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

EXAMPLE
F18B
OPERATIVE
REPORT
Name Melanie Black Hosp. No. 000036
Address
Clinic or Floor Surgery Date 9/29/91
Race White Age 27 Sex Female
Surgeon Rex Glover, MD Assistant Henry Backas, MD
Time Operation Started 11:52 am Ended 3:37 pm
Preoperative 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 sear, 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 of 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
187