Operative Report Male Question & Answer Guide (With Explanation)
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Original Question
OPERATIVE REPORT SEX: MALE AGE: 44 DATE OF OPERATION: 1/1/20XX PREOPERATIVE DIAGNOSIS: AGE-RELATED BRAIN LESION. PROCEDURES: SUB OCCIPITAL CRANIECTOMY AND OPEN BIOPSY OF THE CEREBELLAR (infratentorial)TUMOR POSTOPERATIVE DIAGNOSIS: BRAIN TUMOR of the infratentorial cerebellum. SURGEON: Trenton Kramer, M.D. INDICATIONS: This is a 44-year-old gentleman with mental status changes, hospitalized for several weeks. He had multiple ventriculostomies placed because of hydrocephalus initially subsequent imaging showed multiple lesions. He was treated empirically as well as for fungal and bacterial infection with no improvement in mental status. Imaging study showed some progression of the disease with the enhancing lesions, one in the infratentorial cerebellum close to the surface and this has showed for resective biopsy. PROCEDURE: The patient was brought to the operating room and placed in the supine position. He had already a tracheostomy in place and was given anesthesia through this. His head was then turned to the right exposing the left suboccipital area which was shaved, prepped and draped. He was placed in three point mesial fixation. Once this was done, a paramedial skin incision 2 cm up to midline was made. The prepping and draping was completed. After this, a skin incision was made. A self-retaining retractor was placed using the Midas Rex drill. A 2.5 cm craniectomy was performed just off the midline over the cerebellar hemisphere in the superior portion just under the transverse sinus. Once this was done, the dura was opened in a cruciate fashion and a small corticectomy was performed with bipolar. Next, _____ #1, there was some edematous abnormal appearing cerebellar tissue, which was encountered. Our dissection continued slightly more laterally and the lesion was found. It was clearly abnormal, cheesy and necrotic in nature with multiple specimens taken and sent for both aerobic and anaerobic cultures, TB, fungal as well as permanent section. Remainder of lesion was then removed Once this was done, hemostasis was obtained with bipolar electrocautery. The cavity was lined with Surgical and the dura was re approximated with 4-0 Nurolon. This was then reinforced with Duragen followed by BioGlue. Next, the scalp was closed with 0-Vicryl for the muscle fascia, 3-0 Vicryl for the subcutaneous tissues and 3-0 nylon for the skin. Trenton Kramer, MD Electronically signed by TRENTON KRAMER, MD 1/1/20XX
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