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Lipoma Excision Procedure Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Lipoma of the left upper shoulder.

POSTOPERATIVE DIAGNOSIS:
Lipoma of the left upper shoulder.

PROCEDURE PERFORMED:
Excision of lipoma from left shoulder.

SURGEON:  John Doe, MD

ANESTHESIA:
Monitored anesthesia care with local.

SPECIMENS:
Lipoma from the left shoulder.

COMPLICATIONS:
None.

FLUIDS:
900 mL of crystalloid.

ESTIMATED BLOOD LOSS:
Minimal.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old Hispanic male with complaints of difficulties raising his left shoulder above his head. He is referred to the general surgery clinic for a small soft tissue mass on the top part of his left shoulder, just above his clavicle. It was explained to the patient that this was most likely a lipoma and was not responsible for his restriction in movement of his left shoulder. However, he was still insistent upon having the mass removed. The patient was subsequently set up for removal as an outpatient on an elective basis. The patient was brought through same-day surgery for excision.

DESCRIPTION OF PROCEDURE:
After informed consent was obtained and all risks and benefits had been discussed with the patient and the patient's spouse, the patient was brought through the same-day surgery center, where remaining preoperative preparations were made. The patient was brought to the operating room, where he was placed supine on the operating table. The correct site was confirmed, and monitored anesthesia care was administered by Anesthesia, and the patient was adequately sedated.

The patient was positioned in the right lateral decubitus position. His neck and upper shoulder were prepped with DuraPrep, and he was draped in the usual sterile fashion using sterile towels and sterile drapes. A time-out was then completed by the surgical team, confirming that the patient was present in the room for excision of a left shoulder lipoma.

Carbocaine 1% was then used to anesthetize the skin overlying the soft tissue mass. A 15 blade was used to incise the skin, and the incision was continued through the dermis using Bovie electrocautery on the subcutaneous tissue. At this point, circumferential flaps were created using the Bovie electrocautery around the soft tissue mass. Once adequate exposure was obtained, an Allis clamp was used to grasp the lipoma and deliver it into the wound. The inferior portion of the lipoma was then dissected free again using the Bovie electrocautery and amputated and passed off the table as specimen. The wound bed was then examined and hemostasis was obtained using Bovie electrocautery.

The defect was then palpated, and there was no evidence of remaining lipoma within the wound. The wound was irrigated and dried. There was no evidence of bleeding. A single deep 3-0 Vicryl suture was placed. The skin edges were then reapproximated using 3-0 Vicryl sutures in an interrupted deep dermal fashion. The skin edges were then closed using a single running 4-0 Monocryl suture in an intracuticular fashion. The wound was then cleaned and dried. Mastisol and Steri-Strips were applied. The wound was then infiltrated again using 1% Carbocaine for postoperative pain control. A total of 16 mL of 1% Carbocaine was used for local. Sterile gauze and Tegaderm were then placed over the wound.

The patient tolerated the procedure well without difficulties. The specimen was sent to Pathology for permanent section. A total of 9 mL of crystalloid was given during the course of the case. Estimated blood loss was minimal. The patient was taken to the PACU for recovery in good condition.