Operative Report Example 5 (Page 2)

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Operative Report

Name: Melanie Black
Hospital No.: 000036


Clinic or Floor:
Surgery Date: 09/29/91

Race: White
Age: 27
Sex: Female

Surgeon: Rex Glover, MD
Assistant: Henry Backas, MD

Time Operation Started: 11:52 am Ended: 3:37 pm

Pre-operative Diagnosis: Carcinoma R Breast

Operative Diagnosis: No residual disease

Operation Performed: Right radical mastectomy

Procedure in Detail:

A biopsy of the tumor of the right breast just to the right of the nipple had been performed 2 days previously. The tissue on permanent section was reported as grade 2 adenocarcinoma.

A Halsted type incision was so placed in the skin 2 inches distal to the biopsy scar, and a classical radical mastectomy was performed. The pectoralis major and minor were first divided at their attachments. The axilla was dissected free and the sternal and lateral attachments were divided as the last step. No glands or a suspicious nature were encountered during the dissection. The long thoracic and thoraco nerves were left intact. No glands were present in the supraclavicular area. The wound was closed without drainage. Considerable attention paid in the middle third of the wound because of the large amount of skin removed.

Sponge Count _______________
Drains _________________

Dictated by: Rex Glover, MD
Surgeon: Rex Glover, MD