Preop Diagnosis -
Postop Diagnosis - same
Surgeon - Dr. Luk / Dr. Tran
Anesthesia - Local
Blood Loss - Minimal
Complication - None
Findings - soft tissue lesion
Specimens - same
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 understands and agrees to proceed with the proposed procedure.
Size of the lesion in cm
Length:
Width:
Depth:
The patient was brought to the procedure room. The patient was prep and draped in the standard manner.
Timeout was performed and all was in agreement.
Local anesthetic was given.
An excision was performed where the lesion is.
This was done using a scalpel
Dissection was taken 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 prior to completion.
Area was then irrigated and 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, no complications, and was discharged in good condition.