DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left breast ductal carcinoma in situ with microinvasion.
POSTOPERATIVE DIAGNOSES: Left breast ductal carcinoma in situ with microinvasion.
OPERATION PERFORMED:
1. Injection of Lymphazurin blue dye for sentinel lymph node mapping, left breast.
2. Left axillary sentinel lymphadenectomy.
3. Left breast needle-localized lumpectomy.
SURGEON: John Doe, MD
ANESTHESIA: General laryngeal mask.
ANESTHESIOLOGIST: Jane Doe, MD
DESCRIPTION OF OPERATION: After appropriate consent was obtained, the patient was brought to the operating room, placed on the table in supine position, and general laryngeal mask anesthesia was administered. The patient tolerated this well. The left breast preoperative localization films as well as sentinel lymph node mapping lymphoscintigraphy films were carefully reviewed prior to the procedure.
The patient was placed on the table in supine position, and after induction of anesthesia, the left breast and axillary regions were prepped and draped in sterile manner. Lymphazurin blue dye was injected in the subareolar region as well as around the area in the 10 o’clock region of the breast, where the tumor was located using a 25 gauge needle and approximately 3 mL of the solution.
Next, the location of the tip of the wire was identified upon physical exam and review of the localization films. Breast was marked and a line was marked for curvilinear incision to allow for excision of the lumpectomy specimen, as well as to allow for excision of the area of palpable concern at the 11 o’clock position of the breast. When the specimen was completely resected, the area of palpable concern, based on physical exam at the 11 o’clock position of the breast, was located on the superficial inferolateral aspect of the lumpectomy specimen.
Incision was made in the left axilla over the area that was noted to have increased activity indicated with a Neoprobe. Dissection was carried down with cautery through the subcutaneous and Scarpa’s fascia. The retractors were placed and the sentinel lymph node was easily identified as it had a strong blue color. Hemostat was used to dissect around this area and hemoclips were used as needed for hemostasis.
Once this blue lymph node was removed, there was no significant radioactivity within the axilla. There were no palpable lymph nodes of any suspicion within the left axilla and no further blue lymph nodes. The sentinel lymph node was submitted for touch prep analysis and the pathologist called report to the room noting that there were two lymph nodes together in that specimen and they were both negative on touch prep analysis for metastatic carcinoma.
The operative field in the left axilla was noted to be hemostatic and was closed in layers using interrupted 3-0 Vicryl to close the deep dermis and running 4-0 subcuticular Vicryl suture to close the skin. Benzoin, Steri-Strips, and sterile gauze dressings were placed at the end of the case. Curvilinear incision was then made in the left breast where it had been marked with a marking pen after placing 0.5% plain Marcaine solution for local anesthetic.
Dissection was then carried down with cautery approximately 10 mm under the skin and then tissue flaps were raised medially to allow for the wire to be brought up under the skin and into the incision. Care was taken to incorporate a portion at the 11 o’clock area of palpable concern as described above. The lumpectomy specimen was centered around the area of tip of the wire to assure complete resection. Visualization and palpation of the margins of the lumpectomy as well as lumpectomy cavity revealed no evidence of any suspicious tissues. The specimen was submitted for radiographic analysis and report was called to the room confirming that the wire and tissue clips were completely resected.
The operative field was irrigated, inspected, rendered hemostatic with cautery and then closed in layers using interrupted 3-0 Vicryl to close the deep subcutaneous tissue at a level of approximately 1 cm depth. The sutures were placed so as the knots were facing upward and not down into the lumpectomy cavity. The deep dermis was then closed with interrupted 3-0 Vicryl sutures. The skin was closed with running 4-0 subcuticular Vicryl suture. Benzoin, Steri-Strips, sterile gauze dressings were placed. The patient had her anesthesia reversed. She was taken to the recovery area postoperatively.
