Excision of Lesion
Date of Surgery -
Preop Diagnosis - soft tissue lesion
Postop Diagnosis - same
Surgeon - Dr. Luk / Dr. Tran
Anesthesia - General
Blood Loss - Minimal
Complication - None
Findings -
Specimens - soft tissue lesion
Procedure Performed:
1) Excision of Lesion
2) Layered closure of the entire lesion. See below for length
Patient comes in with the above diagnosis and was consented for the above procedures. Risks, benefits, and alternatives were discussed with patient, which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, post-operative abscess, injury to other organs, or need for further procedures or workup. Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications. The patient was also informed that sometimes, the wound may have to be left open for dressing changes and allowed for healing by secondary intention. The patient understands and agrees to proceed with the proposed procedure.
The patient was given preoperative antibiotics.
The site was marked with the patient's consent in the preop area
Location of lesion:
Length:
Width:
Depth:
Size of the lesion
The patient was brought to the OR and underwent general anesthesia. The patient was prep and draped in the standard manner.
Timeout was performed and all was in agreement.
An excision was performed where the lesion is.
This was done using a scalpel
Electrocautery was used to perform the dissection down beyond the lesion so that it can be removed completely.
Care taken so that all margins were clear.
The specimen was sent for pathology. Hemostasis was complete obtained.
At the end of the case, counts were carried out. When instrument, sponge, and needle counts were completed and reported to me as correct, then I began the closure.
The wound was then closed using absorbable sutures in a layered closure fashion.
Entire lesion was closed with the length as described above.
Patient tolerated procedure well and was transferred to recovery room in stable condition.