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PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,6. Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7. Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:, Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section. The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm. The decision for C-section was made.,PROCEDURE:, The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision. The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors. The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically. The abdominal rectus muscle was divided in the center and extended in a vertical fashion. Peritoneum was entered at a high point and extended in a vertical fashion as well. The bladder blade was put in place. The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally. The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus. The first fetus was vertex. The fluid was clear. The head was delivered followed by the remaining portion of the body. The cord was doubly clamped and cut. The newborn handed off to waiting pediatrician and nursery personnel. The second fluid was ruptured. It was the clear fluid as well. The presenting part was brought down to be vertex. The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel. Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology. At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection. Then, there were multiple omental adhesions on the surface of the uterus itself. This needed to be released as well as on the abdominal wall and then the uterus could be externalized. The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first. The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath. The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized. The same technique was completed on the left side with the knuckle portion cut off and cauterized as well. The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis. Interceed was placed over this area as well. The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood. The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges. The abdominal rectus muscle was irrigated. The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center. The subcutaneous tissue was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue. Skin edges were re-approximated with sterile staples. Sterile dressing was applied. Uterus was evacuated of any remaining blood vaginally. The patient was taken to the recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct. | Surgery |
PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,POSTOPERATIVE DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:, A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9. There was normal pelvic anatomy, normal tubes. The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip. The abdomen was prepped and draped in a sterile fashion. A Pfannenstiel incision was made and carried sharply down to the level of fascia. The fascia was incised transversely. The fascia was dissected away from the underlying rectus muscles. With sharp and blunt dissection, rectus muscles were divided in midline. The perineum was entered bluntly. The incision was carried vertically with scissors. Transverse incision was made across the bladder peritoneum. The bladder was dissected away from the underlying lower uterine segment. Bladder retractor was placed to protect the bladder. The lower uterine segment was entered sharply with a scalpel. Incision was carried transversely with bandage scissors. Clear amniotic fluids were encountered. The infant was out of the pelvis and was in oblique vertex presentation. The head was brought down into the incision and delivered easily as were the shoulders and body. The mouth and oropharynx were suctioned vigorously. The cord was clamped and cut. The infant was passed off to the waiting pediatrician in satisfactory condition. Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact. Uterus was explored and found to be empty. Uterus was delivered through the abdominal incision and massaged vigorously. Intravenous Pitocin was administered. T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis. Secondary running locking stitch was placed for extra strength to the wound. At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut. Intervening knuckle was excised and passed off the field. The proximal end of the tubal mucosa was cauterized. Cul-de-sac and gutters were suctioned vigorously. The uterus was returned to its proper anatomic position in the abdomen. The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl. Uterus was expressed of its contents. Patient was brought to the recovery room in satisfactory condition. There were no complications. There was 600 cc of blood loss. All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:, Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:, General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, 1200 cc.,FLUIDS:, 2700 cc.,URINE:, 400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS: ,Placenta, cord gases and cord blood.,INDICATIONS: ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions. She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm. A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally. There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained. The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery. She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this. After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered. She was then prepped and draped in the normal sterile fashion. Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered. Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife. The fascia was incised in the midline with a second knife. This incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps. It was then dissected in the midline with Mayo scissors. The inferior aspect of this incision was then addressed in a similar manner. The rectus muscles were then separated in the midline with a hemostat. The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly. Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors. This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly. Next, the bladder blade was placed. The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors. This incision was extended laterally in both directions and a bladder flap was created digitally. The bladder blade was then reinserted. Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife. Next, the uterine incision was extended laterally in both directions with the banded scissors. Next, the infant's head and body were delivered without difficulty. There was multiple section on the abdomen. The cord was clamped and cut. Section of cord was collected for gases and the cord blood was collected. Next, the placenta was manually extracted. The uterus was exteriorized and cleared of all clots and debris. The edges of the uterine incision were then identified with Allis _______ clamps. The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis. One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid. After several minutes of observation, the hematoma was seem to be non-expanding. The uterus was replaced in the abdomen. The uterine incision was reexamined and seem to be continuing to be hemostatic. The pelvic gutters were then cleared of all clots and debris. The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion. The peritoneum was then closed with #0 Vicryl in a running fashion. The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch. The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x3. The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy of 39 weeks.,2. Herpes simplex virus, positive by history.,3. Hepatitis C, positive by history with low elevation of transaminases.,4. Cephalopelvic disproportion.,5. Asynclitism.,6. Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy of 39 weeks.,2. Herpes simplex virus, positive by history.,3. Hepatitis C, positive by history with low elevation of transaminases.,4. Cephalopelvic disproportion.,5. Asynclitism.,6. Postpartum macrosomia.,7. Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well. The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1. The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions. The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases. The patient had been seen through our office for prenatal care. The patient is on Valtrex. The patient was found to be 3 cm about 40%, 0 to 9 engaged. Bag of waters was ruptured. She was on Pitocin. She was contracting appropriately for a couple of hours or so with appropriate ________. There was no cervical change noted. Most probably because there was a sink vertex and that the head was too large to descend into the pelvis. The patient was advised of this and we recommended cesarean section. She agreed. We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms. The patient's questions were answered. I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE: ,The patient was then taken back to operative suite. She was given anesthetic and sterilely prepped and draped. Pfannenstiel incision was used. A second knife was used to carry the incision down to the anterior rectus fascia. Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature. The rectus muscles were separated. The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity. There was a very thin lower uterine segment. There seemed to be quite a large baby. The patient had a small nick in the uterus. Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained. A blunt low transverse cervical incision was made. Following this, we placed a ________ on the very large fetal head. The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry. The patient then underwent removal of the placenta after the cord blood and ABG were taken. The patient's uterus was examined. There appeared to be no retained products. The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first. The patient's uterus was hemostatic. Bladder flap was reapproximated with #0 Vicryl. The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic. We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures. The patient had three interrupted sutures of this. The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline. The Scarpa's fascia was reapproximated with #0 gut. There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact. The patient was hemostatic. All counts were correct and the patient tolerated the procedure well. We will see her back in recovery. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,5. Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:, 500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS: ,Normal appearing uterus, tubes, and ovaries. A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively. Infant weight equaled to 4140 gm with clear amniotic fluid. The umbilical cord was wrapped around the leg tightly x1. Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE: ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy. She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery. The patient had a positive group beta strep colonization culture and was started on penicillin. The patient was also started on Pitocin protocol at that time. The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor. IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units. The patient was given a rest from the Pitocin. She walked and had a short shower. The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions. Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position. At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound. Options were discussed with the patient and family and it was determined that we will take her for C-section today. Consent was signed. All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed. She was placed in the dorsal supine position with left upward tilt. She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate. A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel. The fascia was incised in the midline and extended laterally using curved Mayo scissors. The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles. Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle. The rectus muscle was separated in the midline bluntly. The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors. The peritoneum was then bluntly stretched. The bladder blade was placed. The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors. The incision was extended laterally and the bladder flap created digitally. The bladder blade was then reinserted in the lower uterine segment. A low transverse uterine incision was made with a second scalpel. The uterine incision was extended laterally bluntly. The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum. Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically. There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut. Infant was handed to the waiting pediatrician. Cord gas was sent for pH as well as blood typing. The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris. The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion. A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis. The uterus was returned to the abdomen. The gutters were cleared of all clots and debris. The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion. The fascia was reapproximated with #0-Vicryl suture in a running fashion. The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut. The skin was then closed with staples. The incision was dressed with sterile dressing and bandage. Blood clots were evacuated from the vagina. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The mother was taken to the recovery room in stable and satisfactory condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,POSTOPERATIVE:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,4. Delivery of a viable female, weight 5 pound, 14 ounces. Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:, Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS: ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction. The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department. The patient was then repositioned, prepped and draped in a slight left lateral tilt. Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in transverse fashion. Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique. The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. Presenting part was vertex, the head was delivered, followed by the remaining portion of the body. The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. Cord pH blood and cord blood was obtained. The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. This area was then irrigated. Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center. Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl. Skin edges reapproximated with sterile staples. Sterile dressing was applied. The uterus was evacuated of any remaining clots vaginally. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct. | Surgery |
PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:, Primary cesarean section by low-transverse incision.,ANESTHESIA:, Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009. The patient began having prodromal symptoms 2 to 3 days prior to presentation. She was seen on 03/09/2007 and a nonstress test was performed. This revealed some spontaneous variable-appearing decelerations. She was given IV hydration. A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found. Therefore, she was admitted for further fetal monitoring and evaluation. She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated. She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute. Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion. This relieved the decelerations somewhat. However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations. Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery. These findings were reviewed with the patient and recommendation was made for cesarean section delivery. The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced. She was prepped and draped in the usual fashion for the procedure. After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall. This incision was carried down to the level of the fascia, which was also transversely incised. After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle. The rectus muscle was separated in midline exposing the peritoneum. The peritoneum was carefully grasped and elevated with hemostats. It was entered in an up and down fashion with Metzenbaum scissors. The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected. A thin lower uterine segment was noted. The vertex presentation was confirmed. The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall. Clear fluid was noted upon entering into the amniotic space. At 05:27, a term viable female infant was delivered up through the incision. She had spontaneous respirations. She was given bulb suctioning for clear fluid. Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending. The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes. Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity. A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis. The uterus was delivered up into the operative field. The endometrial cavity was swiped clean with a moist laparotomy pad. The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating. Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis. The uterine incision was noted to be hemostatic upon closure. The uterus was rotated forward, normal tubes and ovaries were noted on both sides. The uterus was then returned to its normal position of the abdominal cavity. The sponge and instrument count was performed for the first time at this point and found to be correct. The pelvis and anterior uterine space was then irrigated with saline solution. It was suctioned dry. A final check of the uterine incision confirmed hemostasis. The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture. The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline. The subcutaneous tissue was then irrigated and inspected. No active bleeding was noted. It was closed with a running length of 3-0 plain catgut suture. The skin was then approximated with surgical steel staples. The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic. The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition. The estimated blood loss through the procedure was 450 mL. The sponge and instrument counts were performed two more times during closure and found to be correct each time. | Surgery |
PREOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal fusion.,5. Two previous C-sections. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal effusion.,5. Two previous C-section. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6. Adhesions of bladder.,7. Poor fascia quality.,8. Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1. A repeat low transverse cervical cesarean section.,2. Lysis of adhesions.,3. Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4. The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:, 600 cc.,HISTORY AND INDICATIONS: ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus. The uterus appeared to be intact. This patient is a 26-year-old Caucasian female. The patient is well known to the OB/GYN clinic. The patient had two previous C-sections. She appears to be in probably early labor. She had an amniocentesis early today. She is contracting regularly about every three minutes. The contractions are painful and getting much more so since the amniocentesis. The patient had fetal lung maturity noted. The patient also has probable IUGR as none of her babies have been over 4 lb. The patient's baby appears to be somewhat small. The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound. The patient has had a spinal fusion, however, family planning is definitely complete per the patient. The patient refuses trial labor. The patient and I discussed the consent. She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery. Her questions were answered. The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy. The patient understands this and would like to try our best.,PROCEDURE: ,The patient was taken back to the operative suite. She was given general anesthetic by Department of Anesthesiology. Once again, in layman's terms, the patient understands the risks. The patient had the informed consent reviewed and understood. The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side. The patient had the first knife went through this incision. The second knife was used to go to the level of fascia. The fascia was very thin, ruddy in appearance, and with abundant scar tissue. The fascia was incised. Following this, we were able to see the peritoneum. There was really no obvious rectus abdominal muscles noted. They were very weak, atrophic, and thin. The patient has the peritoneum tented up. We entered the abdominal cavity. The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia. The bladder flap was then entered into the uterus as well. There are some bladder adhesions. We removed these adhesions and we removed the bladder of the fascia. We dissected the bladder of the lower segment. We made a small nick on the lower segment. We were able to utilize the blunt end of the knife to enter into the uterine cavity. The baby was in occiput transverse position with the ear being cocked at such a position as well. The patient's baby was delivered without difficulty. It was a 4 lb and 10 oz baby girl who vigorously cried well. There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection. The patient's placenta was delivered. There was no retained placenta. The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first. The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized. Then we ligated this as there was bleeding and oozing. The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc. The 400 cc was instilled. The bladder appears to be intact. The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment. There was some oozing around the area of the bladder. We placed an Avitene there. The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx. The patient has two clips on each side. There was excellent tubal occlusion and placement. The uterus was placed back into the abdominal cavity. We rechecked again. The tubal placement was excellent. It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx. The patient then underwent further examination. Hemostasis appeared to be good. The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia. We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible. The Scarpa's fascia was reapproximated with #0 gut. The skin was reapproximated then as well via subcutaneous closure. The patient's sponge and needle counts found to be correct. Uterus appeared to be normal prior to closure. Bladder appeared to be normal. The patient's blood loss is 600 cc. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation.,PROCEDURE PERFORMED:, Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces. Apgars were 9 at 1 minute and 9 at 5 minutes. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation. The patient progressed to 8 cm, at which time, Pitocin was started. She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm. A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery. Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where epidural anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction. Clear fluid was noted. The infant was subsequently delivered atraumatically. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform. Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic suture. Hemostasis was visualized. The uterus was returned to the abdomen.,The pelvis was copiously irrigated. The uterine incision was reexamined and was noted to be hemostatic. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS:, Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1. VATS right middle lobectomy.,2. Fiberoptic bronchoscopy thus before and after the procedure.,3. Mediastinal lymph node sampling including levels 4R and 7.,4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA: ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:, The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:, This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1. Right thoracotomy.,2. Extensive lysis of adhesions.,3. Right lower lobectomy.,4. Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. The chest was entered through the fifth intercostal space. A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. The right lower lobe was identified. There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected. Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected. The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis. The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. The mediastinum was then explored. No nodes were identified around the pulmonary ligament or around the esophagus. Subcarinal nodes were dissected, and hemostasis was obtained with clips. The space below and above the osseous was opened, and the station R4 nodes were dissected. Hemostasis was obtained with clips and with electrocautery. All nodal tissue were sent to Pathology as permanent specimen. Following this, the chest was thoroughly irrigated and aspirated. Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures. Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. The incision was then closed with interrupted #2-0 Vicryl pericostal stitches. A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin. A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:, None.,COMPLICATIONS:, None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory. | Surgery |
PREOPERATIVE DIAGNOSIS: ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section. The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner. A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia. Bleeding points were snapped and coagulated along the way. The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles. These were divided in the midline revealing the peritoneum, which was opened vertically. The uterus was in mid position. The bladder flap was incised elliptically and reflected caudad. A low transverse hysterotomy incision was then constructed and extended bluntly. Amniotomy revealed clear amniotic fluid. A live born vigorous male infant was then delivered from the right occiput transverse position. The infant breathed and cried spontaneously. The nares and pharynx were suctioned. The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team. Cord blood samples were obtained. The placenta was manually removed and the uterus was eventrated for closure. The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first. Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl. The cornual sac and gutters were irrigated. The uterus was returned to the abdominal cavity. The adnexa were inspected and were normal. The abdomen was then closed in layers. Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips. Blood loss was estimated at 700 mL. All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition. | Surgery |
OPERATION,1. Right upper lung lobectomy.,2. Mediastinal lymph node dissection.,ANESTHESIA,1. General endotracheal anesthesia with dual-lumen tube.,2. Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition. | Surgery |
OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,PROCEDURES:,1. Revision, right breast reconstruction.,2. Excision, soft tissue fullness of the lateral abdomen and flank.,3. Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:, The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction. She now had lateralization of the implant with loss of medial fullness for which she desired correction. It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length. The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected. She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such. The above-noted procedure was discussed with the patient in detail. The risks, benefits and potential complications were discussed. She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position. Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion. The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear. At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached. This was then opened. The implant was removed and placed on the back table in antibiotic solution. Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast. The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form. The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant. The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness. With this completed, the implant was again removed, antibiotic irrigation was performed. A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed. The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures. The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture. Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours. This was closed with 6-0 Prolene suture. The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus. A Kerlix dressing and a surgical bra was placed to the chest area. A compressive garment was placed. The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition. Sponge, needle, lap, instrument counts were all correct. The patient tolerated the procedure well. There were no complications. The estimated blood loss was approximately 25 mL. | Surgery |
PREOPERATIVE DIAGNOSIS:, Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY: ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA: ,General LMA.,FINDINGS: ,The patient was found to have a displaced fracture. She was found to be in perfect alignment after closed reduction and placement of cast. The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old. She was seen in our office today 1 week after being placed into a cast for a displaced fracture. She was noted to have significant loss of alignment especially on the lateral view. She was indicated for closed reduction and placed of the long-arm cast. Risks and benefits were discussed at length with the family. They wished to proceed.,PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in supine position. General anesthesia was induced without incident. Previous cast was previously removed. An arm was approached and a closed reduction was performed. This was checked under AP and lateral projection and was found to be in adequate alignment. There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding. Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass. The patient was awakened from anesthesia and taken to recovery room in good condition. There were no complications. All instruments, sponge, and needle counts were correct at the end of case.,PLAN: ,The patient will be discharged home. She will return in 3 weeks for cast removal and clinical examination. She would likely be placed into a wrist-guard at that time. She has a prescription for Tylenol with codeine elixir., | Surgery |
PREOPERATIVE DIAGNOSIS:, Mass, left knee.,POSTOPERATIVE DIAGNOSIS: , Lipoma, left knee.,PROCEDURE PERFORMED: ,Excision of lipoma, left knee.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.,HISTORY:, The patient is a 35-year-old female with history of lump on her right knee for the past, what she reports to be six years. She states it had grow in size over the last six months, rarely causes her any discomfort or pain, denies any neurovascular complaints of her right lower extremity. She denies any other lumps or bumps on her body. She wishes to have this removed for cosmetic reasons.,PROCEDURE: , After all potential risks, benefits, and complications of the procedure were discussed with the patient, informed consent was obtained. She was transferred from the Preoperative Care Unit to Operating Suite #1. She was transferred from the gurney to the operating table. All bony prominences were well padded. A well padded tourniquet was applied to her right thigh. Anesthesia then administered some sedation, which she tolerated well. Her right lower extremity was then sterilely prepped and draped in normal fashion. Next, a rubber Esmarch was used to exsanguinate her right lower extremity.,Next, approximately 20 cc of 0.25% Marcaine with 1% lidocaine were used to locally anesthetize her anterior medial right knee in location of the mass. Next, a #15 blade Bard-Parker scalpel was utilized to make an approximately 3 cm vertical incision over the soft tissue mass upon incising the skin and the subcutaneous tissue readily and there was the aforementioned fatty tissue mass. This was easily excised with blunt dissection. Examination of the wound then revealed a second piece of fatty tissue, which resembled a lipoma measuring approximately 1.5 cm x 2 cm. This was then also excised utilizing Littler scissors. Hemostasis was obtained. The wound was then copiously irrigated after this all the underlying bone tissue was removed. #2-0 Vicryl interrupted subcutaneous sutures were then placed and the skin was reapproximated utilizing #4-0 horizontal mattress nylon sutures. Sterile dressings was applied of Adaptic, 4x4s, and Kerlix as well as an Ace wrap. Sedation was reversed. Tourniquet was deflated. The patient was transferred from the operating table to the gurney and to the Postoperative Care Unit in stable condition. Her prognosis for this is good. | Surgery |
PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position. Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy. An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold. A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle. 200 cc was infiltrated on each side. This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula. This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position. This would result in an elevation of the nipple-areolar complex with transposition. The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle. Hemostasis was achieved with electrocautery. After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple. Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture. Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing. The patient tolerated the procedure well. The patient was returned to recovery room in satisfactory condition. | Surgery |
PREOPERATIVE DIAGNOSIS:, Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED: ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE: ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity. The mass has been increasing in size and symptoms according to the patient. The risks and benefits of the surgical excision were discussed. The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps. It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room. She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion. Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity. The skin and subcutaneous tissue were incised as well as the muscular fascia. The fibers of the biceps were divided bluntly and retracted. The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures. The mass was submitted to Pathology. Good hemostasis was seen. The wound was irrigated and closed in layers. The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture. Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion. The patient was given wound care instructions and will follow up again in my office in one week. Overall prognosis is good. | Surgery |
TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL: ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today. The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death. The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion. The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver. Next, a small incision was made with a Bard-Parker #11 scalpel. A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration. Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication. Normal activities can be resumed tomorrow. The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop. An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:, None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended. Risks and benefits for vaccination have been addressed and the patient will consider this option. | Surgery |
PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:, Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:, General.,FINDINGS AND PROCEDURE:, With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion. After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus. Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen. A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood. Attention was then directed to the thighs both inner and outer. A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs. After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh. The patient tolerated the procedure very well. All of this aspirate was mostly fat with little fluid and very little blood. Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied. The patient tolerated the procedure very well and was sent to the recovery room in good condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Torn anterior cruciate ligament, right knee.,2. Patellofemoral instability, right knee.,3. Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1. Complete tear anterior cruciate ligament, right knee.,2. Complex tear of the posterior horn lateral meniscus.,3. Tear of posterior horn medial meniscus.,4. Patellofemoral instability.,5. Chondromalacia patella.,PROCEDURES PERFORMED:,1. Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2. Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3. Partial medial meniscectomy.,4. Partial chondroplasty of patella.,5. Lateral retinacular release.,6. Open medial plication as well of the right knee.,ANESTHESIA:, General.,COMPLICATIONS:, None.,TOURNIQUET TIME:, 130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint. The patella was noted to be situated laterally past the lateral femoral condyle. There was a tear to the posterior horn of the medial meniscus within the white zone. There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus. There was a complete tear of the anterior cruciate ligament. The posterior cruciate ligament appeared intact. Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan.,PROCEDURE: ,On 09/11/03, she was taken to the operating room at ABCD General Hospital. She was placed supine on the operating table. General anesthetic was applied by the Anesthesiology Department. Tourniquet was placed on the proximal thigh and it was then placed in a knee holder. She was sterilely prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. Longitudinal incision was made just medial to the tibial tubercle. The subcutaneous tissue was carefully dissected. Hemostasis was controlled with electrocautery. The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction. They were taken on the back table. The soft tissue debris was removed from the tendons. The ends of the tendons were sewn together using #5 Tycron whip type sutures. The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table. Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee. The knee was inflated with saline solution and operative pictures were obtained. The above findings were noted. A second port site was initiated in the inferomedial parapatellar region. Through this, a probe was placed. Tear in the posterior horn medial meniscus was identified. It was resected using a meniscal resector. It was then further contoured using arthroscopic shaver. Attention was then taken to the lateral compartment. A partial meniscectomy was performed using the resector and the shaver. The posterior periphery of the lateral meniscus was also noticed to be unstable. A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon. There was noted to be excellent fixation. The shaver was then taken into the intrachondral notch. First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint. Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle. Next, a tibial guide was placed through the anterior medial portal. A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament. This tibial tunnel was then drilled using 8 mm cannulated drill. Next, an over-the-top guide was then placed at approximately the 11:30 position. A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm. Next the U shape guide was placed through tibial tunnel into the femur. A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur. It was then pulled out through the tibial tunnel using the You-shaped guide. The tendon was then placed around the wire. The wire was pulled back up through the tibial into the femoral tunnel. A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons. Attention was then pulled through the tibial tunnel. The knee was cycled approximately 20 times. A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft. There was noted definite fixation of the graft. There was no evidence of impingement either in full flexion or full extension. The knee was copiously irrigated and it was then suctioned dry. A longitudinal incision was made just medial to the patellofemoral joint. Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision. Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication. The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture. The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch. She was placed in a DonJoy knee immobilizer. The tourniquet was deflated. It was noted the lower extremity was warm and pink with good capillary refill. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient is guarded. She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension. She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal. She will require one to two more physical therapy to help regain motion and strength to the lower extremity. | Surgery |
OPERATION PERFORMED:, Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint. Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field. Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium. An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint. Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon. The radial beak of the trapezoid was then osteotomized off the head of the scaphoid. The proximal metacarpal was then fenestrated with a 4.5-mm drill bit. Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision. The FCR tendon was divided and this incision was closed with 4-0 nylon sutures. Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal. A bone anchor was then placed distal to the metacarpal fenestration. The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position. The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor. Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect. The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire. The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well. | Surgery |
PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,PROCEDURE PERFORMED: ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office. Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia. A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx. The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords. The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third. The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region. The patient's anterior commissure appeared to be clear. The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord. Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect. The patient's subglottic region was very edematous and with redundant mucosal tissue. The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch. The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps. After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis. The specimen was passed off the field and was sent to Pathology for evaluation. Hemostasis was maintained on the left side. Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand. The Zeiss operating microscope was then brought into view to directly visualize the vocal cords. The biopsies were taken under direct visualization utilizing the Zeiss operating microscope. After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full. This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen. The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions. A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions. There were no signs of any palpable cervical lymphadenopathy. The tooth guard was removed and the patient was then turned back to anesthesia. The patient did receive intraoperatively 10 mg of Decadron. The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well. The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc. | Surgery |
PREOPERATIVE DIAGNOSIS: ,Lateral epicondylitis. | Surgery |
ASSESSMENT: ,The patient needed reintubation due to a leaking tube. I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure. His potassium this morning was normal. Using an 8.5 ET tube under direct visualization, the tube was passed through the cords. The patient tolerated the procedure extremely well. Auscultation of the lungs revealed bilateral equal breath sounds. Chest x-ray is pending. CO2 monitor was positive. | Surgery |
PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY: ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling. The patient was started on alpha-blockers with some help, but had nocturia q.1h. The patient was given anticholinergics with minimal to no help. The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate. At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream. Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed. The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder. The patient was told that he may need anticholinergics. There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was given preoperative antibiotics. The patient was prepped and draped in the usual sterile fashion. A #23-French scope was inserted inside the urethra into the bladder under direct vision. Bilateral pyelograms were normal. The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder. There was enlargement of the lateral lobes of the prostate. The old TUR scar was visualized right at the bladder neck. Using diode side-firing fiber, the lateral lobes were taken down. The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure. Pictures were taken and were shown to the family. At the end of the procedure, there was good hemostasis. A total of about 15 to 20 minutes of lasering time was used. A #22 3-way catheter was placed. At the end of the procedure, the patient was brought to recovery in stable condition. Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night. | Surgery |
PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication. | Surgery |
PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES: ,1. Left testicular torsion.,2. Left testicular abscess.,3. Necrotic testes.,SURGERY:, Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:, Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY: ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000. The patient had significant scrotal swelling and pain. Ultrasound revealed necrotic testicle. Options such as watchful waiting and removal of the testicle were discussed. Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis. The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed. The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR. Anesthesia was applied. The patient was prepped and draped in usual sterile fashion. A midline scrotal incision was made. There was very, very thick scrotal skin. There was no necrotic skin. As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum. The testicle was completely filled with pus and had completely disintegrated with pus. The pus just poured out of the left testicle. The left testicle was completely removed. Debridement was done of the scrotal wall to remove any necrotic tissue. Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum. There was good tissue left after all the irrigation and debridement. A Penrose drain was placed in the bottom of the left hemiscrotum. I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal. So, the right hemiscrotum was opened. The testicle had significant amount of swelling and scrotal wall was very thick. The testicle appeared normal. There was no pus coming out of the right hemiscrotum. At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion. The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress. There was very minimal pus left behind and the skin was very healthy. Decision was made to close it to help the patient heal better in the long run. The patient was brought to the recovery in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Recurrent dysplasia of vulva.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION PERFORMED:, Carbon dioxide laser photo-ablation.,ANESTHESIA: , General, laryngeal mask.,INDICATIONS FOR PROCEDURE: , The patient has a past history of recurrent vulvar dysplasia. She has had multiple prior procedures for treatment. She was counseled to undergo laser photo-ablation.,FINDINGS:, Examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions. After staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,PROCEDURE: ,The patient was brought to the operating room with an IV in place. Anesthetic was administered, after which she was placed in the lithotomy position. Examination under anesthesia was performed, after which she was prepped and draped. Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion. The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid. Setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode. Excellent hemostasis was noted and Bacitracin was applied prophylactically. The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition. | Surgery |
DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition. | Surgery |
TITLE OF OPERATION:, Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07. Subsequently, biopsy confirmed tumor persistence in the right glottic region. Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail. Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level. The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives. He was accompanied by his wife and daughter. Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table. After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm. A #6 endotracheal tube was placed initially. Direct laryngoscopy was performed with a Lindholm laryngoscope. A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis. Subsequently, a decision was then made to go ahead and perform the surgical intervention. A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected. A shoulder roll was applied after the patient was prepped and draped in a sterile fashion. Subsequently, a hemi-apron incision was performed. Subplatysmal flaps were raised at the hyoid bone into the clavicle. Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed. Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle. Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle. The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified. Level 2A contents were then dissected off the floor of the neck including levels 3 and 4. Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4. The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve. Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed. Subsequently, the strap muscles were separated in the midline. The trachea was identified in the midline. The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage. Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively. The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular. Attention was then turned to performing a cricothyrotomy. Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision. A #7 anode tube was then placed in this area and secured. Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis. Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine. It was evident that this tumor had extended more than 1 cm into the subglottic region. Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded. Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy. Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin. A W-plasty was also performed to allow for enlargement of the stoma. Attention was then turned to identifying the common parting wall of the trachea and the esophagus. Attention was then turned to resecting the hyoid bone. The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism. The wound was copiously irrigated. Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect. Once this was performed, a running 3-0 canal stitch was used to close the pharynx. Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied. Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon. The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin. The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Right ectopic pregnancy.,2. Severe abdominal pain.,3. Tachycardia.,POSTOPERATIVE DIAGNOSES:,1. Right ectopic pregnancy.,2. Severe abdominal pain.,3. Tachycardia.,PROCEDURE PERFORMED:, Exploratory laparotomy and right salpingectomy.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS: ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity. Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS: ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain. The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate. Evaluation in the emergency room reveals a second right ectopic pregnancy. Her beta quant was found to be approximately 13,000. The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity. Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy. The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery. Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where general anesthesia was administered without difficulty. The patient was prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors. The rectus muscles were dissected in the midline. The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder. At this time, the blood found in the abdomen was suctioned. The bowel was packed with moist laparotomy sponge. The right ectopic pregnancy was identified. The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture. Hemostasis was visualized. At this time, the left tube and ovary were examined and were found to be normal in appearance. The pelvis was cleared off clots and was copiously irrigated. The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed. The rectus muscles were reapproximated using 3-0 Vicryl. The fascia was reapproximated with #0 Vicryl sutures. The subcutaneous layer was closed with 3-0 plain gut. The skin was closed with 4-0 Monocryl. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Acute pain.,2. Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1. Acute pain.,2. Fever postoperatively.,3. Hemostatic uterine perforation.,4. No bowel or vascular trauma.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:, None.,INDICATIONS: ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03. The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2. The patient denied any nausea, vomiting or diarrhea. She does complain of some frequent urination. Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated. On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus. There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac. The bilateral tubes and ovaries appeared normal. There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap. There is no evidence of injury to the bowel or pelvic sidewall. The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. Veress needle was placed through this incision and the gas turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision. The camera was placed with the above findings noted. A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline. A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs. The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline. At this point, Dr. X was consulted. He performed a rigid sigmoidoscopy, please see his dictation for further details. There does not appear to be any evidence of colonic injury. The saline in the pelvis was then suctioned out using Nezhat-Dorsey. All instruments were removed. The 5 mm trocar was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar removed. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief. Steri-Strips were then placed across the incision. The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics. | Surgery |
PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,PROCEDURE PERFORMED:,1. Laparotomy.,2. Myomectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS: ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium. Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position. After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife. This was carried through the underlying layer of fascia with a second knife. The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly. It was then dissected in the middle with the Mayo scissors. The inferior aspect of this incision was addressed in a similar manner. The rectus muscles were separated in the midline bluntly. The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly. Next, the uterus was grasped bluntly and removed from the abdomen. The fundal fibroid was identified. It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels. 15 cc was injected. Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was also grasped with Lahey clamp to prevent traction. Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse. The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed. At this point, several smaller fibroids were noticed along the endometrial surface of the uterus. Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size. These were also handed to the scrub tech. Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be completely hemostatic after closure. Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline. The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed. Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline. Then the fascia was closed with #0 Vicryl in a running fashion. Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion. The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately. After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital. | Surgery |
PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:, Mild pelvic endometriosis.,PROCEDURE:,1. Attempted laparoscopy.,2. Open laparoscopy.,3. Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS: ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position. She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery. Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall. The anterior lip of the cervix was grasped with a single-tooth tenaculum. A Hulka tenaculum was placed transcervically. The other instruments were removed. A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region. Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum. The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed. The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity. Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion. The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction. The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also. It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area. The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken. The skin incision was expanded with a knife blade. Blunt dissection was used to carry the dissection down to the fascia. This was grasped with Kocher clamps, entered sharply and opened transversely. Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff. Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed. Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary. In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting. The left tube and ovary were normal. There were no adhesions. There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated. Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated. The smoke plume was removed without difficulty. Approximately 50 mL of irrigant was left in the pelvis. Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed. The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site. Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly. They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies. The vaginal instruments were removed. All counts were correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition. | Surgery |
PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac. Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE: ,The patient was taken to the operating room and placed under general anesthesia. She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner. Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated. Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed. Laparoscope was inserted through the cannula and the pelvis was visualized. Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline. Incision sites were transilluminated and injected with Marcaine prior to cutting. Hulka manipulator was placed on the cervix. Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac. The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis. Some more lesions were noted above the left uterosacral ligament. Flame lesions were noted above the right uterosacral ligament. Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube. There was a somewhat leathery appearance to the ovaries. The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window. Pelvis was irrigated and all operative sites were hemostatic. No other abnormalities were visualized and all instruments were moved under direct visualization. Approximately 200 mL of fluid remained in the abdominal cavity. All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape. The patient was taken to the recovery in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS,1. Dysmenorrhea.,2. Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1. Dysmenorrhea.,2. Menorrhagia.,PROCEDURE:, Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:, 30 cc.,COMPLICATIONS:, None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management. Please see clinic notes. Risks of bleeding, infection, damage to other organs have been explained. Informed consent was obtained.,OPERATIVE FINDINGS:, Slightly enlarged but otherwise normal-appearing uterus. Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion. Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field. A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites. Veress needle was inserted, position confirmed using the saline drop method. After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity. Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope. A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side. All these were placed under direct visualization. Pelvic cavity was examined with findings as noted above. The left utero-ovarian ligament was grasped and cauterized using the Gyrus. Part of the superior aspect of the broad ligament was then cauterized as well. Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment. The remainder of the broad and cardinal ligament was then cauterized and excised. A similar procedure was performed on the right side. The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament. After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments. The area was irrigated extensively and cautery used to assure hemostasis. A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination. Hemostasis was again confirmed under low pressure. Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture. The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture. Instruments removed from vagina. Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition. Sponge and needle counts correct at the conclusion of the case. Estimated blood loss was 30 cc. There were no complications. | Surgery |
PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation. She admits to some nausea associated with it. There have been no fevers, chills, and/or genitourinary symptoms. The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant. She had a leukocytosis of 12.8. She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis. Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy. The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS: ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged. The left ovary revealed some follicular cysts. There was no evidence of adnexal masses and/or torsion of the fallopian tubes. The uterus revealed no evidence of mass and/or fibroid tumors. The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient underwent general endotracheal anesthesia. The patient also received a preoperative dose of Ancef 1 gram IV. After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle. Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg. Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty. A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored. Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region. This was inserted under direct visualization. Finally, a suprapubic 12 mm portal was created. This was performed with #10 blade scalpel to create a transverse incision. A bladed trocar was inserted into the suprapubic region. This was done again under direct visualization. Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum. This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly. Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device. Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device. The staple line was visualized and there was no evidence of bleeding. The abdomen was fully irrigated with copious amounts of normal saline. The abdomen was then aspirated. There was no evidence of bleeding. All ports were removed under direct visualization. No evidence of bleeding from the port sites. The infraumbilical and suprapubic ports were then closed. The fascias were then closed with #0-Vicryl suture on a UR6 needle. Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl. The areas were cleaned, Steri-Strips were placed across the wound. Sterile dressing was applied.,The patient tolerated the procedure well. She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition. She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course. | Surgery |
PREOPERATIVE DIAGNOSIS:, Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Pelvic endometriosis.,3. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Laparoscopy.,2. Harmonic scalpel ablation of endometriosis.,3. Lysis of adhesions.,4. Cervical dilation.,ANESTHESIA: ,General.,SPECIMEN: ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:, Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. There are adhesions involving the right ovary to the anterior abdominal wall and the bowel. There are also adhesions from the omentum to the anterior abdominal wall near the liver. The uterus and ovaries appear within normal limits other than the adhesions. The left fallopian tube grossly appeared within normal limits. The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized. There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac. There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE: ,The patient was taken in the operating room and generalized anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. After exam under anesthetic, weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen. An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife. The superior aspect of the umbilicus was grasped with a towel clamp. The abdomen was tented up and a Veress needle inserted through this incision. When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle. This was seen to freely drop in the abdomen so it was connected to CO2 gas. Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting. The abdomen was then insufflated to an adequate distention. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. Next, the laparoscope was inserted through this port. The medial port was connected to CO2 gas. Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis. Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed. Next, a grasper was placed through the suprapubic port. This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions. Bowel was carefully examined afterwards and no injuries or bleeding were seen. Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty. There was a small amount of bleeding from the anterior abdominal wall peritoneum. This was ablated with the Harmonic scalpel. The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac. Both of these areas were seen to be hemostatic. Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac. This was sent to pathology. Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed. It was seen to be completely hemostatic. Next, the two size #5 ports were removed under direct visualization. The camera was removed. The abdomen was desufflated. The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check. | Surgery |
PREOPERATIVE DIAGNOSIS:, Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:, General,NAME OF OPERATION:, Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:, The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and Veress needle placed without difficulty. Gas was entered into the abdomen at two liters. The laparoscope was entered, and the abdomen was visualized. The second puncture site was made, and the second trocar placed without difficulty. The cyst was noted on the left, a 3-cm, ovarian cyst. This was needled, and a hole cut in it with the scissors. Hemostasis was intact. Instruments were removed. The patient was awakened and taken to the recovery room in good condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left. The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION: ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes. Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then palpated and again both testes were nonpalpable. Because of this, a laparoscopic approach was then elected. We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage. We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors. Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens. Insufflation was then done with carbon dioxide up to 10 to 12 mmHg. We then evaluated. There was no bleeding noted. He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized. The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring. So, we elected to do an orchiopexy on the right side. Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas. We then used the Maryland dissector to gently tease this tissue once it was incised. The gubernaculum was then divided with electrocautery and the laparoscopic scissors. We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring. We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery. We used the curved tenotomy scissors to make a subdartos pouch. Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation. Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction. Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis. We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic. We again evaluated the left side and found again that the vessels were quite short. The testis was more atrophic, and the vas was virtually nonexistent. We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present. We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions. At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed. The patient had IV Toradol and was in stable condition upon transfer to recovery room. | Surgery |
PREOPERATIVE DIAGNOSIS:, Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:, Left ovarian lesion.,PROCEDURE PERFORMED: ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,FINDINGS:, The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled. There were a few calcifications on the surface of the mass. The right ovary and fallopian tube appeared normal. There was no evidence of endometriosis. The uterus appeared normal in size. There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm. She does complain of minimal discomfort. Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position. A 1 cm skin incision was made in the infraumbilical vault. While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated. This was done using appropriate flow and volume of CO2. The #11 step trocar was then placed without difficulty. The above findings were confirmed. A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization. Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall. Both #12 step ports were done under direct visualization. Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating. The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision. The skin was extended around this incision and the fascia was extended using the Mayo scissors. The specimen was removed intact in the Endocatch bag through this site. Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic. All the port sites were hemostatic as well. The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated. Steri-Strips were placed on each of the incisions. The patient tolerated the procedure well. Sponge, lap, and needle count were x2. She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her. | Surgery |
PREOPERATIVE DIAGNOSIS:, Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:, Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer. She was counseled to undergo laparoscopic staging.,FINDINGS:, During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries. No ascites was present. On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered. She was placed in a low anterior lithotomy position using Allen stirrups. The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine. There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports. The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty. The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed. There were no adhesions underlying the previous vertical midline scar. The 10-mm port was placed in the umbilicus, and the laparoscope was inserted. Remaining ports were placed under direct laparoscopic guidance. Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy. An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum. The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached. Pedicles were sealed and divided with bipolar cutting forceps. Excellent hemostasis was noted. Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery. Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps. The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially. The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally. The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy. The right infundibulopelvic ligament was divided using the bipolar cutting forceps. The mesovarium was skeletonized. A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder. Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring. The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries. The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum. The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device. The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen. The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture. The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released. The umbilical port was removed using laparoscopic guidance. The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl. The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened and taken to the post anesthesia care unit in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1. Right ureteropelvic junction obstruction.,2. Severe intraabdominal adhesions.,3. Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Attempted laparoscopic pyeloplasty.,3. Open laparoscopic pyeloplasty.,ANESTHESIA:, General.,INDICATION FOR PROCEDURE: ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent. The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic. The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction. Hassan technique was performed for the initial trocar placement in the periumbilical region. Abdominal insufflation was performed. There were significant adhesions noted. A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular. After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially. The kidney was able to be palpated within Gerota's fascia. The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter. The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction. The renal pelvis was also identified and dissected free. There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes. We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open. An incision was made from the right upper quadrant port extending towards the midline. This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum. A Bookwalter retractor was placed. The renal pelvis and the ureter were again identified. Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery. The tissue was sent down to Pathology for analysis. Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted. Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place. The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue. At this point, the indwelling double-J ureteral stent was removed. At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed. This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated. The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture. At this point, a double-J stent was placed with a guidewire down into the bladder. The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture. Renal sinus fat was then placed around the anastomosis and sutured in place. Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue. This was repaired with horizontal mattress sutures #2-0 Vicryl. FloSeal was placed over this and the renal capsule was placed over this. A good hemostasis was noted. A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis. The initial trocar incision was closed with #0 Vicryl suture. The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia. The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture. The skin edges were then closed with staples. Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator. We placed the patient on IV antibiotics and pain medications. We will obtain KUB and x-rays for stent placement. Further recommendations to follow. | Surgery |
PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS: ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent. The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. All pressure points were carefully padded. She was given general anesthesia with endotracheal intubation. SCD stockings were placed on both legs. Foley catheter was placed for bladder decompression. The abdomen was then prepped and draped in standard sterile surgical fashion. Marcaine was then injected through umbilicus. A small incision was made. A Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg. A 12-mm VersaStep port was placed through the umbilicus. I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side. I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port. On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port. A few centimeters below and medial to that, I placed a 15-mm port. I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz. I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler. I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device. I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis. I reapproximated the edges of the defect. I lifted it up and stapled across it with another white load stapler. I then closed the mesenteric defect with interrupted Surgidac sutures. I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic. I then put the patient in reverse Trendelenburg. I placed a liver retractor, identified, and dissected the angle of His. I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space. I fired transversely across the stomach with a 45 blue load stapler. I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch. I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil. I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler. I passed that in the end of my Roux limb and had the spike come out antimesenteric. I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag. I put some additional 2-0 Vicryl sutures in the anastomosis for further security. I then placed a bowel clamp across the bowel. I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch. I distended gastric pouch with air. There was no air leak seen. I could pass the scope easily through the anastomosis. There was no bleeding seen through the scope. We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason. I copiously irrigated out that incision with about 2 L of saline. I then closed the skin of all incisions with running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications. | Surgery |
PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:, Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency. The patient's baseline creatinine was around 1.6 to 1.7. The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass. Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time. The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure. The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed. The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR: ,The patient was brought to the OR. Anesthesia was applied. The patient was given preoperative antibiotics. The patient was bowel prepped. The patient was placed in right side up, left side down, semiflank, with kidney rest up. All the pressure points are very well padded using foam and towels. The left knee was bent and the right knee was straight. There was no tension on any of the joints. All pressure points were well padded. The patient was taped to the table using 2-inch wide tape all the way around. A Foley catheter and OG tube were in place prior to prepping and draping the patient. A periumbilical incision measuring about 6 cm was made. The incision was carried through the subcutaneous tissue through the fascia using sharp dissection. The peritoneum was open. Abdomen was entered. There were some adhesions on the right side of the abdomen, which were released using metz. Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line. A gel porter was placed. Pneumoperitoneum was obtained. All ports were placed under direct vision, and the right colon was reflected medially. Duodenum was cauterized. Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around. Pictures were taken. Superficial biopsies were taken of 2 renal lesions using 3 different probes. The 2 lesions were frozen. The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter. So the R3.8 and R2.4 long probes were used. Freezing/thawing, two cycles were done. The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done. The exact times or exact temperatures are on the chart. There was a nice ice ball with each freezing and with passive sign. The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed. Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding. From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes. So the masses were visualized for a total of 30 minutes without any pneumoperitoneum. Pneumoperitoneum was obtained again. Fibrin glue was placed over it just for precautionary measure. There was about a total of 100 mL of blood loss overall with the entire procedure. Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ. The kidney was kept in the left hand at all times. Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen. The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions. At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially. Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel. Lap count was correct. Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions. No deeper biopsies were done to minimize the risk of bleeding. The 12-mm ports were closed using 0-Vicryl and the middle incision. The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle. Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion. After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,3. Liver cyst.,PROCEDURES PERFORMED:,1. Laparoscopic cholecystectomy.,2. Excision of liver cyst.,ANESTHESIA: ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1. Gallbladder.,2. Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:, Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. Additionally, there was a notable liver cyst. The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy. The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods. She had had multiple attacks in the past of these complaints. She was discovered to have had right upper quadrant pain on examination. Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis. The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms. She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE: ,The patient was brought to the operative suite and placed in the supine position. The patient received preoperative antibiotics with Kefzol. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient did undergo general endotracheal anesthesia. Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel. Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation. The abdomen was insufflated to 15 mmHg. After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder. Decision to proceed with laparoscopic cystectomy was decided. A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen. Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin. All ports were inserted with bladed 5 mm trocar then under direct visualization. After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder. Adhesions adjacent were taken down with a Maryland dissector. Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly. This helped to better delineate the cystic duct as well as the cystic artery. Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one. Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally. Utilizing endoscissors, the cystic duct and cystic artery were ligated. Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed. Electrocautery was used to stop any bleeding encountered along the way. The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen. No evidence of stones were visualized. Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port. This was sent off as an specimen, a gallstone was identified within the gallbladder. Next, utilizing copious amounts of irrigation, the abdomen was irrigated. A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver. This was also taken and sent off as specimen. The abdomen was then copiously irrigated until clear irrigation was identified. All laparoscopic ports were removed under direct visualization. The abdomen was de-insufflated. Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region. All incisions were then closed with #4-0 undyed Vicryl. Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures. The areas were cleaned and dried. Steri-Strips were placed. On the incisions, sterile dressing was applied. The patient tolerated the procedure well. She was extubated following procedure. She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation. | Surgery |
PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs. The patient has now begun to have comorbidities related to the obesity. The patient has attended our bariatric seminar and met with our dietician and psychologist. The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient. Consent was obtained. The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. A Foley catheter was placed for bladder decompression. All pressure points were carefully padded, and sequential compression devices were placed on the legs. The abdomen was prepped and draped in standard, sterile, surgical fashion. Marcaine was injected into the umbilicus. | Surgery |
PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS: ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis. She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones. After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. She was positively identified and the correct surgical site and procedure reviewed. After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created. The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg. A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity. Upper abdominal anatomy was normal. Pelvic laparoscopy revealed bilaterally closed internal inguinal rings. Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____. There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region. Using these, the gallbladder was grasped and retraced cephalad. Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction. A small ductotomy was created. Reddick cholangiogram catheter was then placed within the duct and the balloon inflated. Continuous fluoroscopy was used to instill contrast material. This showed normal common bile duct which entered the duodenum without obstruction. There was no evidence of common bile duct stones. The cholangiogram catheter was removed. The duct was doubly clipped and divided. The artery was divided and cauterized. The gallbladder was taken out of the gallbladder fossa. It was then placed in Endocatch bag and left in the abdomen. Attention was then paid to the appendix. The appendix was identified and window was made in the mesoappendix at the base. This was amputated with an Endo-GIA stapler. The mesoappendix was divided with an Endo-GIA vascular stapler. This was placed in another Endocatch bag. The abdomen was then irrigated. Hemostasis was satisfactory. Both the appendix and gallbladder were removed and sent for pathology. All trocars were removed. The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures. The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide. The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture. The skin was cleaned. Mastisol, Steri-Strips and band-aids were applied. The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition. | Surgery |
PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE: ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The cystic artery was found medially and slightly posterior to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was removed from the abdomen. Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition. | Surgery |
PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder. The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips. Several attempts at passing the cholangiocatheter into the ductotomy were made. Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct. After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography. The distal cystic duct was doubly clipped. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery. Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS:, Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS: ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS: ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1. Laparoscopic cholecystectomy.,2. Intraoperative cholangiogram.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted. Saline test was performed. Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg. The Veress needle was removed. A 10- to 11-mm cannula was inserted. Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it. It was largely mobile. The liver had a normal appearance as did the peritoneal cavity. A 5-mm cannula was inserted in the right upper quadrant anterior axillary line. A second 5-mm cannula was inserted in the subcostal space. A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction. The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal. Extra contrast was aspirated and the aspirating needle was removed. The ampulla was grasped with a second grasper, opening the triangle of Calot. The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided. This was done while the common duct was in full visualization. The cystic artery was similarly controlled and divided. The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution. There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula. The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear. Hemostasis was excellent. CO2 was evacuated and the camera removed. The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon. Sterile dressings were applied. Sponge and needle counts were correct. | Surgery |
PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis.,PROCEDURE PERFORMED: ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION: ,To recovery room and to home.,FLUIDS: ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis. Final pathology is pending.,INDICATIONS FOR THE PROCEDURE: ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge. He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL: ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia. The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities. The anterior abdomen was then prepared and draped in a sterile fashion. Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine. The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade. The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg. The epigastric and right subcostal trocars were placed under direct vision. The right upper quadrant was well visualized. The gallbladder was noted to be significantly distended with surrounding dense adhesions. The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector. Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp. The cystic duct was clipped x3 and then divided. The cystic artery was dissected out in like fashion, clipped x3, and then divided. The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis. Prior to removal of the gallbladder, all irrigation fluid was clear. No active bleeding or oozing was seen. All clips were noted to be secured and intact and in place. The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port. The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology. The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization. The insufflation was allowed to escape. The umbilical fascia was closed using interrupted #1 Vicryl sutures. Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl. Sterile dressings were applied. The patient tolerated the procedure well., | Surgery |
PREOPERATIVE DIAGNOSIS:, Cholelithiasis; possible choledocholithiasis. | Surgery |
PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. The patient is also diabetic. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored. There was no evidence of any peritoneal studding or masses. The abdomen was otherwise within normal limits. The gallbladder was easily visualized. There was an intrahepatic gallbladder. There was no evidence of any inflammatory change.,PROCEDURE:, After informed written consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. Next, an infraumbilical incision was made with a #10 scalpel. The skin was elevated with towel clips and a Veress needle was inserted. The abdomen was then insufflated to 15 mmHg of pressure. The Veress needle was removed and a #10 blade trocar was inserted without difficulty. The laparoscope was then inserted through this #10 port and the abdomen was explored. There was no evidence of any peritoneal studding. The peritoneum was smooth. The gallbladder was intrahepatic somewhat. No evidence of any inflammatory change. There were no other abnormalities noted in the abdomen. Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. Using a curved dissector, the cystic duct was identified and freed up circumferentially. Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct. The cystic artery was transected in similar fashion. Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. It was done without difficulty. The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. Hemostasis was maintained using electrobovie cautery. The liver bed was then copiously irrigated and aspirated. All the fluid and air was then aspirated and then all ports were removed under direct visualization. The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle. The skin was closed with a running subcuticular #4-0 undyed Vicryl. 0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition. | Surgery |
The patient's abdomen was prepped and draped in the usual sterile fashion. A subumbilical skin incision was made. The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. A subumbilical trocar was inserted. The camera was inserted in the panoramic view. The abdomen demonstrated some inflammation around the gallbladder. A 10-mm midepigastric trocar was inserted. A. 2 mm and 5 mm trocars were inserted. The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction. The cystic artery was identified and double Hemoclips applied. The gallbladder was taken down from the liver bed using Endoshears and electrocautery. Hemostasis was obtained. The gallbladder was removed from the midepigastric trocar site without difficulty. The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure well and was taken to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Biliary colic. | Surgery |
PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute cholecystitis.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS: , None.,PROCEDURE: ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia. An open pneumoperitoneum was created with Hasson technique. Three additional ports were placed in the usual fashion. The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas. It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips. The gallbladder was then taken down from the gallbladder fossa with electrocautery. There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie. The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones. The fascia had to be opened. The gallbladder had to be opened, and the stones had to be extracted carefully. When it was completed, I went back to the abdomen and achieved complete hemostasis. The ports were then removed under direct vision with the scope. The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl. All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced. The abdomen was prepped and draped and ports were placed. The gallbladder was grasped and retracted. The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained. The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag. The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak. The ports were removed under direct vision with good hemostasis. The Hasson was removed. The abdomen was desufflated. The gallbladder in its endo catch bag was removed. The ports were closed. The patient tolerated the procedure well. Please see full hospital dictation. | Surgery |
PREOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:, General.,FINDINGS:, The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There was a stone impacted in the cystic duct with the gallbladder. The gallbladder contained numerous stones which were small. With the stone impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:, Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled. | Surgery |
PROCEDURE:,: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. The fascia was elevated between two Ochsner clamps and then incised. A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges. The 11-mm port without the trocar engaged was then placed into the abdomen. A pneumoperitoneum was established. After an adequate pneumoperitoneum had been established, the laparoscope was inserted. Three additional ports were placed all under direct vision. An 11-mm port was placed in the epigastric area. Two 5-mm ports were placed in the right upper quadrant. The patient was placed in reverse Trendelenburg position and slightly rotated to the left. The fundus of the gallbladder was retracted superiorly and laterally. The infundibulum was retracted inferiorly and laterally. Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. The triangle of Calot was carefully opened up. The cystic duct was identified heading up into the base of the gallbladder. The cystic artery was also identified within the triangle of Calot. After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. The cystic artery was clipped twice proximally and once distally. Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. An intraoperative cholangiogram was obtained. This revealed good flow through the cystic duct and into the common bile duct. There was good flow into the duodenum without any filling defects. The hepatic radicals were clearly visualized. The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct. The cystic duct was then divided using scissors. The gallbladder was then removed up away from the liver bed using electrocautery. The gallbladder was easily removed through the epigastric port site. The liver bed was then irrigated and suctioned. All dissection areas were inspected. They were hemostatic. There was not any bile leakage. All clips were in place. The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. All ports were then removed under direct vision. The abdominal cavity was allowed to deflate. The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl. The fascia at the umbilical port was closed by tying the previously placed stitch. All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites. The patient tolerated the procedure well. The patient is currently being aroused from general endotracheal anesthesia. I was present during the entire case. | Surgery |
PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed. No leakage of enteral contents was noted. All trocars were removed under direct visualization. The umbilical fascia was closed with interrupted 0 Vicryl sutures. The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's. The patient was extubated and taken to the recovery area in stable condition. The patient tolerated the procedure well. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Hypermenorrhea.,3. Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1. Dilatation and curettage (D&C).,2. Laparoscopic ablation of endometrial implants.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses. She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side. There are no adnexal masses appreciated. On laparoscopic exam, the uterus is normal appearing but slightly compressible. The bilateral tubes and ovaries appear normal. There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac. There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy. The liver margin, gallbladder, and bowel appeared normal. The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered. The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion. Sterile speculum was placed in the patient's vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded to 9 cm. The cervix was then serially dilated with Hank dilators. A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium. The moderate amount of tissue that was obtained was sent to Pathology. The #20 Hank dilator was then replaced and the sterile speculum was removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. The Veress needle was placed into this incision and the gas was turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted. A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs. A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior. The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel. A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac. The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel. All instruments were then removed. The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar was removed. The skin was closed with #4-0 undyed Vicryl in subcuticular fashion. ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites. The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of procedure. The patient was taken to the recovery room in satisfactory condition. She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives. | Surgery |
PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis. She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table. The abdomen was prepared and draped in usual sterile fashion. After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made. A Veress needle was inserted. Abdomen was insufflated to 15 mmHg. A 5-mm port and camera placed. The abdomen was visually explored. There were no obvious abnormalities. A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two. Blunt dissection was used to isolate the appendix. Appendix was separated from surrounding structures. A window was created between the appendix and the mesoappendix. GIA stapler was tossed across it and fired. Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler. Appendix was placed in an Endobag and removed from the patient. Right lower quadrant was copiously irrigated. All irrigation fluids were removed. Hemostasis was verified. The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device. All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures. Steri-Strips and sterile dressings were applied. Overall, the patient tolerated this well, was awakened and returned to recovery in good condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1. Left adrenal mass, 5.5 cm.,2. Intraabdominal adhesions.,PROCEDURE PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:, None.,DISPOSITION:, The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:, This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length. | Surgery |
PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3. Right L4-S1 posterolateral fusion with local bone graft.,4. Left L4 through S1 segmental pedicle screw instrumentation.,5. Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:, Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots. The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed. General anesthesia was induced. The patient was intubated. Foley catheter was in place. The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. A previous incision was infiltrated with local and incised with a scalpel. The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala. Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting. The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed. Pars interarticularis were maintained. Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. Pedicle screws were placed L4-L5 and S1 on the right side. Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. It showed no penetration outside the pedicle vertebral body. At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed. Good bone purchase was obtained. Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1. Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. Prior to placement of BMP, the wound was irrigated with antibiotic irrigation. Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision. Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl. Skin was stapled. The drain was sutured in place with 2-0 Vicryl and connected to closed drain system. The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. The patient tolerated the procedure well without apparent complication. Final sponge and needle counts are correct. Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back. | Surgery |
PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Ruptured appendicitis.,PROCEDURE:, Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:, This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers. The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's abdomen was prepped and draped in usual sterile fashion. A periumbilical incision was made. The fascia was incised. Peritoneal cavity entered bluntly. A 10-mm trocar and scope was passed. Peritoneal cavity was insufflated. Five-mm ports placed in left lower and hypogastric areas. On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus. We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site. We irrigated and suctioned out the right lower and pelvic areas. We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips. The patient was extubated in the operating table and taken back to recovery room. The patient tolerated the procedure well. | Surgery |
PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1. Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: ,Approximately 1000 cc.,CELL SAVER RETURNED: ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain. He had previous lumbar laminectomy at L4-L5. He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable. He is suffering from neurogenic claudication. He was unresponsive to extensive conservative treatment. He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia. He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded. His lumbar spine was then sterilely prepped and draped in the usual fashion. A previous midline incision was extended from approximate level of L3 to S1. This was in the midline. Skin and subcutaneous tissue were debrided sharply. Electrocautery provided hemostasis. ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia. The lumbar fascia was identified and split in the midline. Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1. Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4. Once this was completed, a self-retaining retractor was then placed. With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable. These were readily mobile with digital palpation. A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1. This bone was morcellized and placed on the back table for utilization for bone grafting. The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1. Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained. Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1. The microscope was utilized during this portion of procedure for visualization. There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure. Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5. Once this was identified, foraminotomies were created to allow additional mobility. The wound was then copiously irrigated with antibiotic solution and suctioned dry. Working type screws, provisional titanium screws were then placed at L4-l5. This was to allow distraction and reduction of the spondylolisthesis. These were placed in the pedicles of L4 and L5 under direct intensification. The position of the screws were visualized, both AP and lateral images. They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5. This allowed for additional decompression of the L5 and L4 nerve roots. Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed. Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval. This was taken in sequence up to a 13 mm space. This was then reduced to a 11 mm as it was much more anatomic in nature. Once this was completed, the spacers were then placed on the left side and distraction obtained. Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally. Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried. A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft. There were impacted at the interspace of L4-L5 under direct image intensification. Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried. The provisional screws and plates were removed. This allowed for additional compression along L4-L5 with the cage instrumentation. Permanent screws were then placed at L4, L5, and S1 bilaterally. This was performed under direct image intensification. The position was verified in both AP and lateral images. Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone. The wound was then copiously irrigated with antibiotic solution and suction dried. The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally. A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1. Appropriate cross connecters were applied and the construct was placed over the pedicle screws. They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra. Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory. All connections were tightened and retightened in Torque 2 specifications. The wound was then copiously irrigated with antibiotic solution and suction dried. The dura was inspected and noted to be free of tension. At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors. An 8-inch Hemovac drain was placed exiting the wound. The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin. The remainder of the Hemovac was assembled. Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape. He was turned and taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded. | Surgery |
PREOPERATIVE DIAGNOSIS:, Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS: ,Acute appendicitis with perforation.,ANESTHESIA:, General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis. A CT scan of his abdomen showed evidence of appendicitis with perforation. He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process. He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options. All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia. A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion. A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion. We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure. A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia. CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum. After these were gently separated, we began to identify the appendix. In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix. The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port. I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system. When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible. The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips. The patient tolerated the operation well. He was awakened and taken to the recovery room in satisfactory condition. His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure. | Surgery |
PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. His abdomen was prepped and draped in a standard, sterile surgical fashion. A Foley catheter was placed for bladder decompression. Marcaine was injected into his umbilicus. A small incision was made. A Veress needle was introduced in his abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus. A 5-mm port was then placed just to the right side of the umbilicus. Another 5-mm port was placed just suprapubic in the midline. Upon inspection of the cecum, I was able find an inflamed and indurated appendix. I was able to clear the mesentery at the base of the appendix between the appendix and the cecum. I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix. I put the appendix in an Endocatch bag and removed it through the umbilicus. I irrigated out the abdomen. I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications. | Surgery |
REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress. ,PROCEDURE: ,I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:, The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. She will come back in two weeks for another adjustment as needed., | Surgery |
PREOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1. Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2. Posterior cervical fusion C4-C5.,3. Songer wire.,4. Right iliac bone graft.,TECHNIQUE: ,The patient was brought to the operating room. Preoperative evaluations included previous cervical spine surgery. The patient initially had some relief; however, his left arm pain did recur and gradually got worse. Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6. There was also noted to be some annular bulges at C3-C4, and C6-C7. The CT scan in March revealed that the fusion was not fully solid. X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication. The patient had undergone several nonoperative treatments. He was given the option of surgical intervention. We discussed Botox, I discussed with the patient and posterior cervical decompression. I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery. If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion. The patient was a smoker and had been advised to quit smoking but has not quit smoking. I have therefore recommended that he use iliac bone graft. I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life. Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire. The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve. His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist. He still had some residual bursitis in his left shoulder and this would not be cured by this procedure. Other procedures may be necessary later. There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function. He could lose total control of his arms or legs and end up in the bed for the rest of his life. He could develop chronic regional pain syndromes. He could get difficulty swallowing or eating. He could have substantial weakness in the arm. He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks. He did not wish to get any other treatments. He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls. His head was controlled by a horseshoe holder. The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes. The arms, the right hip, and the neck was then prepped and draped. Care was taken to position both arms and both legs. Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine. A loupe magnification and headlamp illumination was used. Bleeding vessels were cauterized. Meticulous hemostasis was carried out throughout the procedure. Gradually and carefully I exposed the spinous process of the C6, C5, and C4. A lateral view was done after an instrument in place. This revealed the C6-C7 level. I therefore did a small laminotomy opening at C4-C5. I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5. I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left. I removed some of the superior lamina of C6 and some of the inferior lamina of C4. This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots. There was some bleeding from the epidural veins and a bipolar cautery was used. Absolutely no retractors were ever placed in the canal. There was no retraction. I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent. The nerve roots had been fully decompressed.,I then checked stability. There was micromotion at the C4-C5 level. I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5. I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4. Using a small drill, I opened the facet at C4-C5. I then used a very small curette to clean up the articular cartilage. I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped. An incision made over the iliac crest. Bleeding vessels were cauterized. I exposed just the posterior aspect of the crest. I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5. Drill holes made with a clip. I then packed cancellous bone between the decorticated spinous process. I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5. I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex. Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine. The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed. The patient was taken to the recovery room in good condition. | Surgery |
PREOPERATIVE DIAGNOSES: ,1. Fractured and retained lumbar subarachnoid spinal catheter.,2. Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES: ,1. L1 laminotomy.,2. Microdissection.,3. Retrieval of foreign body (retained lumbar spinal catheter).,4. Attempted insertion of new external lumbar drain.,5. Fluoroscopy.,ANESTHESIA: , General.,HISTORY: ,The patient had a lumbar subarachnoid drain placed yesterday. All went well with the surgery. The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina. The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE: ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls. Her face was resting in a pink foam headrest. Extreme care was taken positioning her because she weighs 92 kg. There was a lot of extra padding for her limbs and her limbs were positioned comfortably. The arms were not hyperextended. Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance. A Foley catheter was in place. She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked. It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina. The incision was carried down through the fascia all the way down to the spinous processes. A self-retaining McCullough retractor was placed. The laminae were quite deep. The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura. The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors. At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right. The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus. Microdissection under high magnification did not expose the catheter. The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle. Dr. Y also tried. Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned. It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus. The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura. The paraspinous muscles were closed with 0 Vicryl interrupted sutures. The subcutaneous fascia was also closed with 0 Vicryl interrupted suture. The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide. The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room. The patient tolerated procedure well. No complications. Sponge and needle counts correct. Blood loss minimal, none replaced. This procedure took 5 hours. This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Pathologic insufficiency.,2. Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1. Pathologic insufficiency.,2. Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1. Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2. Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:, None.,SURGICAL INDICATIONS:, The patient is an 80-year-old female who had previous history of compression fractures. She had recently undergone an additional compression fracture of the T8 vertebrae. She was in extreme pain. This pain interfered with activities of daily living and was unimproved with conservative treatment modalities. She is understanding the risks, benefits, and potential complications as well as all treatment alternatives. The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table. She was given sedative. The thoracodorsal spine was then sterilely prepped and draped in the usual fashion. Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae. Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side. This was directly over the posterior aspect of the pedicle on the left. Once this was localized, the right side was localized as well. Stab incisions were then created over the pedicles of T8 bilaterally. Jamshidi needles were then placed percutaneously. Their position was verified in both AP and lateral images. They were advanced slowly under direct image intensification in biplanar fashion. Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae. The Jamshidi needles were then removed. A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae. This bone was then removed and sent to the lab. The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images. Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle. This was advanced under direct image intensification in a biplanar fashion. Once this was deemed satisfactory, it was impacted. The inner trocar was removed and a guidewire was then placed. An injection cannula was then placed over the guidewire into the body of T7. In a similar fashion, T9 was dressed on the left side as well. A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images. The cement injection cannula was then placed over this entering the T9 vertebrae body. Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae. The balloons were inserted bilaterally. The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg. These were allowed to expand and reduce the fracture. Once this was completed, the balloons were deflated and removed. The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas. This was done directly under image intensification. Once this was completed, additional cement was injected into T9 as there was a larger vertebra. The cement was allowed to cure. The cannula was removed and final radiographs were obtained. The stab incisions were then cleansed with water and antibiotic irrigation. The wounds were then approximated with #4-0 Nylon in interrupted fashion. Compression dressings were applied and fixed with tape. She was aroused and moved to her inpatient bed. She was moving all four extremities without deficit. She had no significant pain. | Surgery |
PREOPERATIVE DIAGNOSIS:, Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1. Dural tear, postoperative laminectomy, L4-L5.,2. Laterolisthesis, L4-L5.,3. Spinal instability, L4-L5.,OPERATIONS PERFORMED,1. Complete laminectomy, L4.,2. Complete laminectomy plus facetectomy, L3-L4 level.,3. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5. Posterior spinal fusion, L4 to S1.,6. Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS: ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago. He presented several days later with headaches as well as a draining wound. He was subsequently taken back for a dural repair. For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines. He has fullness in the back of his wound. The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak. The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:, After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7. The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties. The patient was given intraoperative antibiotics. The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level. Full-thickness skin flaps were developed. It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid. Cultures were taken, aerobic, anaerobic, AFB, fungal. Once this was done, the paraspinal muscles were affected from the posterior elements. It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1. It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis. Once this was done; however, the fluid emanating from the dura could not be seen appropriately. Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left. Complete laminectomy at L3 was done. Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen. Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture. A Valsalva confirmed no significant lead after the repair was made. There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation. The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl. After this the standard starting point was made. Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall. Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall. The screws were subsequently placed. Tricortical purchase was obtained at S1 ________ appropriate size screws. Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1. This was done on the right side first. The screw was torqued at S1 appropriately and subsequently at L5. Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4. Neutral compression distraction was obtained on the left side. Screws were torqued at L4, L5, and S1 appropriately. Good placement was seen both in AP and lateral planes using fluoroscopy. Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette. Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix. This was placed in the posterior lateral gutters. DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately. Deep retractors then removed from the confines of the wound. Fascia was closed using interrupted Prolene running suture #1. Once this was done, suprafascial drain was placed appropriately. Subcutaneous tissues were opposed using a 2-0 Prolene suture. The dermal edges were approximated using staples. Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape. The drain was connected appropriately. The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition. No complications arose. | Surgery |
PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:, Left patellar chondromalacia with tight lateral structures.,PROCEDURE:, Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: ,47 minutes.,MEDICATION: ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referred to physical therapy for patellar tracking exercises. She was also given a brace. The patient reported increasing pain with physical therapy and mother strongly desired other treatment. It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. Risk and benefits of surgery were discussed. Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A nonsterile tourniquet was placed on the upper aspect of left thigh. The extremity was then prepped and draped in the standard surgical fashion. A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. Incisions were then made. Camera was initially inserted into the lateral joint line. Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation. The patient did have congruent articulation about 30 degrees of knee flexion. Visualization of the medial joint line revealed no loose bodies. There was a small plica. Visualization of the medial joint line revealed no significant chondromalacia. Menisci was probed and tested with no signs of tears and instability. ACL was noted to be intact. The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology. Lateral gutter also demonstrated no loose bodies or plica. The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles. The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed. The patient had significant improvement in anteromedial translation from 25% to 50%. At the end of the case, all instruments were removed. The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine. Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case. The portals were then closed using 4-0 Monocryl. The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s. The kneecap was translated medially under pressure and a bias placed. The tourniquet was released at 47 minutes. The patient was then placed in the knee immobilizer. The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer. She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening. Intraoperative findings were relayed to the mother. All questions were answered. | Surgery |
PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:, Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA: ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology. The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded. Tourniquet was placed around the left upper thigh. The limb was then prepped and draped in usual sterile fashion. Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed. Patellofemoral joint showed frequent chondromalacia. Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus. The medial femoral condyle and medial tibial plateau were unaffected. Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus. The femoral condyle and tibial plateau were all stable to probing. Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors. A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry. 20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals. A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose. The patient was then transferred to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:, Left medial compartment osteoarthritis of the knee.,PROCEDURE PERFORMED:, Left unicompartmental knee replacement.,COMPONENTS USED:, Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:, None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side. She has done quite well with this. She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table. After appropriate anesthesia, the left lower extremity was identified with a time out procedure. Preoperative antibiotics were given. Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet. The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used. Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed. The anterior fat pad was removed. The knee was then examined. The ACL was found to be intact. The lateral compartment had very minimal arthritis. There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild. Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place. Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection. Following this resection, the femoral intramedullary guide was placed without difficulty. The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide. Once in the appropriate position, it was pinned and drilled. This was removed, and the posterior cutting block was inserted. It was impacted into place. Posterior bone cut was made for the medium femoral component. Next, a zero spigot was used and the distal femur was reamed. Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well. Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit. Next, the tibia was prepared. The tibial tray was pinned into place, and the cuts for the keel of the tibia were made. These were removed with a small osteotome from the set. Following this, a trial tibial with the keel was placed and it did fit nicely. After this, all trial components were removed. The knee was copiously irrigated. Cement was begun mixing. Drill holes were used along the femur for cement interdigitation. The wound was cleaned and dried. Cement was placed on the tibia. Tibial tray was impacted into place. Excess cement was removed. Tibia was placed in the femur. Femoral component was impacted into place. Excess cement was removed. It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened. Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size. A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion. The intramedullary rod removed from the femur. The wound was irrigated with normal saline. The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin. A sterile dressing was placed. Tourniquet was then desufflated. Sponge and needle counts were correct at the end of the procedure. Dr. Jinnah was present for the surgery. The patient was transferred to the recovery room in stable condition. She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis. Prior to closure, the posterior capsule was injected with the joint cocktail. | Surgery |
PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis. | Surgery |
PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: , Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes. Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used. A NexGen femoral component with a distal femoral augmented block, size 5 mm. A NexGen tibial component, size 3 mm was used. A size 14 mm constrained polyethylene surface was used as well. Original patellar component that the patient had was maintained.,COMPLICATIONS: ,None.,BRIEF HISTORY:, The patient is a 68-year-old female with a history of knee pain for 13 years. She had previous total knee arthroplasty and revision at an outside facility. She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:, The patient was taken to the operative suite and placed on the operating table. Department of Anesthesia administered the spinal anesthetic. Once adequately anesthetized, the patient was placed in a supine position. Care was ensured and she was adequately secured and well padded in position. Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was inflated to approximately 325 mmHg on the right thigh. At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum. A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface. There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well. At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed. This was done without difficulty. Attention was then directed removing the femoral component. Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed. After this was performed, attention was then directed to the tibial component. An osteotome was again inserted around the surface and this was easily pried loose. There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation. This was evaluated. The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component. The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component. At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut. We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut. We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12. At this point, the distal femoral cutting guide based on the intramedullary head was then placed. Care was ensured that this was aligned in proper rotation with the external epicondylar axis. Once this was pinned in position, approximately a six degree valgus cut was then made. This allowed a portion of the medial condyle to be removed distally. The anterior cut was checked next using the intramedullary guide. The anterior surface cutting block was then placed. This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis. Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made. It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface. _______ was then removed and the chamfer cutting guide was then placed on. This allowed us to make a box cut and recut some of the angled cuts of the distal femur. Once this was placed and pinned in position. Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut. It was noted that the anterior chamfers did not need to be cut, take off no bone. The posterior chamfers did remove some bony aspects. This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component. After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed. This appeared to have an adequate fit and then packed in position. It appeared to be satisfactory. At this point, this was removed and attention was then directed to the tibia. The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained. At this point, the intramedullary guide was used to evaluate a tibial cut. This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface. The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component. At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone. This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component. This was placed in a proper position. A 10 mm articular surface was placed in the knee and this was taken through range of motion. This was found to have better alignment and satisfactory position. We elected to take an intraoperative x-ray at this point, to evaluate our cut. The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis. At this point, all trials were removed. The patella was then examined. The rongeur was used to remove the surrounding synovium. The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone. It was elected at this time to maintain this anatomic patella that was previously placed. At this point, the joint again was reevaluated and any bone loose fragments removed. There was noted to be some posterior tightness and mild osteophytes. These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes. Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried. The tourniquet was then reinflated. The canals were prepped for cementing. They were suction-dried and cleaned. The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial. Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component. The stemmed femoral component was then impacted in position and cemented. Again care was ensured that it was in adequate position and proper rotation. A size 14 mm poly was then inserted in between to provide compression. This was then taken through extension and held until cement cured. This was then removed and the components were evaluated. All excess cement was removed and they were well fixed. Size 14 mm trial Poly was then placed and this was taken through range of motion. This was found to have excellent range of motion and good stability. It was elected at this time that we would go with the size 14 mm Poly. This gave us extra Poly for ware and then provide excellent contact throughout the range of motion. The final articular surface was then placed and tightened into position to allow to _______ secured. The knee was then reduced and the knee was taken through range of motion. The patella was tracking with no-touch technique and adequately positioned. At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry. All bleeding was cauterized using a Bovie cautery. The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion. This was reinforced with a running #2-0 Vicryl. The knee was then flexed and noted that the patella was tracking with good alignment. The wound was again copiously irrigated and suctioned dry. A drain was placed prior to retinaculum repair deep to this to provide adequate drainage. At this point, the subcutaneous tissue was closed with #2-0 Vicryl. Skin was approximated with skin clips. Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed. A large Dupre dressing was then placed up the entire lower extremity. The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition. | Surgery |
PRE-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1. KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2. Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:, Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating. She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics. She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2. In addition to the fractures, she presents with kyphotic posture. Films on 1/04 demonstrated L1 and L2 osteoporotic fractures. Films on 2/04 demonstrated increased loss of height at L1. Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1. The L2 fracture is documented on radiographic studies as being chronic and a year or more old. The T12 fracture has the most significant kyphotic deformity. Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:, The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed. The patient was positioned prone on the Jackson table. The back was prepped and draped. The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker. In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate. An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side. Positioning was confirmed on the AP and lateral plane. Following satisfactory placement of the needle, the stylet was removed. A guide pin was inserted through the 11g to a point 3mm from the anterior cortex. AP and lateral images were taken to verify position and trajectory. Alongside of the guide pin a 1-cm paramedian incision was made. The needle was then removed leaving the guide pin in place. The osteointroducer was placed over the guide pin and advanced through the pedicle. Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall. Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel. The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex. After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex. The radiopaque marker bands on the bone tamp were identified using AP and lateral images. The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body. Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi. Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position. The inflation was monitored with AP and lateral imaging. The final balloon volume was 3.5 cc on the right side and 3 cc on the left. There was no breach of the lateral wall or anterior cortex of the vertebral body. Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved. Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement. The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side. Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12. An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved. Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures. The patient was kept in the prone position for approximately 10 minutes post cement injection. She was then turned supine, monitored briefly and returned to the floor. She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications. Estimated blood loss was minimal. | Surgery |
PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis. Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion. Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral. Through the lateral portal, the camera was placed. Through the medial portal, tools were placed. We proceeded to examine scarring of the patellofemoral joint. Then we probed the patellofemoral joint. A chondroplasty was performed using a shaver. Then we moved down to the lateral gutter. Some loose bodies were found using a shaver and dissection. We moved down the medial gutter. No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact. We moved to the lateral joint and found that the lateral meniscus was intact. Pictures were taken. We drained the knee and washed out the knee with copious amounts of sterile saline solution. The instruments were removed. The 2 portals were closed using 3-0 nylon suture. Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed. The patient was successfully extubated and brought to the recovery room in stable condition. I then spoke with the family going over the case, postoperative instructions, and followup care. | Surgery |
TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY: ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death. This list was inclusive, but not exclusive. An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS: ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room. After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table. Lumbar spine was shaved, prepped, and draped in the usual sterile fashion. An incision was carried out from L4 to S1. Hemostasis was obtained with bipolar and Bovie cauterization. A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum. At this time, laminectomy was carried out of L5-S1. Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space. At this time, the disk was entered with a #15 blade and bipolar. The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk. We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root. Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic. At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound. There were no complications. | Surgery |
PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:, None.,INJECTABLES:, Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:, Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well. Vital signs stable. Vascular status intact to all digits. Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s). | Surgery |
PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well. | Surgery |
PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:, Exam under anesthesia. Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:, Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed. She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition. | Surgery |
PREOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA: General endotracheal anesthesia.,OPERATIVE TIME: Three hours.,ANESTHESIA TIME: Four hours.,DESCRIPTION OF PROCEDURE: After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced. A Foley catheter was placed and a right internal jugular central line was placed. The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape. A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered. A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed. With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly. The small bowel was wrapped in moist green towel and retracted in the right upper quadrant. The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein. Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries. The mid left renal artery was likewise identified. The perirenal aorta was prepared for clamp superior to the inferior left renal artery. During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis. The distal dissection was then completed exposing each common iliac artery. The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time. The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps. The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery. The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed. There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site. The vessel was controlled with a microvascular clamp. Two pairs of lumbar arteries were oversewn with 2-0 silk. A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture. At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis. The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture. Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation. The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation. The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous. The colon was normal in appearance and this vessel was oversewn using 2-0 silk. The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion. The posterior peritoneum was reapproximated using running 3-0 PDS. The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera. The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location. The midline fascia was then reapproximated using running #1 PDS suture. The subcutaneous tissues were irrigated with bacitracin and kanamycin solution. The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied. | Surgery |
PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME: ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient. The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. All bony prominences were well padded at this time. At this time, Department of Anesthesia administered general anesthetic to the patient. The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left. The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. The right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg. The patient was a consideration for a unicompartmental knee replacement. So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. Total incision now measured approximately 25 cm. Retractors were placed. Next, attention was directed to establishing medial and lateral flaps of the proximal tibia. Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. At this time, the patella was then everted. The knee was flexed up to 90 degrees. Next, using the large drill bit, the femoral canal was then opened in appropriate position. The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. The guide was then removed. The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. Upon checking, it was noted to be flat with no oscillations. The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. It was secured in place using nails. The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position. Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. The distal finishing guide was then removed and osteotome was then used to remove all resected bone. The oscillating saw was then used to complete the femoral notch cut. Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. There was no posterior osteophytes noted and no fragments to the posterior aspect. Next, attention was directed towards the tibia. The external tibial guide was reflected. This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. Next, collateral ligament retractors were placed as well as McGill retractors for the PCL. Oscillating saw was then used to make the proximal tibial cut. Osteotome was used to remove this excess resected bone. The laminar spreader was then used to check the flexion and extension. The gaps appeared to be equal. The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray. The knee was taken through range of motion and had very good flexion as well as full extension. There appeared to be good varus and valgus stability as well. Next, attention was directed towards the patella. There noted to be a sufficient ware and it was selected to replace the patella. It was sized with caliper, pre-cut and noted to be 26 mm depth. The sizing guide was then used and a size 51 resection guide selected. A 51 mm reamer was then placed and sufficient amount of patella was then removed. The calcar was then used to check again and there was noted to be 15 mm remaining. The 38 mm patella guide was then placed on the patella. It was noted to be in proper size and the three drill holes for the pegs were used. A trial component was then placed. The knee was taken through range of motion. There was noted to be some subluxation lateral to the patellar component and a lateral release was performed. After this, the component appeared to be tracking very well. There remained a good range of motion in the knee and extension as well as flexion. At this time, an AP x-ray of the knee was taken with the trial components in place. Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. The knee was then copiously irrigated and dried. The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled. The knee again was copiously irrigated and suction dried. The final components were then selected again consisting of size F femoral components. A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella. Polymethyl methacrylate was then prepared at this time. The proximal tibia was dried and the cement was then pressed into place. The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. Next, the proximal femur was cleaned and dried. Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. This was then impacted in place as well. At this time, all excess cement was removed from both the tibial and femoral components. A size 12 mm trial tibial articular surface was then put in place. The knee was reduced and held in loading position throughout the remaining drying position of the cement. Next, the resected patella was cleaned and dried. The cement was placed on the patella as well as the backside of the patellar component. The component was then put in proper positioning and held in place with a clamp. All excess polymethyl methacrylate was removed from this area as well. This was held until the cement had hardened sufficiently. Next, the knee was examined. All excess cement was then removed. The knee was taken through range of motion with sufficient range of motion as well as stability. The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. Again range of motion was noted to be sufficient. The knee was copiously irrigated and suction dried once again. A drain was then placed within the knee. The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl. The knee was again copiously irrigated and dried. The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin. The ConstaVac was then _______ to the drain. Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh. Department of Anesthesia then reversed the anesthetic. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications. | Surgery |
TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06. This was complicated by posterior capsule rupture. An intraocular lens implant was not attempted. He developed corneal edema and a preretinal hemorrhage. He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,POSTOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,ANESTHESIA: , General.,SPECIMEN: ,1. Donor corneal swab sent to Microbiology.,2. Donor corneal scar rim sent to Eye Pathology.,3. The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT: ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered. The patient was brought to the preoperative holding area, where the operative left eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced. The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. A lid speculum was placed. The posterior segment infusion was placed by the vitreoretinal service. Peritomy was performed at the 3 and 9 o'clock limbal positions. A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. The cornea was then measured and was found to accommodate a 7.5-mm trephine. The center of the cornea was marked. The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface. This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. Corneoscleral scissors were then used to excise completely the central cornea. The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. This was done without difficulty. At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. The 9-0 Prolene sutures double armed were then placed on each lens haptic loop. The keratoprosthesis was removed. Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. Wet-field cautery also was performed to achieve hemostasis. The leading hepatic sutures were then passed through the bed of the scleral flap. These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. The trailing hepatic was then placed into the posterior segment of the eye as well. The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. These were tied securely into position with the IOL nicely centered. At this point, the donor cornea punched at 8.25 mm was then brought into the field. This was secured with four cardinal sutures. The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. The knot was secured and buried after adequate tension was adjusted. The corneal graft was watertight. Attention was then turned back to the IOL sutures, which were locked into position. The ends were trimmed. The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. No complications were noted. The attending surgeon, Dr. X, performed the entire procedure. No complications of the procedure were noted. The intraocular lens was selected from preoperative calculations. No qualified resident was available to assist. | Surgery |
PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED: ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:, This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. It appears to be right down to the bone. MRI shows findings suggestive of osteomyelitis. The patient is being brought to operating room for debridement of this ulcer. Procedure, indication, and risks were explained to the patient. Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped. Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer. This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base. The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone. The deeper portion of the excised tissue was also sent for tissue cultures. Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix. Sterile dressing was applied. The patient transferred to recovery room in stable condition. | Surgery |
TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY: ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture. The patient was admitted and splinted and had compartment checks. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia. The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:, 900.,ESTIMATED BLOOD LOSS: ,100.,COMPLICATIONS:, None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL: ,The patient was met in the preoperative holding area and operative site was marked. The patient was brought to the operating room and given preoperative antibiotics. Left leg was then prepped and draped in the usual sterile fashion. A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue. The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence. This was advanced and confirmed on the AP and lateral fluoroscopic images. The opening reamer was then used and the ball-tip guidewire was passed. The reduction was obtained over a large radiolucent triangle. After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer. At this point, a 10 x 390 mm was passed without difficulty. The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws. The final images were taken with fluoroscopy and a 15-mm end-cap was placed. The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision. The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity. He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks. | Surgery |
PREOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:, None.,TOURNIQUET TIME:, None.,ESTIMATED BLOOD LOSS:, 50 mL.,ANESTHESIA: , General.,INDICATIONS: ,The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities. She was diagnosed with displaced left subcapital hip fracture, now was asked to consult. With this diagnosis, she was indicated the above-noted procedure. This procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,Risks and benefits were also discussed. Risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood these well and consented, and the son signed the consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on the operating table and general anesthesia was achieved. The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment. External positions were felt to be present. At this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner. A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire. An overlying drill was inserted to the proper depths. A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth. Proper rotation was obtained and the guide for the helical blade was inserted. A small incision was made for this as well. A guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on AP. This placed the proper depths and lengths better. The outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done. Appropriate size screw was then tightened down. At this point, a distal guide was then placed and drilled across both the cortices. Length was better. Appropriate size screw was then inserted. Proper size and fit of the distal screw was also noted. At this point, on fluoroscopic control, it was confirming in AP and lateral direction. We did a near anatomical alignment to the fracture site and all hardware was properly fixed. Proper size and fit was noted. Excellent bony approximation was noted. At this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,The fascial layers were then reapproximated using #1 Vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated with staples. The area was then infiltrated with a mixture of a 0.25% Marcaine with Epinephrine and 1% plain lidocaine. Sterile dressing was then applied. No complication was encountered throughout the procedure. The patient tolerated the procedure well. The patient was taken to the recovery room in stable condition. | Surgery |
PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:, Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair. The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right. The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced. The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:, After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion. An infraumbilical incision was made with a #15 Bard-Parker scalpel. The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty. Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg. Next, the Veress was removed and #10 bladed trocar was inserted without difficulty. The 30-degree camera laparoscope was then inserted and the abdomen was explored. There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible. Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus. Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization. A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization. Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral. The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty. Dissection was carried out, freeing up the hernia sac from the peritoneum. This was done without difficulty reducing the hernia in its entirety. Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract. The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples. This was done without difficulty. All three ports were removed under direct visualization. No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle. Skin was closed with running subcuticular #4-0 undyed Vicryl. Steri-Strips and sterile dressings were applied. Attention was next made to carrying out the circumcision. The foreskin was retracted back over the penis head. The desired amount of removing foreskin was marked out with a skin marker. The foreskin was then put on tension using a clamp to protect the penis head. A #15 blade scalpel was used to remove the foreskin and sending off as specimen. This was done without difficulty. Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially. This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing. The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition. | Surgery |
PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.,PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty. The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used. The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty. The guidewire was removed. Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty. The ports were flushed with injectable normal saline secondary to the patient going for dialysis today. Thus, he will not need heparinization of the lines. Again, he tolerated the procedure well. A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax. | Surgery |
PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Care was taken not to injure the ilioinguinal nerve. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and sent to Pathology. The stump was examined and no bleeding was noted. The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring. In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition. | Surgery |
Subsets and Splits