was carried from an inferior to superior direction on the internal jugular vein, carotid artery and the carotid sheath. The vagus nerve was identified and spared. Veins from the internal jugular vein were ligated, the hypoglossal nerve was identified at the carotid bulb and spared as was the ansa hypoglossi to the strap muscles. The facial vein was ligated at the internal jugular vein. Further dissection was then carried superiorly and the accessory nerve was identified and spared from the dissection. Level IV and III lymph nodes were dissected free.
Next, blunt and sharp dissection was used to dissect Level II lymph nodes from underneath the sternocleidomastoid muscle superiorly.
We then divided the fascia, the great auricular nerve and external jugular vein over the superficial aspect of the sternocleidomastoid muscle. A portion of this fascia was dissected anteriorly into the medial area and a portion was reflected laterally into the posterior neck. We then dissected underneath completely the sternocleidomastoid muscle. We found the spinal accessory nerve again medially and then identified it also along the posterior aspect of the sternocleidomastoid muscle. It was spared and dissected into the trapezius muscle. The Level V lymph nodes were dissected free from the spinal accessory nerve and the sensory cervical posterior branch was divided at Erb's point.
The transverse cervical artery and vein were ligated inferiorly and the external jugular vein was ligated inferiorly. The belly of the omohyoid muscle was divided inferiorly at the clavicle. The specimen was removed. The transverse cervical artery and vein were also ligated posteriorly at the trapezius muscle.
A Valsalva maneuver was performed and no chyle leak was identified. A 2 x 2 cm piece of Gel foam was placed over the origin of the thoracic duct area at the base of the neck. The wound was irrigated with normal saline and final hemostasis was obtained. The spinal accessory nerve and marginal mandibular branch of the facial nerve were again identified intact.
We then placed two 1 cm flat Jackson-Pratt drains through separate inferior stab wounds on the chest. A short drain was placed into the inferior lateral aspect of the neck and the longer drain was placed anteriorly and medially. The drains were secured with a 2-0 silk suture.
Next, the skin incisions were closed with 3-0 Monocryl suture to approximate the platysma muscle and deep dermis and 4-0 nylon suture on the skin in a running manner.
A sterile dressing was applied with Mastisol and Steri-Strips and the patient was discharged to the recovery room in satisfactory condition. Before leaving the OR, the bladder catheter was removed.
I was present during the key portions of the operation and immediately available during non-key portions of the operation.