Get Answer: Operative Report Preoperative Question Guide

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Original Question

OPERATIVE REPORT Preoperative Diagnosis: Mass left breast Postoperative Diagnosis: Infiltrating ductal carcinoma Procedure(s) Performed: Excisional biopsy left breast, lumpectomy and axillary node dissection The left breast and axilla were prepped and draped in the usual manner. The patient had a palpable lump in the upper left breast. A transverse incision was made and the palpable mass was excised down to the deeper layer. The lesion was about 2 cm above the areola. The specimen was removed and x-rayed, and sent to Pathology for frozen section. The results were infiltrating ductal carcinoma less than 1.5 cm in diameter with adequate margin, the closest margin being 4 mm from the tumor. While we were waiting for the frozen section, the incision was closed. The decision was made to proceed with lumpectomy and axillary node dissection as agreed to by the patient earlier. An elliptical incision was made, and the incision was carried down to the pectoralis fascia. The previous biopsy site was not entered. The identified mass was completely removed. We then proceeded with the axillary node dissection, which was made through a separate axillary incision about 6 cm in length. This was deepened through subcutaneous tissue. The axilla was entered. Palpable nodes were noted. A few were enlarged and suspicious, about 1 cm in diameter. There was no evidence of any lymph nodes adherent to the nerves or the axillary vein, and the apex of the axilla was clear. The dissection was completed and submitted for pathology. Signed Surgeon Signature 19301-LT, 38525 19302-LT 19302-LT. 38525 19301-LT

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