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Operative Report Robert Randall

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Operative Report Robert Randall
OPERATIVE REPORT

Patient Name: Robert Randall

Patient ID: 110123 DOB: 01/11/xx Age: 27 Sex: Male

Date of Admission: 08/09/2014

Date of Procedure: 08/09/2014

Admitting Physician: Lyndon F. Talcott, MD, Neurology

Surgeon: Shelia Goodman, MD, Neurosurgery

Scrub Nurse: Anna M. Iaccarino, RN

Preoperative Diagnosis: Recurrent nerve sheath tumor.

Postoperative Diagnosis: Recurrent nerve sheath tumor.

Operative Procedure: Reexploration of left L5-S1 hemilaminotomy for excision of recurrent left S1 nerve sheath tumor.

Anesthesia: General endotracheal.

Specimen Removed: Cystic left S1 para root mass (frozen and permanent).

IV Fluids: See anesthesia records.

Estimated Blood Loss: ______.

Complications: None.

INDICATIONS: This is a 27-year-old male with the recurrent left S1 nerve sheath tumor.

Patient had undergone a previous left L5-S1 hemilaminotomy for a cyst aspiration and partial tumor removal in February. At that time, he was given the pathologic diagnosis of ganglioneuroma.

(Continued)

OPERATIVE REPORT

Patient Name: Robert Randall
Patient Id: 110123
Date of Surgery: 08/09/2014
Page 2

Patient developed recurrent left leg symptoms including pain and weakness. This corresponded with the progressive enlargement of the cysts on ___________________ MRIs. I explained the risk, benefits, and alternatives. All questions were answered and the patient elected to proceed with reexploration.

DESCRIPTION OF OPERATION: Patient was brought to the operating room and identified by name and bracelet. General endotracheal anesthesia was administered in the supine position. Patient was then flipped into the prone position on a Jackson table with a Wilson frame. Neurophysiologic monitoring was applied to the patient.

Previous incision site was then prepped and draped in the usual sterile fashion. Then 10 mL of 1% lidocaine with 1:200,000 epinephrine was injected along the previous

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