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Needle Localized Excisional Breast Biopsy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left breast mass associated with a papilloma on core biopsy.

POSTOPERATIVE DIAGNOSIS:
Left breast mass associated with a papilloma on core biopsy.

PROCEDURE PERFORMED:
Needle localized excisional left breast biopsy.

SURGEON:  John Doe, MD

ANESTHESIA:
Local, 11 mL of 0.5% lidocaine with 0.25% Marcaine at final concentration, with monitored anesthesia care.

ESTIMATED BLOOD LOSS:
Less than 20 mL.

COMPLICATIONS:
None.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old Hispanic female with family history of breast cancer. She recently underwent an ultrasound-guided left breast core biopsy for a complex cyst that she had palpated prior. A papilloma had been identified and core biopsied, and this can be associated with up to 10% chance of an associated malignancy, specifically there being a sampling error. Consequently, a needle-localized excision was recommended as this was no longer palpable with resolution of the cyst on prior core biopsy.

INTRAOPERATIVE FINDINGS:
The excised specimen was oriented with a short suture placed superiorly and a long suture placed laterally. The abnormality was identified within the intraoperative specimen mammogram.

DESCRIPTION OF PROCEDURE:
The patient was brought initially to the imaging center, where needle localization under ultrasound guidance took place in the upper outer quadrant of the left breast. The patient was then brought back to the same day surgery area and then to the operating room, where she was placed in the supine position. After administration of IV sedation, her left breast with needle inserted was carefully prepped and draped in the usual aseptic fashion.

A time-out was called and the patient's identity as well as the procedure planned, site, and side confirmed before we proceeded. The needle localization site was relatively short and straight forward. We then planned our incisions through the needle insertion site in the upper outer quadrant. It was drawn on the skin with a sterile skin marker. Local anesthetic was used to infiltrate the underlying dermis and subcutaneous tissues. The incision was made with a #15 blade scalpel and then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. It should be noted that local anesthetic was used to infiltrate each plane of dissection before the dissection was performed in order to maintain adequate anesthesia.

Skin flaps were raised both medially and laterally for the extent of the excision for a diameter of 1 to 1.5 cm about the needle hub and the tissue carefully excised. Two Allis clamps were then placed about the needle as it inserted into the breast tissue in order to maintain that relationship and keep the needle in place. Once excised, the tissue was oriented with a short suture placed superiorly and a long suture placed laterally. This was then passed off the field for intraoperative specimen mammogram.

The operative field was inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then inspected for adequacy of hemostasis. Having obtained excellent hemostasis, we then proceeded to close the skin in two layers, having received word from intraoperative specimen mammogram that the abnormality was present within the specimen mammogram.

The patient tolerated the procedure well. Sponge, needle, and instrument counts were all correct at the end of the procedure. The patient was brought back to the PACU at the end of the procedure, awake, and in good condition. Estimated blood loss was less than 20 mL, and there were no complications.