PREOPERATIVE DIAGNOSIS: Right antecubital fossa mass.
POSTOPERATIVE DIAGNOSIS: Right antecubital fossa mass.
PROCEDURE PERFORMED: Excision of right antecubital fossa mass (subfascial).
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local.
DISPOSITION: To home.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMENS: Pathology x1, right arm mass.
IMPLANTS: None.
INDICATIONS FOR PROCEDURE: The patient is known from previous consultation and previous surgery to have a right antecubital fossa mass. This is causing him discomfort. It has been previously imaged with ultrasound.
Ultimately, decision was made to perform an excision after the patient had an excision of a left arm mass, which he found to be not problematic.
Risks, benefits and alternatives were discussed, and informed consent was obtained to proceed with the procedure.
CONSENT: Prior to the procedure, the patient had ample time to ask all his questions and have these questions answered to his satisfaction. Risks discussed included but were not limited to infection, bleeding, mass recurrence, poor scarring, need for revision, need for re-removal of the mass and damage to small cutaneous branches of nerves in the area. Understanding these risks, the patient gave consent to proceed with the procedure.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating room table. The patient previously had been given a local field block with 9 cc of 1% lidocaine with epinephrine, which was well tolerated.
The patient was then placed supine on the operating room table with his right hand outstretched on the hand table. The patient’s arm was then prepped and draped in the standard sterile fashion.
After a standard operative time-out, including the patient’s input, the procedure was begun.
An incision in line with the skin fold was made, and spreading dissection was performed. Small cutaneous nerve branches were identified and protected.
Spreading dissection was performed, and the mass was palpable but was seen to be below the fascia. The fascia was then entered under direct visualization in a transverse oblique fashion.
Spreading dissection was then performed, and the mass was encountered. The mass was fatty in appearance, and dissection was performed over the top of it on all sides.
Once the mass was freed up, it was expressed out of the fascia and retracted. Dissection was then performed below it, and the mass was seen to be free. The mass was removed.
There was seen to be a small piece that had broken up and this too was dissected out and removed. These were sent to pathology as one specimen, as right arm mass.
The wound was then copiously irrigated and closures performed with 5-0 Monocryl suture in buried dermal fashion followed by a dressing of Dermabond.
At the end of the case, the counts were correct x2. The patient tolerated the procedure well and left the operating room under his own power.
Postoperative examination showed the patient ambulating comfortably, able to dress himself and move his hand with full function. Sensation testing was performed, and there was sensation intact to the volar forearm across the entire aspect of the volar forearm.
Biceps function was intact and median nerve function and sensation was intact. Discharge instructions were reinforced.
