OT notes · General Surgery

Excision of fibroadenoma breast

Usual anaesthesia
General; local infiltration for small superficial lumps
Position
Supine
Setting
elective

Operative note template for excision of a breast fibroadenoma, with a filled example for a 3 cm fibroadenoma removed through a circumareolar incision under general anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding and haematoma
  • seroma
  • wound infection
  • visible or thick scar
  • areolar skin necrosis with a circumareolar incision
  • change in nipple sensation or shape
  • dent or asymmetry of the breast
  • histology may show another lesion (for example phyllodes tumour) needing further surgery
  • new fibroadenomas can appear later

Pre-operative details for this operation

  1. Side and quadrant / clock positiondistance from the nipple in cm; marked on the skin with the patient awake
  2. Clinical size and featuressize in cm, mobile, well defined, skin and nipple normal, axilla normal
  3. ImagingUltrasoundMammogramBothsize, BI-RADS category, date
  4. Tissue diagnosisFNACCore biopsyNoneresult and date
  5. Reason for excisionPatient choiceSize / growthGiant fibroadenoma (over 5 cm)Discordant or uncertain biopsySuspected phyllodes tumour
  6. Pregnancy / lactation status and LMP

Anaesthesia and position

  1. AnaesthesiaGeneralLocal infiltrationLocal with sedationfor local: drug, strength, volume
  2. PositionSupine

Operative findings

  1. Lumpsize in cm, encapsulated, shelled out easily or not
  2. Cut surfaceFirm, white, whorledLeaf-like clefts / soft areas (phyllodes suspected)Other
  3. Number of lumps removed
  4. Surrounding breast tissuenormal / nodular / cysts

Procedure (steps)

  1. Skin preparation and drapingantiseptic
  2. IncisionCircumareolarCurvilinear over the lumpInframammary (submammary)Radial (medial / lateral lesions only)position and length in cm
  3. Flap raisedplane between subcutaneous fat and breast; under the areola keep the plane deep to avoid areolar necrosis
  4. Traction suture on the lumpfigure-of-eight suture; material and size
  5. Lump excisedEnucleated around the capsuleExcised with a rim of normal tissue (phyllodes suspected)sharp or cautery dissection; avoid charring the specimen surface; pectoral fascia not breached
  6. Cavity checked by palpationno residual lump
  7. Haemostasis and washcautery; saline wash

Closure, drains and dressing

  1. CavityLeft to fill (no deep sutures)Breast tissue approximated (large / giant lump)
  2. Subcutaneous layerinterrupted absorbable, material and size
  3. SkinSubcuticular absorbableSubcuticular non-absorbablematerial and size
  4. DrainNoneSuction drain
  5. DressingLight dressing with supportive braCompression dressing

Specimens and implants

  1. Lump sent for HPEYes, oriented and labelledside, quadrant, number of pieces, orientation sutures if used

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Dressing checkswelling or soakage (haematoma)
  2. Analgesiadrug, dose, frequency; ice pack over the dressing if needed
  3. Supportive braday and night until the wound settles
  4. Drainif placed: record output, remove at about 48 hours
  5. Diet and dischargeday care or next day
  6. Stitch removalonly if non-absorbable skin suture
  7. Follow-upOPD with HPE report; further surgery if phyllodes or other lesion

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Ms. P.K., 21 years, college student, with a 3 cm mobile lump in the upper outer quadrant of the left breast at 2 o'clock, 3 cm from the areolar margin. Ultrasound BI-RADS 3, FNAC: fibroadenoma. She wants it removed.

Case details

Date: 07/08/2026. Elective, day care. OT 5.

In OT 12:30. GA induced 12:40. Skin incision 12:55. Skin closure completed 13:25.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: 3 x 2.5 cm fibroadenoma, left breast, upper outer quadrant, 2 o'clock, 3 cm from the areolar margin. Patient requests excision.

Ultrasound (25/07/2026): well-defined oval hypoechoic lesion 2.8 x 2.2 cm, BI-RADS 3. FNAC (29/07/2026): benign, consistent with fibroadenoma. Axilla clinically normal. LMP 26/07/2026, not pregnant, not lactating.

Consent: general, procedure-specific (including scar, areolar necrosis, change in nipple sensation, need for further surgery if HPE differs) and anaesthesia consent taken in English from the patient.

Lump and side marked with the patient awake. WHO checklist sign in and time out done. No antibiotic prophylaxis (clean procedure, no risk factors).

Anaesthesia and position

General anaesthesia. Supine. Parts painted with povidone-iodine and draped.

Procedure

Circumareolar incision along the upper outer areolar margin, about 4 cm long.

Flap raised in the plane between subcutaneous fat and breast tissue towards 2 o'clock, keeping deep under the areola.

Figure-of-eight traction suture of silk 2-0 on a cutting needle placed through the lump.

Lump dissected out along its capsule with scissors and cautery, keeping cautery away from the specimen surface. Pectoral fascia not breached.

Findings: single encapsulated lump 3 x 2.5 cm, shelled out easily. Cut surface firm, white and whorled. Surrounding breast tissue normal.

Cavity palpated, no residual lump. Haemostasis with cautery. Cavity washed with saline.

Closure

No deep sutures in the breast tissue. Subcutaneous fat approximated with interrupted polyglactin 910 (Vicryl) 3-0.

Skin closed with subcuticular poliglecaprone 25 (Monocryl) 4-0. No drain.

Light dressing and a supportive bra.

Specimens and implants

Left breast lump, 2 o'clock, one piece, sent for HPE in formalin with the requisition form. No implants.

End of procedure

Estimated blood loss 20 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Patient shifted to recovery in stable condition. Pulse 80/min, BP 112/70 mmHg.

Post-op orders

Oral fluids when fully awake, then normal diet.

Oral analgesic as charted. Ice pack over the dressing for pain if needed.

Check dressing for swelling or soakage before discharge.

Supportive bra until the wound settles.

Discharge the same evening if comfortable. Review in surgery OPD with the HPE report.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 07/08/2026, 13:40.

Must document for this operation

  • Side, quadrant, clock position and distance from the nipple. If the report shows phyllodes tumour or cancer, the next surgeon must find the exact cavity again.
  • Pre-operative imaging and tissue diagnosis with dates. It shows the lump was assessed before surgery and explains why a simple enucleation was chosen instead of a wider excision.
  • Whether the lump shelled out along a capsule, and the cut surface. An ill-defined lump or leaf-like cut surface raises suspicion of phyllodes tumour and helps the pathologist.
  • Number of lumps removed and how the specimen was labelled. With multiple fibroadenomas, each report must match the right lump.
  • Incision used and how the areola was handled. Areolar necrosis after a circumareolar incision is a known complaint, and the note shows the flap was kept deep.

Common mistakes in these notes

  • Writing 'left breast lump excised' with no quadrant or clock position.
  • Not recording the pre-op FNAC or core biopsy result.
  • Heavy cautery on the specimen, which spoils margin assessment.
  • Sending more than one lump in one container without labels.
  • No follow-up plan for the HPE report.

Sources

  • Scott-Conner CEH, Dawson DL. Operative Anatomy / Essential Operative Techniques. Wolters Kluwer; 2015, Ch 16, Breast Biopsy, Lumpectomy, and Partial Mastectomy, pp. 120-124.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 16, Surgeries for Breast Diseases: Excision of benign breast lump, pp. 474-476.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 5, Surgery of the breast and axilla: benign breast lumps, breast lump excision, pp. 62-63.
  • Atlas of Breast Surgery (Springer), Ch 4.3, Excision of giant fibroadenoma, pp. 46.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Breast procedures: prophylaxis for clean procedures with risk factors; not routine otherwise. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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