Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.

PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1. Open reduction internal fixation of the talus.,2. Medial malleolus osteotomy.,3. Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:, 50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:, A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament. There was no evidence of osteochondral defects of the talar dome.,HISTORY: ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply, the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03. A spinal anesthetic was administered. A nonsterile tourniquet was placed on the left upper thigh, but not inflated. He was then positioned on the beanbag. The extremity was then prepped and draped in the usual sterile fashion for this procedure. An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg. At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site. At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus. This was curved anteromedial along the root of the saphenous vein. The saphenous vein was located. Its tributaries going plantar were cauterized and the vein was retracted anterolaterally. At this time, we identified the medial malleolus. There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus. This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem. It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact. This pedicle was the anterior portion of the deltoid ligament. At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus. Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply. This provided us with excellent exposure to the fracture site of the medial side. At this time, any loose comminuted pieces were removed. The dome of the talus was also checked and did not reveal any osteochondral defects. There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site. It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site. At this time, a reduction was performed. The #7-0 partially threaded cannulated screws were used in order to fix the fracture. At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site. Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in. A depth gauze was then used to measure screw length. A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw. A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site. Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction. This projection gave us excellent view of our screw placement and excellent compression across the fracture site. At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft. This was placed using a freer elevator into the fracture site where the comminution was. At this time, we copiously irrigated the wound. The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps. Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws. Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury. A tight repair was performed of the deltoid ligament. At this time, again copious irrigation was used to irrigate the wound. A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision. At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied. The patient was then placed in a plaster splint for mobilization. The tourniquet was then released. The patient was then transferred off the operating table to recovery in stable condition. The prognosis for this fracture is guarded. There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk. The patient is aware of this and he will be followed as an outpatient for this problem.

open reduction internal fixation of the talus


Orchiopexy & inguinal herniorrhaphy.

OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating room table. The patient was prepped and draped in usual sterile fashion. An incision was made in the groin crease overlying the internal ring. This incision was about 1.5 cm in length. The incision was carried down through the Scarpa's layer to the level of the external oblique. This was opened along the direction of its fibers and carried down along the external spermatic fascia. The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free. A hernia sac was identified and the testicle was located. Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring. This was performed by incising the transversalis fascia circumferentially. The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity. Care was taken not to injure the testicular vessels. Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance. The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high. This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum. The testicle was viable. This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum. A small 1 cm incision was made in the anterior superior scrotal wall. Dissection was carried down through the dartos layer. A subdartos pouch was formed with blunt dissection. The hemostat was then pushed against the tissues and this tissue was divided. The hemostat was then passed through the incision. A Crile hemostat was passed back up into the inguinal canal. The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision. The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle. The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture. Benzoin and a Steri-Strip were placed. Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly. This was done with 2 to 3 interrupted 3-0 silk sutures. The external oblique was then closed with interrupted 3-0 silk suture. The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch. Benzoin and Steri-Strip were applied. The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.

: 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.


Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.

PREOPERATIVE DIAGNOSES:,1. Displaced intraarticular fracture, right distal radius.,2. Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1. Displaced intraarticular fracture, right distal radius.,2. Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1. Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2. Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago. This was an intraarticular four-part fracture that was displaced dorsally. In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop. She is admitted for reconstructive operation. The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:, The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia. Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner. Tourniquet was placed around the right upper extremity. The upper extremity was then elevated and exsanguinated using an Esmarch dressing. The tourniquet was elevated to 250 mmHg. The entire operation was performed with 4.5 loop magnification. At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally. This was carried down to the flexor carpi radialis, which was then retracted ulnarly. The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles. The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin. It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced. This was an intraarticular four-part fracture. Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced. Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece. A third K-wire was then drilled from the volar radial to the dorsal ulnar piece. The fracture was then manipulated. The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it. Further K-wires were then placed through the radial styloid into the proximal fragment. A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires. At this time, the distal screws were then placed. The distal screws were the small screws. These were non-locking screws, all eight screws were placed. They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth. Again, these were 18-20 mm screws. After placing three of the screws it was necessary to remove the K-wires. There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture. After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit. The screws were then placed. These were 12 mm screws. They were placed 4 in number. The K-wires were then removed. Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist. This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure. It was dissected free from the structure out to its trifurcation. The motor branches seen entering the thenar fascia and obstructed. The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm. In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon. Incisions were then copiously irrigated with normal saline. Homeostasis was maintained with electrocautery. The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion. A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position. The tourniquet was let down. The fingers were immediately pink. The patient was awakened and taken to the recovery room in good condition. There were no operative complications. The patient tolerated the procedure well.

carpal
carpal ligament
carpal tunnel
carpal tunnel release
carpal tunnel syndrome
carpi radialis
esmarch
flexion crease
flexor carpi
flexor carpi radialis
flexor pronator muscles
intraarticular
intraarticular fracture
k-wires
open reduction and internal fixation
pronator quadratus
right distal radius
surgery
tourniquet
transverse carpal ligament
volar
volar flexion crease


Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.

PREOPERATIVE DIAGNOSIS: ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum. Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses. There is a hernia on the left side. The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table. General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically. A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision. An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia. External ring was exposed with dissection as well. The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal. The testes were freed with dissection by removing cremasteric and spermatic fascia. The hernia sac was separated from the cord, twisted and suture ligated at the internal ring. Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring. However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided. This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel. The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures. The skin was approximated with interrupted #5-0 chromic catgut sutures. Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good. Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture. Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion. However, on this side, there was no inguinal hernia. The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side. The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure. Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision. The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition. Instrument and sponge counts were correct. There were no apparent complications. Estimated blood loss was less than 20 to 30 mL.

bilateral orchiopexy
bilateral undescended testes
canal
cord
dartos pouch
inguinal canal
inguinally
internal ring
orchiopexy
prentiss maneuver
scrotal incisions
spermatic
spermatic cord
subcutaneous tissues
surgery
testes
ultrasound
undescended
undescended testes
vicryl


PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours.

c-arm
depo-medrol
die-punch
distal
distal radial ulnar joint
distal radius
fracture
frykman
intra-articular
jones-type dressing
kantrex
lidocaine
marcaine
open reduction and internal fixation
orif
pronator quadratus
radial
radial styloid
radial ulnar joint
screws
surgery
ulnar styloid


Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.

PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.


PREOPERATIVE DIAGNOSIS: , Right undescended testis (ectopic position).,POSTOPERATIVE DIAGNOSES:, Right undescended testis (ectopic position), right inguinal hernia.,PROCEDURES: , Right orchiopexy and right inguinal hernia repair.,ANESTHESIA:, General inhalational anesthetic with caudal block.,FLUIDS RECEIVED: ,100 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS:, No tissues sent to pathology.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION: ,The patient is an almost 4-year-old boy with an undescended testis on the right; plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room; surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. He was then placed in the supine position and sterilely prepped and draped. Since the testis was in the ectopic position, we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery. Electrocautery was also used for hemostasis. A subdartos pouch was then created with a curved tenotomy scissors. The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments. As we were dissecting it, we then found the testis itself into the sac, and we opened the sac, and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment, not being attached to the top. We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps. Once this was dissected off, we then twisted it upon itself, and then dissected it down towards the external ring, but on traction. We then twisted it upon itself, suture ligated it with 3-0 Vicryl and released it, allowing it to spring back into the canal. Once this was done, we then had adequate length of the testis into the scrotal sac. Using a curved mosquito clamp, we grasped the base of the scrotum internally, and using the subcutaneous tissue, we tacked it to the base of the testis using a 4-0 chromic suture. The testis was then placed into the scrotum in the proper orientation. The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic. The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic, and Dermabond tissue adhesive was used on the incision. IV Toradol was given. Both testes were well descended in the scrotum at the end of the procedure.

caudal block
curved mosquito clamp
dissected
ectopic position
gubernacular attachments
hernia
hernia repair
hernia sac
inguinal
inguinal hernia
inguinal hernia repair
orchiopexy
surgery
testis
testis ectopic position
tunica vaginalis
undescended testis


PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:, Left undescended testis plus left inguinal hernia.,PROCEDURES:, Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:, A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:, Sponge and needle counts were correct x2.,SPECIMENS,: No tissues sent to Pathology.,ANESTHESIA:, General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left. The plan is for repair.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped. A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue. We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring. We were able to dissect all the way up to the ring, but were unable to get the testis delivered. We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia. The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors. The testis itself was quite high up in the upper canal. We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors. Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture. We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length. We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off. We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum. The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch. The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture. The testis was then placed into the scrotum in the proper orientation. We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well. We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure. The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure. Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure. The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.

cord length
dissected
epididymal attachment
external oblique fascia
external ring
fascia
hernia
hernia repair
ilioinguinal nerve
ilioinguinal nerve block
inguinal
inguinal hernia
inguinal hernia repair
inguinal incision
nerve block
scarpa fascia
surgery
testis
undescended testis


Right undescended testicle. Orchiopexy & Herniorrhaphy.

PREOPERATIVE DIAGNOSIS:, Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:, Right undescended testicle.,OPERATIONS:,1. Right orchiopexy.,2. Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis. The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding. The testis was identified right at the external inguinal ring. The testis was unable to be brought down into the scrotal sac. The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown. Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed. Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed. The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in the inguinal and scrotal area. After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal. The incision came through the subcutaneous tissue and external oblique fascia was identified. The external oblique fascia was opened sharply and was taken all the way down towards the external ring. The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture. After dissecting proximally, the testis was identified in the distal end of the inguinal canal. The testis was pulled up. The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring. There was very small hernia, which was removed and was tied at the base. PDS suture was used to tie this hernia sac all the way up to the base. There was a Y right at the vas and cord indicating there was enough length into the scrotal sac. The testis was easily brought down into the scrotal sac. One centimeter superior scrotal incision was made and a Dartos pouch was created. The testicle was brought down into the pouch and was placed into the pouch. Careful attention was done to ensure that there was no torsion of the cord. The vas was medial all the way throughout and the cord was lateral all the way throughout. The epididymis was in the posterolateral location. The testicle was pexed using 4-0 Vicryl into the scrotal sac. Skin was closed using 5-0 Monocryl. The external oblique fascia was closed using 2-0 PDS. Attention was drawn to re-create the external inguinal ring. A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord. Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia. After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion. Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable. It was smaller than the other side, probably by 50%. There were no palpable testicular masses. Plan was for the patient to follow up with us in about 1 month. The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours. No tub bath for 2 months. The patient and family understood all the instructions.

external oblique fascia
herniorrhaphy
inguinal
inguinal ring
oblique fascia
orchiopexy
orchiopexy & herniorrhaphy
scrotal sac
surgery
testicle
undescended testicle


Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess.

PREOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA: ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA. The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology. The patient states that this was started approximately 24 hours ago. The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain. The patient admits to poor dental hygiene. Denies any recent or dental abscesses in the past. The patient is a substance abuser, does admit to smoking cocaine approximately three days ago. The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted. After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE: ,The patient was brought in upright and supine position. Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side. This was done at the base of #18, #19, and #20 teeth. After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control. After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed. There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination. The patient understood consequences of her actions. Does state that she does not care at this time and just wants to be left alone. At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin. The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.

abscess
buccogingival
cellulitis
drainage
facial cellulitis
fna
i&d
incision and drainage
odontogenic
odontogenic abscess
surgery


PREOPERATIVE DIAGNOSIS:, Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUID RECEIVED: ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:, The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:, Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring. Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis. The plan is for evaluation and repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. The patient was placed in supine position and examined. The left testis well within scrotum. The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped. An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage. We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl. We entered the peritoneum with the 5-mm one-step system. We then used the short 0-degree lens for laparoscopy. We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg. There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found. Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures. Then skin was closed with subcutaneous closure of 4-0 Rapide. A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery. Electrocautery was used for hemostasis. A curved tenotomy scissor was used to open the sac. The tunica vaginalis was visualized and grasped and then dissected up towards external ring. There was no apparent testicular tissue. We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent. We then closed the subdartos area with the subcutaneous closure of 4-0 chromic. We then did a similar curvilinear incision on the left side for testicular fixation. Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age. We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum. At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure. The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.

caudal block
diagnostic laparoscopy
laparoscopy
orchiectomy
scrotum
subcutaneous closure
surgery
testicular
testis
testis fixation
undescended testis


Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.

TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. Recommendation was for an Ommaya reservoir. Risks and benefits have been explained. They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS: ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest. The right frontal region was prepped and draped in the usual sterile fashion. Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line. Once this was completed, a burr hole was then created with a high-speed burr. The dura was then coagulated and opened. The Ommaya reservoir catheter was inserted up to 6.5 cm. There was good flow. This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision. This was then cut and __________. It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies. Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin. The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.

caprosyn
chemotherapy
intrathecal
leukemia
leukemic
leukemic meningitis
meningeal
meningitis
ommaya
ommaya reservoir
surgery


Left orchiopexy. Ectopic left testis. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.

PREOPERATIVE DIAGNOSIS:, Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General. The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle. The risks, benefits, and alternatives of the proposed procedure were discussed with the patient. Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS: ,The patient did receive Ancef antibiotics prior to the procedure. He was then wheeled to the operative suite where a general anesthetic was administered. He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure. Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region. The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery. The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors. This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord. With this accomplished, the testis was then identified. It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord. Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens. Weitlaner retractor was placed to provide further exposure. There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl. Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis. Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment. This was taken down to approximately the two-thirds length of the left scrotal compartment. Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision. A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment. Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors. A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision. A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord. With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis. The sutures were then tied creating the orchiopexy. The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures. Once again hemostasis was maintained with Bovie electrocautery. Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures. External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad. Once this was created, the created ring was inspected and there was adequate room for the cord. There appeared to be no evidence of compression. Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion. The patient had been injected with bupivacaine prior to closing the skin. Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum. He will follow up with Dr. X in 10 to 14 days. Appointment will be made.

bovie electrocautery
cord
dartos
dartos pouch
ectopic
ectopic left testis
ectopic testis
metzenbaum scissors
orchiopexy
pubic tubercle
scrotal
surgery
testis


Bilateral scrotal orchiectomy

BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,: The patient is placed in the supine position, prepped and draped in the usual manner. Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision. Hemostasis was obtained with the Bovie and the spermatic cord was identified. It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief. The left testicle was delivered through the same incision. The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine. The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin. A dry sterile dressing fluff and scrotal support applied over that. The patient was sent to the Recovery Room in stable condition.


Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.

PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1. Incision and drainage, left elbow.,2. Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION: ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage. He was then scheduled for I&D and excision of the bursa. Risks and benefits were discussed. No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine. The left upper extremity was prepped and draped in standard sterile fashion. On examination of the left elbow, there was presence of thickening of the bursal sac. There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted. An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin. The incision was carried proximally and distally. The olecranon bursa was significantly thickened and scarred. Excision of the olecranon bursa was performed. There was significant evidence of thickening of the bursa with some evidence of adhesions. Satisfactory olecranon bursectomy was performed. The wound margins were debrided. The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution. There was no evidence of a loose body. There was no bleeding or drainage. After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion. The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient tolerated the procedure very well. He was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noticed.

bursa
drainage
elbow
excision
incision and drainage
infected olecranon
olecranon
olecranon bursa
olecranon bursitis
surgery
wound


Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.

PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:, Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:, The patient has had a longstanding history of foot problems. The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care. The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed. The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain. All questions were thoroughly answered. The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities. The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE: ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure. The patient was brought to the operating room and placed in the supine position. Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected. The lower extremity was prepped and draped in the usual sterile manner. Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot. The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band. A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel. Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band. The lateral plantar fascial band was left intact. Visualization and finger probe confirmed adequate transection. The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples. The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression. The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact. A walker boot was dispensed and applied. The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days. The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions. After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.

anesthesia
band
fascia
fascial
fasciotomy
foot
plantar
plantar fascial
plantar fascial band
plantar fasciitis
plantar fasciotomy
surgery


Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.

PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: ,Gallbladder.,BRIEF HISTORY: ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture. The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department. Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure. The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain. During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder. The patient did well postdrainage. The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp. However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003. A HIDA scan had been performed, which showed no cystic duct obstruction. A tube cholecystogram was performed, which showed no cystic or common duct obstruction. There was abnormal appearance of the gallbladder, however, the pathway was patent. Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy. Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS: ,The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family. The patient was brought to the operating room after an epidural was performed per anesthesia. Local anesthesia was given with 1% lidocaine. A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel. Next, hemostasis was obtained using electro Bovie cautery. Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel. Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered . The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view. Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified. The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors. The cystic duct was identified. A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors. The gallbladder was then removed from the liver bed using electro Bovie cautery. A plane was created. The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel. The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections. Permanent sections are still pending. The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen. The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.

acalculous cholecystitis
acute acalculous
bovie cautery
cholecystectomy
cholecystitis
cystic
cystic duct
fascia
gallbladder
hemorrhagic
liver bed
metzenbaum scissors
open cholecystectomy
rectus fascia
serosal
surgery


Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.

PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was then placed in a modified lithotomy position taking great care to pad all extremities. TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis. Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg. A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 4 other 10/11 mm trocars were placed. Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line. All of the trocars were placed without difficulty. The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula. The gastrohepatic ligament was then identified and incised in an avascular plane. The dissection was carried anteromedially onto the phrenoesophageal membrane. The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice. This incision was extended to the right to allow identification of the right crus. Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus. The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve. This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus. At its left border, the left crus was identified. The dissection plane between it and the left aspect of the esophagus was freed. The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch. By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch. This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel. This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade. The esophagus was lifted by a Babcock inserted through the left upper quadrant port. Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall. Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus. A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus. The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired. Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve. With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left. It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap. The,52-French bougie was used to calibrate the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.

antireflux
esophagus
fundoplication
gastric pouch
insufflation
ligament
nissen
nissen fundoplication
penrose
phrenoesophageal membrane
surgery
trocars
umbilicus


Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy

PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2. Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure. The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region. This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease. The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion. The area was dressed with antibiotic ointment and then a Peri-Pad. The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes. Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex. Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized. Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple. At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple. When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft. At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola. At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic. The areolar skin graft was pie crusted. Then, at this point, the area of areola was dressed with silicone gel sheeting. A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position. Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made. The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out. When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision. Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola. The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.

areolar
areolar reconstruction
breast
breast asymmetry
breast cancer
frog-leg position
full-thickness skin graft
general endotracheal
general endotracheal anesthesia
graft
mastopexy
nipple
nipple areola
nipple areolar complex
nipple areolar reconstruction
nipple flap
peri-pad
prepped and draped
skin graft
surgery
surgi-bra
transverse mastopexy


PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient underwent general anesthesia with endotracheal intubation. An orogastric was placed and a Foley catheter placed. He was placed in a modified flank position with the hips rotated to 45 degrees. Pillow was used to prevent any pressure points. He was widely shaved, prepped, and draped. A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus. The incision was made through the premarked site through the skin and subcutaneous tissue. The aponeurosis of the external oblique was incised in the direction of its fibers. Muscle-splitting incision was made in the internal oblique and transversus abdominis. The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring. Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions. Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially. This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava. Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed. The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery. The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device. After the arteries had been divided, the renal vein was divided again using a stapling device. The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed. Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel. Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion. The estimated blood loss was negligible. There were no complications. The patient tolerated the procedure well and left the operating room in satisfactory condition.

endotracheal
foley catheter
gerota fascia
laparoscopic
muscle-splitting incision
nephrectomy
orogastric
pneumo
pneumo sleeve
radical
renal
renal fossa
renal mass
right lower quadrant
surgery
trocar
umbilicus
vena cava


Transplant nephrectomy after rejection of renal transplant

PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago. The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction. Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed. The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space. The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space. During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved. The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed. The ureter was encountered during the course of resection, but was not ligated. The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS: 900 mL.

blake drain
iliac artery
ilioinguinal
immunosuppression
kidney
kidney function
nephrectomy
nephrostomy tube
rejection
renal
renal transplant
retroperitoneal
retroperitoneal space
surgery
toxic
transplant
ureter
vein


PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.

discectomy
epidural
epidural fibrosis
foramen
needle
nerve root
nerve root decompression
nerve root entrapment
neural foramen
neuroplasty
surgery
transforaminal
transforaminal neuroplasty


Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.

PREOPERATIVE DIAGNOSIS:, Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2. 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1. Repair of nerve and tendon, right ring finger.,2. Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME: ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION: ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle. The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well. The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room and placed in the supine position. All bony prominences were adequately padded. Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time. The right upper extremity was prepped and draped in the usual sterile fashion. The hand was inspected. Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture. The sutures were removed and the wound was explored. It was found that the ulnar digital neurovascular bundle was 100% transected. The radial neurovascular bundle on the right ring finger was found to be completely intact. We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP. We copiously irrigated the wound. Repair was undertaken of the FDS with #3-0 undyed Ethibond suture. The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact. Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair. Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury. The digital nerve was dissected proximally and distally to likely visualize the nerve. The nerve was then approximated using microvascular technique with #8-0 nylon suture. The hands were well approximated. The nerve was not under undue tension. The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture. Sterile dressing was placed and a dorsal extension Box splint was placed. The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition. Overall prognosis is good.

bundle
digital
digital laceration
fds
finger
flexor
flexor digitorum
flexor tendon
injury
laceration
nerve
neurovascular
neurovascular bundle
repair
ring
surgery
tendon
ulnar
ulnar slip
volar laceration


Laparoscopic right partial nephrectomy due to right renal mass.

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:, 250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter. I had a long discussion with him concerning variety of options. We talked in particular about extirpated versus ablative surgery. Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically. All questions were answered, and he wished to proceed with surgery as planned. Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table. After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest. All pressure points were carefully padded, and he was securely taped to the table. Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia. His abdomen was then prepped and draped in a standard surgical fashion. Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube. The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident. We then placed a Visiport 10 x 12 trocar in the right lateral abdomen. With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization. We placed three additional trocars. An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt. The colon was reflected medially, and the retroperitoneum was exposed on that side. This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial. With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver. The ureter and gonadal vein were identified on the right side and elevated. The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum. Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs. The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally. A cap of fat was left overlying this mass. Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated. Based on this finding, I decided to go ahead and clamp the renal hilum during resection. A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc. Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum. With the renal hilum clamped, we did resect the tumor using cold scissors. There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion. We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section. With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning. We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure. We then released the vascular clamp. Total clamp time was 11 minutes. There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp. We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning. A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon. The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm. It was evaluated on the table and passed off the table for Pathology to evaluate. They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor. In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma. Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia. We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis. Any bleeding points were controlled primarily using bipolar cautery or hemoclips. The area was copiously irrigated with normal saline. The colon was then replaced into its normal anatomic position. The mesentry was evaluated. There were no defects noted. We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl. All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar. The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion. Benzoin and Steri-Strips were placed. The patient was returned in supine position and awoken from general anesthetic without incident. He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring. At the end of the case, sponge, instrument, and needle counts were correct. I was scrubbed and present throughout the entire case.

bulldogs
endotracheal
foley
foley catheter
gerota fascia
gonadal vein
hilum
jp drain
kidney
kocher maneuver
laparoscopic
ligasure device
nephrectomy
partial nephrectomy
renal
renal hilum
renal mass
renal parenchyma
resection
satinsky
satinsky clamp
surgery
toldt
urethra
vicryl sutures


Laparoscopic right radical nephrectomy due to right renal mass.

PREOPERATIVE DIAGNOSIS:, Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:, Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:, 100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA: ,General endotracheal.,DRAINS:, 16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass. This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma. I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy. All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:, After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table. Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia. After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest. All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure. Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage. The abdomen was insufflated in the right outer quadrant. Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy. The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident. We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus. Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed. Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar. There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt. This exposed the retroperitoneum on the right side. The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only. We then identified the ureter and gonadal vein in the retroperitoneum. The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum. Sequential packets of tissue were taken using primarily the LigaSure Atlas device. Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins. We proceeded then and skeletonized the structures into four individual packets. We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland. The adrenal was spared during this procedure. There was no contiguous connection between the renal mass and a right adrenal gland. This plane of dissection was taken down primarily using the LigaSure device. We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring. Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments. The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected. The kidney was then freed within the retroperitoneum. A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction. We extended the lower most trocar site approximately 6 cm to facilitate extraction. The kidney was removed and passed off the table as a specimen for pathology. This was bivalved by pathology, and we reviewed the specimen.

abdomen
carter thomason
carter thomason closure
carter thomason closure device
carter-thomason
endocatch bag
endotracheal
foley catheter
gi stapler
kidney
laparoscopic
laparoscopic right radical nephrectomy
laparoscopic scissors
ligasure
nephrectomy
oncocytoma
radical
radical nephrectomy
renal
renal hilum
renal mass
screw-type trocar
surgery
toldt
umbilicus
upper pole
urethra