Operative Note: Excisional Biopsy (Mucosa)

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Clinic Name
Clinic Address
Clinic Phone Number
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Surgeon(s): ***

Assistant Surgeon(s):  ***

Preoperative Diagnosis: ***

Postoperative Diagnosis: Same

Procedure(s): Buccal nodule excision

Anesthesia: General

Implants: None

Specimen: Mucosal biopsy

Drains: None

Fluids: See anesthesia record

EBL: Minimal

Complications: None

Counts:  Correct x2

Indications: ​Mucosal lesion

Findings: As expected

Procedure in Detail:

The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

1% lidocaine with 1:100,000 epi was infiltrated into the surgical site. A #15 blade was used to make an elliptical incision around the specimen which was carefully excised and sent for histopathological examination. Hemostasis was achieved. The site was closed with 3-0 chromic gut.

The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.