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Superficial Parotidectomy Medical Transcription Sample / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right superficial parotid mass.

POSTOPERATIVE DIAGNOSIS:  Right superficial parotid mass.

OPERATION PERFORMED:  Right superficial parotidectomy with facial nerve dissection.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  25 mL.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, identified as the correct patient and transferred to the operating room table in supine position. MRIs of the head and neck were available for intraoperative viewing. General oral endotracheal anesthesia was then administered. The patient's bed was rotated 90 degrees and a shoulder roll was placed under the shoulders. The right neck and face were then prepped and draped under sterile conditions. The nerve integrity monitor electrodes were placed on the patient's orbicularis oculi and orbicularis oris muscles and calibrated. Approximately 3 mL of 2% Xylocaine with 1:100,000 epinephrine was then injected anterior to the auricle, the tragus, and into the right neck.

A #15 blade was then used to make an incision anterior to the right tragus and this incision ran inferiorly around the right earlobe and posteriorly into the neck approximately 2 fingerbreadths below the inferior border of the right hemimandible. An anterior-based preparotid flap was then elevated. Careful dissection was then initiated between the tragus and the posterior aspect of the parotid gland. This dissection was continued inferiorly into the neck revealing the tail of the parotid gland. The tail of the parotid gland was then reflected anteriorly and superiorly, identifying the anterior border of the right sternocleidomastoid muscle. Further dissection was then continued deeply approximately 1 cm deep and inferior to the tragal pointer. The mid portion of the superficial lobe demonstrated a well-circumscribed mass consistent grossly with a pleomorphic adenoma. This mass was then carefully retracted anteriorly and superiorly. Deep to the mass was the main trunk of the right facial nerve. The mass was then carefully dissected away from the superficial aspect of the trunk of the facial nerve. The branch of the facial nerve was then carefully followed anteriorly while retracting the mass and the superficial lobe of the parotid gland. Hemostasis was achieved during the procedure with bipolar cautery. The entire mass was then carefully removed, leaving the facial nerve branches intact. The mass along with the superficial lobe of the parotid gland was then sent for pathology. After removal, the facial nerve main trunk was stimulated and there was positive stimulation in the orbicularis oculi and oris muscles and buccal region.

The wound was then irrigated with copious amounts of saline. Hemostasis was achieved with bipolar cautery. A #7 flat JP drain was placed into the wound and brought out through a separate stab incision, sewn in place using 2-0 silk in interrupted fashion. The remaining parotid tissue was reapproximated using 3-0 Vicryl in interrupted fashion. The superficial aspect of the parotid gland was reapproximated using 4-0 Vicryl in interrupted fashion. The skin was closed using a 5-0 fast absorbing gut in a running subcuticular fashion. A jaw bra head dressing was then placed over the right cheek region. The patient was then extubated in the recovery room. There were no complications.

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