mraymond74
Contributor
I am having a difficult time with this one. I have 56605, but I feel that I am missing something.
Any other opinions would be greatly appreciated. I have attached part of the note below.
POSTOPERATIVE DIAGNOSIS: Left lipoma of canal of Nuck.
PROCEDURES:
1. Exploration of vulvar mass.
2. Excision of left lipoma.
ANESTHESIA: MAC anesthesia with local.
IV FLUIDS AND URINE OUTPUT: Per anesthesia records.
FINDINGS: An approximately 6 x 3 x 2-cm lipomatous mass consistent with a lipoma covered with a peritoneal covering found within the mons pubis space just above or overlying the pubic bone on the left labium extending too high for complete removal or evaluation. A 1-cm size barely palpable similar mass noted on the right in similar location. Normal external genitalia otherwise.
DETAILED PROCEDURAL NOTE: The patient was taken to the operating room where MAC anesthesia was performed. She was then placed in the dorsal lithotomy position using Allen stirrups. Care was taken to assure that the knees and hips were flexed no greater than 90 degrees and the ipsilateral ankle, knee, and hip were aligned to the contralateral shoulder. The patient was then prepped and draped in the usual sterile fashion. Then, 0.5% Marcaine with epinephrine was injected at the planned incisional sites bilaterally and surrounding it underneath both vulvar mass lesions. Using the 15 blade, a 1.5 to 2-cm incision was then made in the upper aspect between the labia majora and labia minora on the left. Using sharp dissection, the space beneath the labium was opened and the mass was palpable. This mass was then grasped and gently brought through the incision. At this time, the above noted findings were noted and concern regarding potential hernia despite previously being ruled out for hernia by a general surgeon was felt and Dr. C kindly scrubbed and assisted in the lipectomy, dissecting out individual portions of this large lipoma after removing the peritoneal sheath and serially clamping, transecting, and free tying each pedicle. Once the majority of the lipoma was removed from where it could be reasonably accessed in case of bleeding, excellent aesthetics were noted. No lump was visible any longer overlying her previous mass area. Palpable deep to this, it could be felt there was some remaining lipomatous tissue, but this was not readily apparent. In agreement with Dr. C, the remainder of the lipoma if bothersome to the patient will need to be removed from a laparoscopic or open technique from above to safely access the canal of Nuck and the potential bleeding vessels that could pose a problem from a vulvar approach. At this time, the incision was assured to be hemostatic. The skin was closed with a subcuticular layer of 4-0 Vicryl. The patient tolerated the procedure well. The decision was not to pursue the right side as it may be the same problem and is not best treated through a vulvar approach and is not readily visible. The patient was then taken out of the dorsal lithotomy position, awakened without difficulty, and taken to the recovery room in stable condition. Sponge, lap, and needle counts were correct.
Any other opinions would be greatly appreciated. I have attached part of the note below.
POSTOPERATIVE DIAGNOSIS: Left lipoma of canal of Nuck.
PROCEDURES:
1. Exploration of vulvar mass.
2. Excision of left lipoma.
ANESTHESIA: MAC anesthesia with local.
IV FLUIDS AND URINE OUTPUT: Per anesthesia records.
FINDINGS: An approximately 6 x 3 x 2-cm lipomatous mass consistent with a lipoma covered with a peritoneal covering found within the mons pubis space just above or overlying the pubic bone on the left labium extending too high for complete removal or evaluation. A 1-cm size barely palpable similar mass noted on the right in similar location. Normal external genitalia otherwise.
DETAILED PROCEDURAL NOTE: The patient was taken to the operating room where MAC anesthesia was performed. She was then placed in the dorsal lithotomy position using Allen stirrups. Care was taken to assure that the knees and hips were flexed no greater than 90 degrees and the ipsilateral ankle, knee, and hip were aligned to the contralateral shoulder. The patient was then prepped and draped in the usual sterile fashion. Then, 0.5% Marcaine with epinephrine was injected at the planned incisional sites bilaterally and surrounding it underneath both vulvar mass lesions. Using the 15 blade, a 1.5 to 2-cm incision was then made in the upper aspect between the labia majora and labia minora on the left. Using sharp dissection, the space beneath the labium was opened and the mass was palpable. This mass was then grasped and gently brought through the incision. At this time, the above noted findings were noted and concern regarding potential hernia despite previously being ruled out for hernia by a general surgeon was felt and Dr. C kindly scrubbed and assisted in the lipectomy, dissecting out individual portions of this large lipoma after removing the peritoneal sheath and serially clamping, transecting, and free tying each pedicle. Once the majority of the lipoma was removed from where it could be reasonably accessed in case of bleeding, excellent aesthetics were noted. No lump was visible any longer overlying her previous mass area. Palpable deep to this, it could be felt there was some remaining lipomatous tissue, but this was not readily apparent. In agreement with Dr. C, the remainder of the lipoma if bothersome to the patient will need to be removed from a laparoscopic or open technique from above to safely access the canal of Nuck and the potential bleeding vessels that could pose a problem from a vulvar approach. At this time, the incision was assured to be hemostatic. The skin was closed with a subcuticular layer of 4-0 Vicryl. The patient tolerated the procedure well. The decision was not to pursue the right side as it may be the same problem and is not best treated through a vulvar approach and is not readily visible. The patient was then taken out of the dorsal lithotomy position, awakened without difficulty, and taken to the recovery room in stable condition. Sponge, lap, and needle counts were correct.