DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left hard palate lesion.
POSTOPERATIVE DIAGNOSIS: Left hard palate lesion.
OPERATION PERFORMED: Excision of left hard palate region.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
OPERATIVE FINDINGS: Left lateral hard palate lesion excised with no exposed dental roots. The gross consistency lesion resembled trabecular bone and cartilage.
INDICATION FOR OPERATION: The patient is a (XX)-year-old male with a history of a gradually enlarging left hard palate lesion. The lesion was asymptomatic, except for mass effect. It did result in difficulty with articulation and some mild dysphagia. He denied any pain. CT scan demonstrated a left hard palate lesion with ground-glass consistency. Options were discussed with the patient. We have recommended transoral conservative excision for removal of the lesion and biopsy. The risks, benefits, and alternatives were discussed with the patient with emphasis on the risk of general anesthesia, recurrent lesion, postoperative hemorrhage, loss of adjacent teeth and palatal defect. The patient verbalized understanding of these risks and consented to the procedure.
DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia with endotracheal intubation was induced without difficulty. The eyes were protected with ointment and tape. The table was turned 90 degrees. The head drape was applied. A Crowe-Davis mouth gag was used to expose the oral cavity and the hard palate. The mucosa over the left hard palate mass was injected with 1% lidocaine with 1:100,000 epinephrine.
An incision was made in the mucosa over the mass. A Freer elevator was used to elevate the overlying mucosa off of the mass. A large portion of the mass was then removed using Takahashi forceps. This was sent for routine pathology. The remainder of the mass was removed using a #4 cutting bur on a Stryker drill with continuous irrigation. Care was taken not to violate the dental root of the adjacent molar.
At the completion of the excision, the wound was irrigated copiously with saline. Hemostasis was obtained with point bipolar electrocautery. A cotton pledget soaked in thrombin was applied over the excision site and direct pressure was held. The incision was then closed with interrupted 3-0 Vicryl sutures. The gastric contents were suctioned at the completion of the procedure. The patient tolerated the procedure well and without complication.
