OPERATION PERFORMED: ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1. Impacted wisdom teeth.,2. Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1. Impacted wisdom teeth.,2. Moderate gingivitis.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,Minimal.,DURATION OF SURGERY: ,One hour 17 minutes.,BRIEF HISTORY: ,The patient was referred to me by Dr. X. He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him. I agreed. I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination. This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION: ,The patient was brought to Hospital Day Surgery accompanied by her mother. I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with a nasal endotracheal tube and the tube was stabilized. The head was wrapped and the eyes were taped shut for protection. An Angiocath was previously placed in preop. The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath. A moist continuous throat pack was placed beyond tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative digital intraoral photographs were taken. No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office. A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done. She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars. She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were taken. The continuous gauze throat pack was removed with continuous suction and visualization. Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition. Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander. Oral hygiene was fair. There was generalized plaque and calculus throughout. She did not have any caries, did not require any restorative dentistry.,CONCLUSION:, Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates. There were no postop pain requirements. I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.

anesthesia
dental
dental prophylaxis
dental rehabilitation
digital radiographs
gingivitis
impacted
impacted wisdom teeth
moderate gingivitis
oral
prophylaxis
restorative
restorative dentistry
surgery
teeth
throat pack
wisdom
wisdom teeth


Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.

PREOPERATIVE DIAGNOSIS:, Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Torn rotator cuff, right shoulder.,2. Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with subacromial decompression.,2. Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity. There is moderate amount of synovitis noted throughout the glenohumeral joint. There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repair. All risks and benefits of the surgery were discussed with her at length. She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital. She was placed supine on the operating table. General anesthesia was applied by the Anesthesiology Department. She was placed in the modified beachchair position. Her upper extremity was sterilely prepped and draped in usual fashion. A stab incision was made in the posterior aspect of the glenohumeral joint. A camera was placed in the joint and was insufflated with saline solution. Intraoperative pictures were obtained and the above findings were noted. A second port site was initiated anteriorly. Through this a probe was placed and the intraarticular structures were palpated and found to be intact. A tear of the inner surface of the rotator cuff was identified. The camera was then taken to the subacromial space. A straight lateral portal was also used and a shaver was placed into the subacromial space. Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed. The edges of the rotator cuff were then debrided. The camera was then removed and the shoulder was suction and dried. A lateral incision was made over the anterolateral border of the acromion. Subcuticular tissues were carefully dissected. Hemostasis was controlled with electrocautery. The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur. A trough was then made in the greater tuberosity using the rongeur. Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff. The ends of the suture were tied down from the fixating the rotator cuff within the trough. The rotator cuff was then further oversewed using the Panalok suture. The wound was then copiously irrigated and it was then suction dried. The deltoid muscle was reapproximated using #1 Vicryl. A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control. The subcutaneous tissues were reapproximated with #2-0 Vicryl. The skin was closed with #4-0 PDS running subcuticular stitch. Sterile dressing was applied to the upper extremity. She was then placed in a shoulder immobilizer. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient was guarded. She will begin pendulum exercises postoperative day #3. She will follow back in the office in 10 to 14 days for reevaluation. Physical therapy initiated approximately six weeks postoperatively.

arthroscopy
diagnostic arthroscopy
panalok
panalok suture
repair of rotator cuff
shoulder
subacromial
subacromial decompression
subacromial space
subacromial spur
surgery
torn rotator cuff


DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital. The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital. Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started. The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started. The patient did have labor epidural, which worked well. It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep. The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth. The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid. DeLee suctioning was performed at the perineum. A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl. The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.

: thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. all names and dates have beenchanged (or removed) to keep confidentiality. any resemblance of any type of name or date orplace or anything else to real world is purely incidental.


Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.

DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09. The patient is a patient of Dr. X's. Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She also has a history of tobacco abuse with asthma. She was admitted here and labor was confirmed with rupture of membranes. She was initially 5, 70%, -1. Her bag was ruptured, IUPC was placed. She received an epidural for pain control and Pitocin augmentation was performed. She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation. Delivery of the head was manual assisted. The shoulders and the rest of body then followed without difficulty. Baby was bulb suctioned, had a vigorous cry. Cord was clamped twice and cut and the infant was handed to the awaiting nursing team. Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord. The inspection of the perineum revealed it to be intact. There was a hymenal remnant/skin tag that was protruding from the vaginal introitus. I discussed this with the patient. She opted to have it removed. This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis. Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair. Overall EBL is 300 mL. Mom and baby are currently doing well. Cord gases are being sent due to prematurity.,


Pitocin was started quickly to allow for delivery as quickly as possible. Baby was delivered with a single maternal pushing effort with retraction by the forceps.

Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck. These were variable decelerations occurring late in the contraction phase. The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps. The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes. The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet. Cord gases were sent and the placenta was sent to Pathology. The cervix, the placenta, and the rectum all seemed to be intact. The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl. Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place. She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter. The baby's father was present for the delivery, as was one of the patient's sisters. All are relieved and pleased with the good outcome.


DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. Apgars were 8 at 1 minute and 9 at 5 minutes. Placenta was delivered intact with three-vessel cord. The cervix was visualized. No lacerations were noted. Perineum remained intact. Estimated blood loss is 300 mL. Complications were none. Mother and baby remained in the birthing room in good condition.


DELIVERY NOTE: ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor. The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum. Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes. No meconium was noted. Infant was delivered on 12/25/08 at 2154 hours. Two doses of ampicillin was given prior to rupture of membranes. GBS status unknown. Intrapartum events, no prenatal care. The patient had epidural for anesthesia. No observed abnormalities were noted on initial newborn exam. Apgar scores were 9 and 9 at one and five minutes respectively. There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child. Placenta was delivered spontaneously and was normal and intact. There was a three-vessel cord. Baby was bulb suctioned and then sent to newborn nursery. Mother and baby were in stable condition. EBL was approximately 500 mL, NSVD with postpartum hemorrhage. No active bleeding was noted upon deliverance of the placenta. Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone. Pitocin was started following deliverance of the placenta. Baby delivered vertex from OA position. Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.


The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.

DELIVERY NOTE:, The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009. The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting. She was Group B Streptococcus positive, however, was 5 cm dilated. The patient was started on Group B Streptococcus prophylaxis with ampicillin. She received a total of three doses throughout her labor. Her pregnancy was complicated by scanty prenatal care. She would frequently miss visits. At 37 weeks, she claims that she had a suspicious bump on her left labia. There was apparently no fluid or blistering of the lesion. Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2. I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery. The patient requested an epidural anesthetic, which she received with very good relief. She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions. She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum. The baby delivered in the occiput anterior position. The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated. The umbilical cord was doubly clamped and then cut. The baby's Apgars were 8 and 9. The placenta was delivered spontaneously intact. There was a three-vessel cord with normal insertion. The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol. The perineum was inspected and was found to be fully intact. Estimated blood loss was approximately 400 mL. The patient's blood type is A+. She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.


DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. Cord clamped and cut and infant handed to the awaiting nurse in attendance. Cord blood sent for analysis, intact. Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours. A 15 units of Pitocin was started after delivery of the placenta. Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion. Estimated blood loss was approximately 400 mL. The patient was taken to the recovery room in stable condition. Infant was taken to Newborn Nursery in stable condition. The patient tolerated the procedure well. The only intrapartum event that occurred was thick meconium. Otherwise, there were no other complications. The patient tolerated the procedure well.


Spontaneous controlled sterile vaginal delivery performed without episiotomy.

The patient presented in the early morning hours of February 12, 2007, with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilation, but 80% effacement by nurse examination. The patient was admitted. Expected management was utilized initially. Stadol was used for analgesia. Examination did not reveal vulvar lesions. Epidural was administered. Membranes ruptured spontaneously. Cervical dilation progressed. Acceleration-deceleration complexes were seen. Overall, fetal heart tones remained reassuring during the progress of labor. The patient was allowed to "labor down" during second stage. Early decelerations were seen as well as acceleration-deceleration complexes. Overall, fetal heart tones were reassuring. Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty. Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck. There was no loop or coil of cord. Infant was vigorous female sex. Oropharynx was aggressively aspirated. Cord blood was obtained. Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue. Examination of the cervix did not reveal lacerations. Upper vaginal lacerations were not seen. Multiple first-degree lacerations were present. Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule. All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried. Post-approximation examination of the rectum showed smooth, intact mucosa. Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders. Nursing personnel will be notified of Gilbert's syndrome.


Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder.

TITLE OF OPERATION: ,1. Incision and drainage with extensive debridement, left shoulder.,2. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3. Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections. Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES: ,1. Deep extensive infection, left total shoulder arthroplasty.,2. Biceps tenosynovitis.,3. Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE: ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder. He was then placed Beach chair position and all bony prominences were well padded. Pillows were placed around his knees to protect his sciatic nerve. He was brought to the side of the table and secured with towels and tape. The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch. Left upper extremity was then prepped and draped in usual sterile fashion. Unfortunately, preoperative antibiotics were given prior to the procedure. This occurred due to lack of communication between the surgical staff and the anesthesia staff. The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped. Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made. The patient's had a cephalic vein, it was identified and protected throughout the case. It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible. The patient did have significant scar from this point on and did bleed from many surfaces throughout the case. As a result, he was transfused 1 unit postoperatively. He did not have any problems during the case except for one small drop of blood pressure. However this was due primarily because of the extensive scarring of his proximal humerus. He had scar between the anterior capsular structures and the conjoint tendon. Also there was significant scar between the deltoid and the proximal humerus. The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve. Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3. This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid. As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material. There was some suggestion of a synovitis type reaction also inside this cystic area. This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment. This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm. All of the mucinous material and fibrinous material was removed from the proximal humerus. This was fairly extensive debridement. All of this was sent to pathology and also sent for culture and sensitivity. It should be noted that Gram stain became as multiple white blood cells but no organism seen. The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it. There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous. This was also removed. Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever. It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever. As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion. The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps. It was tracked proximally and transverse ligament released. The biceps tendon was flat and somewhat erythematous. As a result, it released and tagged with an 0 Vicryl suture. It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures. The joint was then entered and noted significant synovitis throughout the entire glenoid. This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set. Unfortunately, this device would not hold the proximal humerus and we could not get the component to release. As a result, bone contact of the metal proximally was released using a straight osteotome. Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it. There was no cement. There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate. This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection. It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid. The glenoid component was very carefully dissected free and found to be very loose. It was essentially removed with digital dissection. There was no remaining cement in the cavity itself. The patient's glenoid was very carefully debrided. The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself. This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation. Rather than place a spacer, it was elected to use antiobiotic beads. This was with antibiotic impregnated cement with one package with 3 gram of vancomycin. These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region. These three did not have a Prolene attached to them. The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon. There was essentially no capsule left purely to close over the proximal humerus. It was electively the proximal humerus. A portion of bone intact because it did have some bleeding surfaces. Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and shoulder immobilizer. The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case. This was a significantly scarred patient which required extra dissection and attention. Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case. Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis. The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case. This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.

antibiotic beads
beads
biceps tenosynovitis
biomet
cemented
extensive debridement
glenoid
humerus
incision
incision and drainage
proximal
proximal humerus
rotator cuff tear
shoulder
shoulder arthroplasty
surgery
tendon
total shoulder arthroplasty
uncemented humeral
vicryl sutures


Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.

PREOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE: ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour. He was on a curve and lost control. He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding. There were no other injuries. He was treated in Kentucky. A close reduction was performed and splint applied. Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan. The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight. The patient showed up in the emergency department where a CT scan was asked to be performed. This was performed and reviewed. The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days. At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches. The patient was x-rayed in the office. He had lost some of his reduction. Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally. It appeared as an abduction type injury with minimal rotation. This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type. The syndesmosis appeared to be intact. This appeared as an AO type B fracture. However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted. CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner. A posterior Tillaux fragment appeared to be separate. However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient. He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness. We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan. We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery. We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness. Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly. We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions. We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally. He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula. We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction. He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space. With this, the patient understood that the hardware may necessitate removal as well in the future. We discussed hardware irritation. We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly. With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:, The patient was brought to operating theater and given successful general anesthetic. His right leg was prepped and draped in the usual fashion. Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction. It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up. However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue. The superficial peroneal nerve was seen and this was avoided. The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally. The fracture was seen. The fracture was elevated and medialized and de-rotated. The anterior portion of the distal fibula was significantly comminuted with defect. The posterior aspect was still intact. However, there were multiple fracture lines demonstrating a crush-type injury. This was reduced manually. At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon. No sharp dissection was performed. The posterior malleolar fragment was palpated with the distal fibula reduced. The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus. This was taken only through subcutaneous tissue. The saphenous vein was found, dissected out. Its branches were cauterized. Penrose drain was placed around this.,Dissection was undertaken. The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides. Next, the towel clip was used. Ends were freshened up using irrigation. The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws. Anatomic reduction was gained. X-rays were taken showing excellent anatomic reduction. Next, attention was drawn towards the fibula. Standard 6-hole one-third tubular plate was applied to this. Again, this was more of a transverse impacted fracture. Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction. Screws were placed. It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled. They were double-checked. Screws had excellent purchase and were tightened up. At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond. This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used. Finger was placed on this fragment and the pin was advanced even before the finger. X-ray views could show the posterior cortex and location of the pin. This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed. This was double checked to ensure good positioning and this was so. On the lateral view, we could see this was not in the joint. AP views and mortise views showed this was not in the joint. One could palpate this as well. The screw was placed slightly proximal to distal in the anteroposterior plane. At the distal tip of it, it was just in the subchondral bone but not in the joint. There was slight to excellent purchase of this posterior lateral fragment. Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin. Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage. Posterior splint was placed on the patient. The patient's leg was placed in neutral position. Significant amount of cast padding were used and large bulky trauma ABD type dressings. The heel was padded and leg was padded with approximately 2 inches of padding. Tourniquet was deflated. The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications. Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied. Positioning of the leg was accomplished by the physician assistant. As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue. The patient is expected to do well overall. He does have an area of comminution shown on the CT scan. However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment. Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.


She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.

DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated. Membranes ruptured this morning by me with some meconium. An IUPC was placed. Some Pitocin was started because the contractions were very weak. She progressed in labor throughout the day. Finally getting the complete at around 1530 hours and began pushing. Pushed for about an hour and a half when she was starting to crown. The Foley was already removed at some point during the pushing. The epidural was turned down by the anesthesiologist because she was totally numb. She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping. She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed. With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance. Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly. The placenta separated with some bleeding seen and was assisted expressed and completely intact. Uterus firmed up well with IV pit. Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural. Once this was complete, mom and baby doing well. Baby was a female infant. Apgars 8 and 9.


Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.

PREOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1. Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2. Sharp excision of left distal foot plantar fascia.,ANESTHESIA:, None required.,INDICATIONS:, The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation. She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:, The procedure was performed in the patient's room. The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound. Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided. There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure.

amputation
cellulitis
debridement
foot
foot ulcer
interosseous
joint capsule
metatarsal
osteomyelitis
plantar
plantar fascia
plantar fascitis
ray amputation
surgery


HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X. This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:, She was admitted. She was 3 cm dilated on admission. She desired induction of labor. Therefore, Pitocin was started. Epidural was placed for labor pain. She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy. She remained febrile, approximately 100.3. She then progressed. On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated. She had reported previously some mucous discharge with no ruptured membranes. Upon my exam, no membranes were noted. Attempted artificial rupture of membranes was performed. No fluid noted and there was no fluid discharge noted all the way until the time of delivery. Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor. She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:, Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise. Placenta delivery spontaneous. Condition was intact with a three-vessel cord. Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration. These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively. Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal. Apgars were 0 and 0. Weight pending at this time.,NARRATIVE OF DELIVERY:, I was called. This patient was completely dilated. I arrived. She pushed for three contractions. She was very comfortable. She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant. There was a tight nuchal cord x1 that was reduced after delivery of the fetus. Cord was doubly clamped. The infant was transferred to a bassinet cleaned by the nursing staff en route. The placenta delivered spontaneously, was carefully examined, found to be intact. No signs of abruption. No signs of abnormal placentation or abnormal cord insertion. The cord was examined and a three-vessel cord was confirmed. At this time, IV Pitocin and bimanual massage. Fundus firm as above with minimal postpartum bleeding. The vagina and perineum were carefully inspected. A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture. At this time, the repair is intact. She is hemostatic. All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time. We have called pastor in to baptize the baby as well as calling social work. They are deciding on a burial versus cremation, have decided against autopsy at this time. She will be transferred to postpartum for her recovery. She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise. I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.

cord
decreased fetal movement
delivery
delivery note
dilated
fetal
fetal demise
fetal position
intrauterine
labor pain
lacerations
preterm labor
spontaneous
surgery
vaginal delivery


Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.

decompression
decompressive
decompressive laminectomy
facetectomies
kerrison rongeur
laminectomy
leksell rongeur
nerve roots
pedicle
pedicle screws
posterolateral fusion
process
rods
screws
spinous
spinous process
surgery
synthes click'x system
thecal sac
transverse processes


Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area. Pannus and left peritoneal specimen sent to Pathology.

PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:, Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:, Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,ANESTHESIA:, General.,FLUIDS:, 800 cc given.,ESTIMATED BLOOD LOSS: ,350 cc.,SPECIMEN,: Pannus and left peritoneal specimen sent to Pathology.,REASON FOR PROCEDURE:, This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin. The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control. He has had a groin abdominal wound drained for about four days. The patient states that there has been pus that has saturated his sheath. He has had a possible fever at home that he did not chart with a thermometer. He has had the same groin infection twice in the past with tunneling lesions. The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day. Bowel habits and eating were essentially normal.,Urinary habits were normal. The patient is morbidly obese and is approximately 450 lb. He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,PAST MEDICAL HISTORY:, Diabetes, morbid obesity, and nephrolithiasis.,PAST SURGICAL HISTORY:, Appendectomy and stone extraction.,PROCEDURE: , The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture. The patient had a white count of 11.4 and a hemoglobin of 13.4. Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products. The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted. In the operative suite, he was prepped and draped in the usual sterile fashion. The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen. Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized. Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis. Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated. The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards. The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis. The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia. The necrotic tissue was lifted out of the abdomen. All bleeding was cauterized using the Bovie. A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned. A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing. The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm. The tissue was incised to the muscle layer of the muscle. There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well. There was a mild amount of pus that drained from the wound. Cultures were taken from the groin wound and were sent to pathology. The specimen was excised using traction with the Allis clamps as well as Bovie set on coag. Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit. After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.,It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date. The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology. The patient tolerated the procedure well and was taken to recovery in good condition.

abdomen
debridement
groin
infection
necrotic tissue
necrotizing
necrotizing infection
pannus
pathology
peritoneal
surgery
tissue
wound


DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,

PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name: Sigma.,Model #: SDR203.,Serial #: 123456.,ATRIAL LEAD,Model #: 4568-45 cm.,Serial #: 123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #: 4068-52 cm.,Serial #: 123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.,Again, thank you for allowing to participate in this care.


Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.

PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,3. Hemoperitoneum.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Right salpingectomy.,4. Lysis of adhesions.,5. Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:, Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile. No adnexal masses, however, were appreciated on the bimanual exam. Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus. There were also adhesions to the left fallopian tube and the right fallopian tube. There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood. There was some questionable gestational tissue ________ on the left sacrospinous ligament. There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:, After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. A weighted speculum was then placed in the vagina. The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology. At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed. Next, attention was then turned to the abdomen. The surgeons all are removed the dirty gloves in the previous portion of the case. Next, a 2 cm incision was made immediately inferior to umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision. Next, a syringe was used to inject normal saline into the Veress needle. The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting. The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting. The abdomen was insufflated to an adequate distension. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted. Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera. A Veress needle and a step sheath were inserted through this incision. Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization. Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion. A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization. The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes. Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen. Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port. Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy. An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy. This was then sent to the pathology. Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic. The abdomen was further irrigated. The liver was examined and appeared to be within normal limits. At this point, the two size #5 ports and a size #12 port were removed under direct visualization. The camera was then removed. The CO2 gas was disconnected and the abdomen was desufflated. The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit. All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion. They were then steri-stripped and bandaged appropriately. At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She was discharged home with a postoperative hemoglobin of 8.9. She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain. She will follow up within a week in the OB resident clinic.

abdomen
bimanual exam
cervix
curettage
d&c
dilation
ectopic
ectopic pregnancy
fallopian tube
hemoperitoneum
laparoscopy
lysis of adhesions
pelvic pain
pregnancy
salpingectomy
surgery
tube
umbilicus
veress needle


PREOPERATIVE DIAGNOSIS:, Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:, Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field. The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin). The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. The lateral compartment appeared contractile. The anterior compartment appeared necrotic for most of the muscle in the compartments. What appeared viable was left intact. A vacuum-assisted closure system was utilized on each fasciotomy wound. Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there. This was included in the VAC seal, as well as the traumatic wound. A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded. He tolerated the procedure well, was taken to the recovery room in good condition.

accident
anterior
anterior compartment
assisted closure systems
closure systems
compartment
contractile
debridement of muscle
debridement of wound
debridements
fasciotomies
fasciotomies debridement
fasciotomy
fasciotomy wounds
lateral compartments
left lower extremity
lower extremity
motorcycle
muscle
polytrauma
status post motorcycle accident
surgery
traumatic
traumatic wound
vacuum
vacuum assisted
vacuum assisted closure
vacuum assisted closure systems
vacuum-assisted closure systems
wound
wound fasciotomies


Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.

PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Right ruptured tubal pregnancy.,2. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain. She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900. Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis. It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted. There were no adnexal masses appreciated although there was some fullness in the right lower quadrant. The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary. There were some pelvic adhesions in the right abdominal wall as well. The left fallopian tube and ovary and uterus appeared normal. There was no evidence of endometriosis. There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position. The bimanual exam was performed, which revealed the above findings. A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated using Hank dilators up to a #10. A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue. The tissue was sent to pathology for evaluation. The uterine elevator was then placed in the patient's cervix. Gloves were changed. The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made. While tenting up the abdominal wall, the Veress needle was placed without difficulty. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 step trocar was then placed without difficulty in abdominal wall. The placement was confirmed with a laparoscope. It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents. The above findings were then noted. Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen. A #12 step trocar port was placed under direct visualization. Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers. This was removed with the gallbladder grasper through the right lateral port site. There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached. Partial salpingectomy was therefore performed. This was done using the LigaSure. The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected. Good hemostasis was obtained in all of the right adnexal structures. The pelvis was then copiously suction irrigated. The area again was then visualized and again found to be hemostatic. The instruments were then removed from the patient's abdomen under direct visualization. The abdomen was then desufflated and the #11 step trocar was removed. The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips. The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well. The sponge, lap, and needle count were correct x2. She will follow up postoperatively as an outpatient.

abdominal wall
ectopic pregnancy
laparoscopy
lower quadrant mass
pelvic adhesions
pregnancy
salpingectomy
surgery
tubal pregnancy


Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. Carpal tunnel release and de Quervain's release. A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.

PREOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1. Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat. The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat. The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl. Care was taken to avoid entrapping the motor branch of the median nerve in the suture. A hemostat was placed under the repair to ensure that the median nerve was not compressed. The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip. Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches. I released the compartment in a separate subsheath for the EPB on the dorsal side. Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl. It was checked to make sure that there was significant room remaining for the tendons. This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers. Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed. The patient was sent to the recovery room in good condition, having tolerated the procedure well.

aponeurosis
carpal
carpal tunnel syndrome
cut
de quervain's release
incision
surgery
tenosynovitis
tunnel


Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.

PREOPERATIVE DIAGNOSIS:, Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2. Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid. Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected. Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve. I then incised it under direct vision dorsal to its axis and incised it both proximally and distally. The EPB subsheath was likewise released.,I irrigated the wound thoroughly. In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position. I did this with 3-0 Vicryl. I then passed an instrument underneath to check and make sure that the sheath was not too tight. I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately. The patient was sent to the recovery room in good condition, having tolerated the procedure well.

de quervain
de quervain release
dorsal
dorsal compartment
fascial lengthening flap
sheath
surgery
tenosynovitis
tourniquet
wrist


Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.

PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Enterolysis.,4. Lysis of the pelvic adhesions.,5. Left salpingo-oophorectomy.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:, None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions. Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 12 cm. The cervix was then serially dilated with Hank dilators to a size #20 Hank. Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum and weighted speculum were removed. Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision. Small amount of normal saline was injected into Veress needle and seemed to drop freely. So, the Veress needle was connected to he CO2 gas, which was started at the lower setting. It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. The abdomen was then insufflated to an adequate distention. Next, the Veress needle was removed and a size #11 step trocar was inserted. Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas. At this point, the initial operative findings were seen. Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization. A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. These were used to see the above operative findings. Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. Care was taken at all times to avoid the bowel and the ureters. The fallopian tubes appeared massively scarred and completely obliterated from disease. After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel. At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. Next, the needle was removed and the ligature device was inserted. This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. Then, the attention was turned to the inferior aspect of the ovary. First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. This was grasped with a clamp. The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port. The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant. Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. At this point, the remaining two size #5 ports were removed under direct visualization. The camera was removed and the abdomen was desufflated. Next, an introducer was replaced on a #11 port. The #11 port was removed. Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle. Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.


D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining. 6. Grade 1+ rectocele.

PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,6. Grade 1+ rectocele.,PROCEDURE PERFORMED: ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery. She has heavy periods lasting 7 to 14 days with spotting in between her periods. The patient's uterus is 12.2 x 6.2 x 5.3 cm. Her endometrial thickness is 2 cm. Her adnexa is within normal limits. The patient and I had a long discussion. Consent was reviewed in layman's terms. The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery. Questions were answered. The patient was taken back to the operative suite. The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position. The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities. The patient's history is that she is at risk for development of condyloma. The patient's husband was found to have a laryngeal papillomatosis. She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation. Her uterus appears to be mobile by 12-week size. There is a good descend. There appears to be no adnexal abnormalities. Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis. The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens. The patient underwent hysteroscopy. The outflow valve was opened at all times. The inflow valve was opened just to achieve appropriate distension. The patient did have no evidence of trauma of the cervix. No Trendelenburg as we were in room #9. The patient also had the bag held two fingerbreadths above the level of the heart. The patient was seen. There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature. The patient also has one in the fundal area. The thickened tissue was removed via sharp curettage. Therefore, we reinserted the hysteroscope. It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed. The patient's procedure was ended with specimen being obtained and sent to Department of Pathology. We will follow her up in the office.

abnormal uterine bleeding
bleeding
d&c
endometrium
enlarged fibroid uterus
fibroid
hypermenorrhea
hysteroscopy
intermenstrual
intermenstrual spotting
pelvic examinatio
surgery
thickened endometrium
uterine
uterus