皮下血肿清除记录模板.docx

皮下血肿清除记录模板Operative ReportOperation date:Pre-op diagnosis: Soft tissue tumor on right sura.Post-op diagnosis: Same as above (inflammatory granuloma).Operation done: Removal of mass.Surgeons: Anesthesia done: Epidural anesthesia.Anesthesiologists:Procedure:1.患者麻醉实施成功后取平卧位，右下肢常规消毒、铺巾，右下肢充气止血带充至0.08mpa。2.作右小腿中段后方切口约8cm，逐层切开皮肤、皮下组织、深筋膜，进入腓肠肌直达肿块。3.见肿块无包膜，约8cm×3cm×3cm大小，与周围肌肉组织粘连明显，活动度。肿块质地较硬，两端处质地则相对较软。将肿块完整切除，送冰冻病理检查。报告首先考虑“良性病变”。4.遂予冲洗、严密止血后，逐层缝合。局部加压包敷。5.术程顺利，经PACU复苏后安返病房。