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Foot Neuroma Excision Wrist Excisional Biopsy Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left foot third and fourth interdigital neuroma.
2.  Right volar radial wrist mass.

POSTOPERATIVE DIAGNOSES:
1.  Left foot third and fourth interdigital neuroma.
2.  Right volar radial wrist mass.

OPERATIONS PERFORMED:
1.  Left foot excision of an interdigital neuroma.
2.  Right wrist excisional biopsy of the mass.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

TOURNIQUET TIME:  For the foot, 28 minutes; for the wrist, 14 minutes.

ANESTHESIA:  LMA.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male who had an ultrasound-proven bulbous neuroma, refractory to conservative measures.  He had a wrist mass on the radial artery that was painful, and he elected to have it excised.  All the risks and complications were explained in great detail and understood, and the patient elected to proceed.  Among the risks explained were infection, bleeding and nerve problems, persistent pain, loss of motion, failure of the procedure to meet his expectations, possibility of further surgical procedures.  The patient elected to proceed.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed in the supine position.  General anesthesia was induced by LMA.  A pneumatic tourniquet was placed on the right upper arm and a gram of Ancef was given intravenously for prophylaxis. A sandbag was placed underneath the left buttock, and the leg and arm were prepped and draped freely in the normal fashion.

We started with the foot first, which was exsanguinated with an Esmarch up to the ankle.  We made a skin incision over the third-fourth dorsal interspace, which was carried down to the subcutaneous tissue and bluntly dissected.  We were able to cut the intermetatarsal ligament, which then brought us down into the area of the neuroma.  We were able to identify it and resect it.  We were trying to follow it out and we made sure we explored around the flexor tendons, which were kept intact.  We were able to find the bulbous portion more distally, which again was resected.  The nerve was resected from both sides, which was exactly what we wanted to do.  We then removed the Weitlaner retractor that we were using.  We irrigated the wound out, obtained good hemostasis and closed the subcutaneous with 2-0 Vicryl with Steri-Strips over the top.  Sterile dressings were applied.  We used a compressive wrap to keep the metatarsals together with a couple of 3-inch Klings with an Ace wrap.  The Esmarch was removed at 28 minutes.

At this point, we went over to the hand, where we exsanguinated the limb and inflated the tourniquet to 250 mmHg pressure.  We proceeded to make a Z-type incision over the volar radial aspect of the wrist, and we carried the incision down to the subcutaneous tissue, ensuring hemostasis along the way.  We identified where the mass was and very carefully got down to the mass.  The mass actually went down to the flexor sheath of the flexor carpi radialis.  We were very careful to avoid cutaneous nerve branches, as well as the artery and excised the mass in toto.  This was sent for biopsy.

We then proceeded to irrigate the wound out.  We then closed the skin with 3-0 Vicryl with Steri-Strips over the top.  Sterile dressings were applied.  Tourniquet was deflated at 14 minutes.  The patient was then awakened, extubated and transferred to the recovery room in stable condition, without complications.