Breast Lumpectomy and Sentinel Lymph Node Biopsy Operative Note

Patient name and MRN: [Patient full name], [MRN]

Date of birth: [Date of birth]

Date of procedure: [Date of procedure]

Facility: [Facility name]

Operating room: [Operating room] (Omit if not available)

Primary surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s) / None]

Anesthesia: [Anesthesia type] by [Anesthesia provider]

Preoperative diagnosis: [Laterality and pathology diagnosis]

Postoperative diagnosis: [Postoperative diagnosis / Same as preoperative diagnosis]

Procedure performed: [Full procedure title with laterality and site]

Indications

[Clinical rationale for surgery in 3–6 sentences: whether lesion is palpable or nonpalpable; if nonpalpable, why localization was required; relevant context such as prior biopsy results, neoadjuvant therapy, or interval imaging changes]

Pre-Procedure Verification

Informed consent verified, surgical site marked, and time-out performed prior to incision. [Antibiotic prophylaxis administered / Antibiotic prophylaxis not indicated]. [VTE prophylaxis administered / VTE prophylaxis not indicated]. Patient positioned supine with [arm position for axillary access], with all pressure points padded and protected.

Operative Findings

• Breast: [Findings: palpable mass, biopsy cavity, clip presence, proximity to skin and pectoralis fascia, skin involvement] (If not assessed, state "Not assessed")
• Axilla: [Findings: blue lymphatics, radiotracer localization, palpable adenopathy] (If not assessed, state "Not assessed")
• Unexpected findings: [None / Description of unexpected findings and how the operative plan was modified]

Procedure Details

Breast

[Skin preparation and draping]. [Incision type: periareolar / radial / inframammary / other] centered over [target location]. [Dissection approach through subcutaneous tissue to the lesion or biopsy cavity].

Localization: [Lesion palpable, localization not required / Wire localization / Radioactive seed / Magnetic seed / Radar reflector / Intraoperative ultrasound]. [Target location: clock-face position and distance from nipple]. (Include injection or device placement site and timing if applicable)

The main specimen was excised en bloc to include [targeted lesion / clip / biopsy cavity] with grossly negative margins where feasible. Hemostasis achieved with [technique or device].

Specimen orientation: [Orientation scheme, e.g., short suture superior, long suture lateral]. Named margins: superior, inferior, medial, lateral, anterior (superficial), posterior (deep). [Note any anatomically constrained margins, e.g., posterior margin at pectoralis fascia].

Additional margins: [No additional margins taken / Cavity shave margins taken: specify margins and rationale / Directed margin taken: specify margin and rationale].

Specimen imaging: [Specimen radiograph / Specimen ultrasound / Not performed: brief rationale]. Intraoperative review [confirmed / did not confirm] [clip retrieval / calcifications / localization device]. [If inadequate confirmation, describe additional action taken]. (If pending final read, state "Pending final read")

Cavity markers: [Number] clips placed at [approximate positions] for radiation planning. (Omit if not placed)

Closure: [Deep tissue approximation technique], [dermal or subcuticular closure], [skin closure method]. [Oncoplastic maneuvers if performed / None].

Axilla

Sentinel node mapping: [Radiocolloid / Blue dye (specify type) / Indocyanine green / Magnetic tracer / Combination]. Injection site: [periareolar / subareolar / peritumoral]. Timing: [preoperative / intraoperative]. (If blue dye used, document allergy prophylaxis given or any reaction)

Dissection: Axillary incision at [location and length]. Dissection carried through subcutaneous tissue and clavipectoral fascia.

Sentinel nodes: [Total number] sentinel lymph node(s) identified and removed. Characteristics: [hot / blue / palpably suspicious]. Ex vivo counts: [counts by node or as group]. (Include if radiotracer used)

Termination criteria: [No additional hot or blue nodes identified / Background count threshold met / Axilla palpated with no additional suspicious nodes].

Drain: [No drain placed / Drain placed: type, size, location, method of securing, planned removal threshold].

Hemostasis achieved with [method]. Closure with [closure technique].

Specimens Submitted

1. [Main lumpectomy specimen: laterality, site, orientation scheme with named margins]
2. [Additional margin specimen(s): laterality, exact label as sent] (Include only if taken)
3. [Sentinel lymph node #1: laterality, characteristics]
4. [Sentinel lymph node #2: laterality, characteristics] (Continue numbering for all nodes)
5. [Other specimens: skin, fascia, additional lesions] (Include only if applicable)

Devices and Adjuncts

• Localization device: [Wire removed with specimen / Seed retrieved and accounted for / Not applicable]
• Cavity clips: [Number and approximate positions / None placed]
• Hemostatic agents: [Agent name and location] (Include only if used)

(Omit this section entirely if no devices or adjuncts were used)

Perioperative Summary

Estimated blood loss: [Volume in mL]

Counts: [Correct and verified / Discrepancy reconciled and documented]

Complications: [None / Description of complication and management]

Disposition and Postoperative Plan

Disposition: [Patient condition and destination, e.g., to PACU in stable condition].

Postoperative plan:

• Wound care: [Dressing type, when to remove or change, showering instructions]
• Activity: [Arm range-of-motion guidance and lifting restrictions]
• Drain care: [Type, location, output recording instructions, removal threshold, follow-up] (Include only if drain placed)
• Pain management: [Regimen and prescriptions provided]
• Pathology follow-up: [Method of communication, expected timeline, next steps including tumor board review if applicable]
• Follow-up: [Clinic visit timeframe]