RECORD OF OPERATION

RECORD OF OPERATION
PATIENT: Ann Zantza
PHYSICIAN: Dennis Munoz, MD
PREOPERATIVE DIAGNOSIS: Cancer of right breast.
POSTOPERATIVE DIAGNOSIS: Cancer of right breast.
PROCEDURE: Right total mastectomy with axillary dissection.
SURGEON: Morton Holden, MD
HISTORY: This patient has cancer of the right breast. It was elected to do a right total mastectomy with an axillary dissection.
PROCEDURE: The patient was given a general anesthetic. The right arm was free draped, and she was prepped and draped in this position. We marked our superior and inferior skin incisions, and then we developed our superior flap and went down to the chest wall. We then developed the inferior flap and went down to the chest wall. We then removed the breast going from medial to lateral. We then marked it for pathological orientation. I then opened up the clavipectoral fascia. There was an easily palpable node in an area where I had felt palpable nodes before her neoadjuvant chemotherapy. I dissected this node out. This could be a sentinel node, but I obviously do not know that for sure. However, it is in the area where I felt palpable nodes, and I elected to send it for frozen section with the idea that if I saw tumor within the node, then I would consider being more aggressive with my axillary dissection. We sent this for frozen section, and it came back with no tumor. It could be that there was tumor in this node and chemotherapy dealt with it. Either way, we continued with our axillary dissection, but we elected not to go after level II nodes, because this was negative. We identified the axillary vein, the long thoracic nerve, and the thoracodorsal vessels and nerves, and then we did a formal axillary dissection going from below the axillary vein all the way down. We sent this for pathology. We had excellent hemostasis. We clipped multiple small vessels and lymphatics. We irrigated out the wound with fluid that had Ancef in it. We then put a Hemovac drain through a separate wound laterally inferiorly and put one limb in the axilla and one limb on the chest wall. We sutured these in place with silk sutures. We went ahead and closed the skin with interrupted Vicryl stitches, and then staples were placed in the skin. Telfa toppers and gauze were applied. The patient tolerated this very well and went to the recovery room in good condition.

CPT Anesthesia Code: Answer