DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: History of right breast cancer with a family history of breast cancer and increased risk for breast cancer development.
POSTOPERATIVE DIAGNOSES: History of right breast cancer with a family history of breast cancer and increased risk for breast cancer development.
OPERATIONS PERFORMED:
1. Left total mastectomy.
2. On-Q pump placement.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal intubation in addition to the medication from the On-Q pump.
ESTIMATED BLOOD LOSS: Less than 50 mL.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female who had previously undergone a right total mastectomy several years ago for an invasive ductal carcinoma. Because of her family history and her own personal history, the patient chose to undergo a prophylactic mastectomy to keep her risk of a second breast cancer to its minimal if possible.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After smooth induction, she was carefully endotracheally intubated and administered a general anesthetic. A time-out was called, and the patient’s identity as well as the procedure planned, site and side confirmed before we proceeded.
An incision was planned in an elliptical fashion above the nipple-areolar complex, beginning in the lower inner quadrant and extending to the posterior axillary fold just under the hair-bearing area. Once this was drawn on the skin with a sterile skin marker, an incision was made with a #10 blade scalpel, then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. The skin flaps were then raised superiorly, medially, inferiorly and laterally within the plane that divides the adipose that invest the skin with the adipose that invest the breast. The skin flaps were then raised and the dissection taken down to the chest wall in the superior, medial and inferior positions. Laterally, this was taken down to the lateral border of the latissimus dorsi muscle. The breast tissue was then taken off the chest wall, including the investing fascia of the pectoralis major muscle. This was taken down in the superior, inferior, medial to lateral directions. The breast was slowly rotated laterally until the lateral border of the pectoralis major was identified. The lateral fascia was then carefully incised, and the breast was carefully taken off the axilla superficially. The specimen was then oriented with a short suture placed superiorly and a long suture placed laterally before it was passed off the field for evaluation by pathology.
The operative field was then inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated and inspected again. Having obtained excellent hemostasis, an On-Q pump catheter was introduced and tunneled under the skin in a medial to lateral direction from the superior aspect of the chest wall flap. The catheter was then introduced, and the peel-away sheath was removed and discarded. The catheter was then directed till the majority of the catheter then laid within the axillary area. This was then secured to the skin using Steri-Strips. A small 15 blade scalpel was used to make a stab wound in the lower left axilla. A 10 mm Jackson-Pratt drain was then inserted under the inferior chest wall flap and brought out through that stab wound and secured to the skin externally using a 3-0 nylon suture. It was then connected to bulb suction.
The incision was then approximated using interrupted staples on a temporary basis. The skin was then closed in two layers. The deep dermis was approximated using running simple suture of 3-0 Vicryl and the skin closed with running subcuticular suture of 4-0 Monocryl. The staples were removed as we progressed. The skin was then cleansed, dried, then dressed with Steri-Strips before placement of gauze and Tegaderm dressings. The gauze and Tegaderm dressings were also placed above the exit site of the drain. The patient tolerated the procedures well. Sponge, needle and instrument counts were all correct at the end of the procedure. The patient was then brought back to the PACU at the end of the procedure, extubated, awake and in good condition. Estimated blood loss was less than 50 mL, and there were no complications.
