Self Instructional Manual for Cancer Registrars - SEER - National ...

EXAMPLE F13
OPERATIVE
REPORT
Name: Abner Hodges Service: Surgery Hospital No.: 000031
Sex: Male Age: 40 Race: White Ward: W505 Date: 10/21/91
Surgeon: Dick Dixon, MD Assistant: Jim Jackson, MD Anesthetist: R. Bop, MD
Name of Operation:
Mediastinoscopy, sternal puncture biopsy
Pre-Operative Diagnosis:
Post-Operative Diagnosis: Probable Hodgkin's Disease or lymphoma
Operation Started: 8:30 am Operation Ended: 9:50 am
i
f
PROCEDURE
IN DETAIL:
The patient was anesthetized without complication. A nasotracheal tube was placed.
The patient was prepped from the nipples to the chin region. A small lateral incision
was placed just above the jugular notch. Dissection was carried down to the trachea.
The peritracheal fascia was found to be fibrotic and adherent around the trachea, and it
was impossible to burrow the mediastinoscope into this region. An approximately 2 x 3
cm firm, somewhat hard grayish lymph node was discovered in the pretracheal region,
and excisional biopsies were taken of this node and sent for culture for fungus,
tuberculosis, and for pathologic report. Good hemostasis was obtained. The patient was
then closed using #3 nylon for the skin sutures. It was decided because of the
presumption of good diagnostic material in the lymph node that bronchoscopy should not
be attempted at this time. It was also felt that bronchoscopy could add significantly to
the morbidity of the procedure, and the procedure was discontinued at this time. Before
the patient was aroused from anesthesia a sternal bone marrow tap was done with good
aspiration and no complications. Post-operative diagnosis: Probable Hodgkin's disease
or lymphoma. Estimated blood loss between 250 and 300 cc. Complications--None.
Dictated: 10/21/91 Date transcribed: 10/26/91
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