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Breast Needle Localized Lumpectomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right breast cancer.

POSTOPERATIVE DIAGNOSIS:  Right breast cancer.

OPERATION PERFORMED:
1.  Right breast needle-localized lumpectomy.
2.  Sentinel node biopsy.
3.  Axillary node dissection.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None.

INDICATION FOR OPERATION:  This is a (XX)-year-old Hispanic female who underwent a needle biopsy, which showed right breast carcinoma.  After weighing options, the patient opted for right breast needle localization, lumpectomy, sentinel node biopsy, possible axillary node dissection.

The risks and benefits of the procedure were explained to the patient. Informed consent was obtained. The patient then underwent preoperative needle localization by the radiology department.

DESCRIPTION OF OPERATION:  The patient was taken to the operating suite and placed in the supine position. General anesthesia was given by the anesthesiology department. The right breast and arm area were prepped and draped in the normal sterile fashion. Lymphazurin was injected in the right retroareolar area. Breast massage was then performed.

A small incision was made directly in the right axilla. Dissection was carried down through the subdermal layers using cutting. Once the clavipectoral fascia was incised, there was clearly a very large synovial cyst, suspicious for possible malignancy, noted.

At this point, a formal axillary node dissection was done due to intraoperative findings. Clips were used to ligate the small veins. At this point, the specimen was submitted for pathology. The wound was copiously irrigated. There was no active bleeding noted. A #10 JP drain was brought in through a separate stab incision. The drain was sutured to the skin using #2-0 nylon. The wound was closed with a 4-0 Vicryl in a running subcuticular manner. The wound was injected with lidocaine and Marcaine solution.

A whole new setup was then used for the lumpectomy. A small incision was made directly at the exit site of the needle.  Dissection was carried out through the subdermal layers using cutting. The needle was then brought into the wound, and a small skin flap was then created, and a wide circumferential dissection was performed all the way to the pectoralis muscle.

Subfascial dissection was then performed. Specimen was appropriately tagged and forwarded to Radiology. The radiologist confirmed the presence of the malignancy in the specimen with a greater than 1 cm margin all the way around.

The wound was copiously irrigated. No signs of bleeding noted. Clips were placed for future radiation therapy in the cavity. Skin was injected with Marcaine and lidocaine solution. Then 4-0 Vicryl was used to close the skin in a running subcuticular manner. Steri-Strips and sterile dressings were then applied. The patient was sent to recovery room in satisfactory condition.

INTRAOPERATIVE FINDINGS:
1.  Right breast needle-localized lumpectomy and axillary node dissection.
2.  All needle, sponge, and instrument counts were noted to be correct.