Excision of lipoma / sebaceous cyst

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 or haematoma
• wound infection
• seroma or collection, sometimes needing a drain
• recurrence if cyst wall or lipoma is left behind
• visible or stretched scar
• numbness around the scar
• histology may show a different diagnosis, needing further surgery

Pre-operative details for this operation

1. Clinical diagnosisLipomaSebaceous (epidermoid) cystOther subcutaneous swelling
2. Site, size and durationexact site and side, size in cm, recent growth or pain
3. Features against a simple lesionrapid growth, pain, fixity to deep structures, size, near bone fusion lines: imaging before surgery
4. ImagingNot neededUSG doneMRI / CT done
5. Infection status (cyst)Not infectedInfected: I&D only, excision later
6. Incision markedalong or parallel to skin tension lines; for a cyst, ellipse around the punctum
7. Patient weight (for local anaesthetic dose)

Anaesthesia and position

1. AnaesthesiaLocal: lignocaine 1% plainLocal: lignocaine 1% with adrenaline 1:200,000GeneralSpinal / regionaldrug, strength and total volume; check against maximum dose
2. IV lineSecured before infiltrationNot secured (reason)
3. PositionSupineProneLateral

Operative findings

1. Size of swellingin cm, after excision
2. PlaneSubcutaneousSubfascialIntramuscularSubgaleal (scalp)
3. CapsuleWell encapsulatedThin pseudocapsuleNot encapsulated / infiltrating
4. Cyst contents (cyst)cheesy keratin, pus, blood; wall intact or ruptured
5. Relation to nerves, vessels, muscleany structure preserved or divided
6. Gross appearancenormal yellow fat lobules / anything suspicious

Procedure (steps)

1. Skin preparation and drapingantiseptic used
2. Local anaesthetic infiltrationalong incision line, then deep and around the swelling; volume used
3. IncisionLinear (lipoma)Elliptical including punctum (cyst)Small stab incision with squeeze-out (small lipoma)length in cm, direction
4. Skin flaps raisedskin hooks or artery forceps for traction
5. DissectionSharp (No. 15 blade / scissors)Blunt on the capsuleBipolar cautery
6. Lesion removedIntactCyst ruptured: wall removed completely and wound washedPiecemeal (reason)
7. Deep extensionNoneMuscle split to remove extension
8. HaemostasisBipolar cauteryMonopolar cauteryLigatures
9. Cavity checked for residual lipoma or cyst wallYes, none left

Closure, drains and dressing

1. Dead spaceClosed with absorbable suturesNot neededmaterial and size
2. DrainNoneSuction drain (large cavity)
3. SkinInterrupted polypropylene (Prolene) or nylon (Ethilon)SubcuticularVertical mattressLeft open (inflamed cyst)material and size
4. DressingSimple dressingPressure dressing

Specimens and implants

1. Specimen sent for HPEYesNo (reason)label with site; size and weight if large

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. Wound checklook for bleeding and swelling (haematoma) before discharge
2. Analgesiadrug, dose, frequency
3. Drainif placed: output chart, planned removal (about 48 hours for a large lipoma)
4. Dischargesame day for local anaesthetic cases
5. Dressingkeep dry; first change on
6. Suture removalface about day 5; most of the body after at least 1 week; back and legs 10 to 14 days
7. Follow-upHPE report date; further plan if unexpected diagnosis

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