PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate. Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Injury to the adjacent viscera.,6. Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room. Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty. The patient was shaved, prepped, and draped using the usual sterile technique. A sterile 16-French Foley catheter was then placed with clear urine drained. A midline infraumbilical incision was performed by using a #10 scalpel blade. The rectus fascia and the subcutaneous space were opened by using the Bovie. Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly. A Bookwalter retractor was then placed. The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected. Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy. The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors. Opening was enlarged by using sharp dissection. Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device. The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures. The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion. With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie. Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors. The urethra could then be easily identified. Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors. This exposed the blue Foley catheter. Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture. Six of these were placed evenly spaced out anteriorly to posteriorly. The Foley catheter was then removed. This allowed for better traction of the prostate laterally. Lateral pelvic fascia was opened bilaterally. This effectively released the neurovascular bundle from the apex to the base of the prostate. Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat. The prostate was then dissected from laterally to medially from this opening in the perirectal fat. The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate. Maximal length of ureteral stump was preserved. The prostate was carefully lifted cephalad by using gentle traction with fine forceps. The prostate was easily dissected off the perirectal fat using sharp dissection only. Absolutely, no traction to the neurovascular bundle was evident at any point in time. The dissection was carried out easily until the seminal vesicles could be visualized. The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side. The bladder neck was then dissected out by using a bladder neck dissection method. Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy. Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles. This was developed without any difficulty. Both vas deferens were identified, hemoclipped and transected. The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis. About two-thirds of the seminal vesicles were able to be removed. The tip was left behind. Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected. This was performed on the left side and then the right side. This completely freed the prostate. The prostate was sent for permanent section. The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures. The mucosa of the bladder neck was everted by using 4-0 chromic sutures. Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature. The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures. The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck. This was performed by using a French ***** needle. A 20-French Foley catheter was then inserted and the sutures were sequentially tied down. A 15 mL of sterile water was inflated to balloon. The bladder anastomosis to the urethra was performed without any difficulty. A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region. All instrument counts, lap counts, and latex were verified twice prior to the closure. The rectus fascia was closed in running fashion using #1 PDS. Subcutaneous space was closed by using 2-0 Vicryl sutures. The skin was reapproximated by using metallic clips. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

adenocarcinoma
bladder
bladder neck
bladder neck dissection
core biopsy
dissection
dorsal vein complex
fascia
figure-of-eight
foley catheter
gleason
lymph node dissection
neck
nerve sparing
nerve-sparing
perirectal fat
posteriorly
prostate
prostate cancer
prostatectomy
psa
rectus fascia
retropubic
seminal
seminal vesicles
surgery
sutures
urethra
vesicles


Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.

PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA: ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies. He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Deep venous thrombosis.,6. Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area. Preoperative antibiotic was also given in the preoperative holding area. The patient was then taken into the operating room after which general LMA anesthesia was administered. The patient was shaved and then prepped using Betadine solution. A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain. A midline infraumbilical incision was performed. The rectus fascia was opened sharply. The perivesical space and the retropubic space were developed bluntly. Bookwalter retractor was then placed. Bilateral obturator pelvic lymphadenectomy was performed. The obturator nerve was identified and was untouched. The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder. Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips. The lymph nodes were palpably normal and were set for permanent section. The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors. The puboprostatic ligament was taken down sharply. The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures. The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area. The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle. The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors. The urethra was then identified and was dissected out. The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors. This was extended circumferentially until the Foley catheter could be seen clearly. 2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later. The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected. The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides. The plane between Denonvilliers' fascia and the perirectal fat was developed sharply. No tension was placed on the neurovascular bundle at any point in time. The prostate dissected off the rectal wall easily. Once the seminal vesicles were identified, the fascia covering over them were opened transversely. The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected. The bladder neck was then dissected out carefully to spare most of the bladder neck muscles. Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen. The specimen was inspected and appeared to be completely intact. It was sent for permanent section. The bladder neck mucosa was then everted by using 4-0 chromic sutures. Inspection at the prostatic bed revealed no bleeding vessels. The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck. Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck. A 20-French Foley Catheter was used. The anterior sutures were then placed. The Foley was then inflated. The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly. Mild traction of the Foley catheter was placed to assure the anastomosis was tight. Two #19-French Blake drains were placed in the perivesical spaces. These were anchored to the skin by using 2-0 silk sutures. The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed. The fascia was closed in running fashion using #1 PDS. Subcutaneous tissue was closed by using 2-0 Vicryl suture. Skin was approximated by using metallic clips. The patient tolerated the operation well.

adenocarcinoma
bladder
bladder neck
dorsal vein
dorsal vein complex
foley
foley catheter
lymph node
lymph node dissection
lymphadenectomy
metzenbaum scissors
pelvic lymph node dissection
perivesical
prostate
prostate cancer
prostatectomy
radical retropubic
radical retropubic prostatectomy
retropubic
surgery
sutures
urethra
urethral
vein complex


HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. He also has VACTERL association with hydrocephalus. As an infant, he underwent placement of a right modified central shunt. On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt. On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt. A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization. He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels. Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units. On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation. A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion. The patient then followed conservatively since that time. The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:, After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava. This catheter was then exchanged for a 5-French VS catheter of a distal wire. Apposition of the right pulmonary artery over, which the wedge catheter was advanced. The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle. The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance. Left ventricular pressure was found to be suprasystemic. A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure. Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum. Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium. There was a disappearance of a mild waist prior to spontaneous tear of the balloon. The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve. A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste. Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle. Further attempts to cross tricuspid valve were thus abandoned. Attention was then directed to a Fontan fenestration. A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg. With less than 10% fall in calculated cardiac index. The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm. A 7-French flexor sheath was again advanced cross the fenestration. A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium. Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk. Once the stable device configuration was confirmed, device was released from the delivery catheter. Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to systemic arterial desaturation. There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow. The right pulmonary veins were fully saturated. Left pulmonary veins were not entered. There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration. Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery. Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg. Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta. Phasic ascending and descending aortic pressures were similar and normal. The calculated systemic flow was normal. Pulmonary flow was reduced to the QT-QS ratio of 0.7621. Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle. The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries. There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle. Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis. There was symmetric contrast flow to both pulmonary arteries. A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration. There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow. The branch pulmonaries appeared mildly hypoplastic. Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility. Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava. Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery. There was an increase in the systemic arterial pressures. Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%. The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921. Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow. An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries. A small degree of contrast returned to the heart.,INITIAL DIAGNOSES: ,1. Pulmonary atresia.,2. VACTERL association.,3. Persistent sinusoidal right ventricle to the coronary communications.,4. Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Systemic to pulmonary shunts.,2. Right bidirectional Glenn shunt.,3. Revision of the central shunt.,4. Ligation and division of patent ductus arteriosus.,5. Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6. Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES: ,1. Favorable Fontan hemodynamics.,2. Hypertensive right ventricle.,3. Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4. Patent Fontan fenestration.,CURRENT INTERVENTION: ,1. Balloon dilation tricuspid valve attempted and failed.,2. Occlusion of a Fontan fenestration.,MANAGEMENT: ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair. Further cardiologic care will be directed by Dr. X.


Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer.

PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter. The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter. The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance. The needle was removed. An incision was made over the guidewire for entrance of the dilator with sheath. A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade. Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir. The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion. The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability. Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin. It was placed on the chest, measured, and cut to the appropriate length. This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance. The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance. Fluoroscopy revealed the Port-A-Catheter to be in excellent position. The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily. It was flushed with heparinized saline connected in cath. This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture. This having been done, attention was applied to the reservoir incision. It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch. A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care.

catheter
circumferential
counter incision
fluoroscopic
fluoroscopic guidance
guidewire
insertion
ovarian cancer
port
port a catheter
port-a-catheter
subclavian
subcutaneously
superior vena cava
surgery
vein


PREOPERATIVE DIAGNOSIS: ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS: ,3 units of packed cells.,DRAINS:, None.,COMPLICATIONS: , None.,PROCEDURE: ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma. Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery. The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps. The bone flap, which had not been fixed in place was removed. An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation. Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery. It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex. The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior. This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation. Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission. Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation. Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel. Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard. The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region. The wound was then closed. It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap. The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.

aneurysm
arteriovenous
arteriovenous malformation
bipolar coagulation
bone flap
hematoma
hemorrhage
intracerebral
malformation
pterional
pterional craniotomy
surgery


Insertion of Port-A-Cath via left subclavian vein using fluoroscopy in a patient with renal cell carcinoma.

TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:, This is a 49-year-old gentleman was referred by Dr. A. The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia. He has developed recurrence with metastases to the lung and to bone.,The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere.,In the operating room under monitored anesthesia care with intravenous sedation, the patient was prepped and draped suitably. Lidocaine 1% with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty. A J-wire was guided into place under fluoroscopic control. A 7.2-French vortex titanium Port-A-Cath was now anchored in the subcutaneous pocket made just below using 3-0 Prolene. The attached catheter tunneled, cut to the appropriate length and placed through the sheath that was then peeled away. Fluoroscopy showed good catheter disposition in the superior vena cava. The catheter was accessed with a butterfly Huber needle, blood was aspirated easily and the system was then flushed using heparinized saline. The pocket was irrigated using antibiotic saline and closed with absorbable suture. The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr. A's office later today for the commencement of chemotherapy. There were no complications.

butterfly needle
carcinoma
catheter
cell carcinoma
fluoroscopy
french vortex
huber
insertion
jugular
metastatic
nephrectomy
permcath
port
port a cath
port-a-cath
renal cell carcinoma
subclavian
subclavian vein
surgery
vena cava


Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.

PROCEDURES PERFORMED,1. Insertion of subclavian dual-port Port-A-Cath.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good 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.


Right subclavian Port-a-Cath insertion in a patient with bilateral breast carcinoma.

PREOPERATIVE DIAGNOSES: ,1. Bilateral breast carcinoma.,2. Chemotherapy required.,POSTOPERATIVE DIAGNOSES:,1. Bilateral breast carcinoma.,2. Chemotherapy required.,OPERATION: , Right subclavian Port-a-Cath insertion.,FINDINGS AND PROCEDURE: ,With the patient under satisfactory general orotracheal anesthesia and in the supine position, the right upper anterior chest, neck, and arm were prepared with Betadine in the usual fashion. The skin, subcutaneous tissue, and fascia of the pectoralis major muscle medially beneath the inferior third of the right clavicle was infiltrated with 0.5% Marcaine with epinephrine. An incision transverse, parallel, and inferior to the middle third of the right clavicle was performed. A subcutaneous pocket on the surface of the pectoralis major muscle was created. The muscular fascia was also infiltrated with 0.5% Marcaine with epinephrine. With the patient in the Trendelenburg position, utilizing the provided introducer needle, the right subclavian vein was cannulated. A guidewire was passed without difficulty and the needle was removed. Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium. A dilator and sheath was passed over the guidewire. The guidewire and dilator were removed and a provided catheter was inserted through the sheath and the sheath was carefully withdrawn. Fluoroscopy again confirmed satisfactory position of the catheter and the catheter under fluoroscopic guidance was retracted into the superior vena cava. The catheter had been preflushed with dilute heparin solution (100 units/mL). The port, which had been preflushed with saline, was attached to the catheter at approximately 13 cm level. The locking cap had been placed on the catheter. The port was connected to the catheter and the locking cap was secured. The port was again flushed with dilute heparin solution and placed within the subcutaneous pocket. Fluoroscopy again confirmed satisfactory position. A hard copy of the fluoroscopy was obtained. The catheter and port were secured to the pectoralis fascia in four locations with 2-0 Prolene suture. Site was irrigated with saline. Hemostasis was verified. The subcutaneous tissue was approximated with interrupted 2-0 Vicryl suture. The subcutaneous and dermis were closed with a running subcuticular 3-0 Vicryl suture. A 0.25-inch Steri-Strips were applied. The provided needle and butterfly attachment was flushed with saline, passed through the skin into the port, and then flushed again with dilute heparin solution thus confirmed satisfactory. The site was dressed with Tegaderm type dressing and the needle catheters were covered with 4x4's and paper tape. Estimated blood loss was less than 15 mL. The patient tolerated the procedure well and left the operating room in good condition.

bilateral breast carcinoma
carcinoma
cath insertion
catheter
chemotherapy
fluoroscopy
heparin
insertion
pectoralis fascia
port a cath
port a cath insertion
port-a-cath
subclavian
subclavian port a cath
surgery


Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.

PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:, Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:, General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding. Digital exam reveals bright red blood on the finger. He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before. In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa. There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture. No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position. After adequate general anesthesia was induced, the patient was then placed in modified prone position. His buttocks were taped, prepped and draped in a sterile fashion. The anterior rectal wall was exposed using a Parks anal retractor. The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery. There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well. This was controlled with a 3-0 Monocryl figure-of-eight suture. At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.

anesthesia
anterior base lesion
bleeding
diarrhea
polypoid lesion
surgery
transanal
transanal excision


The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS: ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time.

berry ligaments
follicular variant
hemithyroidectomy
papillary carcinoma
parathyroid
rubber band drain
sternocleidomastoid
strap muscles
surgery
thyroid
thyroid gland


Placement of a Port-A-Cath under fluoroscopic guidancein a patient with anal cancer.

PREOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,OPERATIVE PROCEDURE:,1. Placement of a Port-A-Cath.,2. Fluoroscopic guidance.,ANESTHESIA:, General LMA.,ESTIMATED BLOOD LOSS:, Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy. Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed. The patient was taken to the operating room, placed in supine position. General LMA anesthesia was administered. She is prepped and draped in the usual sterile fashion. She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire. Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava. The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery. A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements. The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer. Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch. Heparin flush was used to flush the port. Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition. All counts were reported as correct and I was present for the entire procedure.

anal cancer
chemotherapy
fluoroscopic
fluoroscopy
insertion
iv access
port a cath
port-a-cath
subclavian
subclavian vein
subcutaneous tissues
surgery
trendelenburg position


Port insertion through the right subclavian vein percutaneously under radiological guidance. Metastatic carcinoma of the bladder and bowel obstruction.

PREOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL: ,The patient was electively taken to the operating room after obtaining an informed consent. A time-out process was followed. Antibiotics were given. Then, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated. The right subclavian vein was percutaneously cannulated without any difficulty. Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.,A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl. Then, the fascia was closed using subcuticular suture of Monocryl. The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed. A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.,The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.

bowel obstruction
catheter
metastatic carcinoma
metastatic carcinoma of the bladder
percutaneously
port insertion
subclavian vein
surgery


Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.

PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Minimal.,PROCEDURE IN DETAIL: ,Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was performed. Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. Once the catheter was advanced through the sheath, the sheath was peeled away. Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed. No hemorrhage was identified. The port was in appropriate position with fluoroscopic confirmation. The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch. Dressed with Steri-Strips and 4 x 4's. Port was checked. Had good blood return, flushed readily with heparinized saline.

cath insertion
catheter
dilators
fluoroscopic
fluoroscopic confirmation
hemostasis
insertion
port a cath insertion
sheath
subcutaneous
surgery
wire


Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.

TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI demonstrated an increased growth with hemorrhage. This was then discontinued. Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion. All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL: ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine. The fluoroscope was then positioned. The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus. Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed. It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent. Once this was ensured and completed and hemostasis obtained, the wound was irrigated. There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate. The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure. All sponge and needle counts were correct. The patient was extubated and transported to the recovery room in stable condition. Blood loss was minimal.

pituitary
pituitary tumor
prolactin
resection
surgery
transnasal
transnasal transsphenoidal approach
transsphenoidal
tumor


Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.

PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE: ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA: ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None. Post-fixation x-rays, nonalignment, no new changes. Post-fixation neurologic examination normal.,CLINICAL HISTORY: ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:, The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine. A large PMT crown was brought in and fixed to the skull with pins under local anesthetic. Excellent fixation achieved. It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck. The vest was brought in from the front as well and connected. Head was tilted appropriately, slightly extended, and in the midline. All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout. X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days. Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery. She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.

anterior cervical discectomy
cervical
cervical spondylosis
corpectomy
crown
decompression
fusion
pmt
pmt halo
surgery
vest


Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.

PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.

dyspnea
gliding sign
hemidiaphragm
pleural
pleural catheter
pleural effusion
pleurocentesis
respiratory
serosanguinous fluid
surgery
ultrasound


PREOPERATIVE DIAGNOSIS:, Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE: ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The right upper extremity was then prepped and draped in standard surgical fashion. A small incision was made at the tip of the olecranon. Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. This was changed for a 0.79 K-wire. This was driven up to the fracture site. The fracture was manually reduced and then the K-wire passed through the distal segment. This demonstrated adequate fixation and reduction of both bones. The pin was then cut short. The fracture site and pin site was infiltrated with 0.25% Marcaine. The incision was closed using 4-0 Monocryl. The wounds were cleaned and dried. Dressed with Xeroform, 4 x 4. The patient was then placed in a well-moulded long-arm cast. He tolerated the procedure well. He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. X-rays of the right forearm will be taken. The patient may need additional mobilization time. Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. Intraoperative findings were relayed to the parents. All questions were answered.

arm cast
closed reduction
forearm refracture
fracture site
pinning
surgery


Plantar fascitis, left foot. Partial plantar fasciotomy.

PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint. The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment. The patient has been NPO since mid night. Consent is signed and in the chart. No known drug allergies.,Details Of Procedure: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach. Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia. The foot was then prepped and draped in the usual sterile orthopedic fashion. An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge. Attention was then directed to the plantar medial aspect of the left heel. An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated. A #15 blade was then used to transect the medial and central bands of the plantar fascia. Care was taken to preserve the lateral fibroids. The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted. The air was then flushed with copious amounts of sterile saline. The skin incision was then closed with #3-0 nylon in simple interrupted fashion. Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot. Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case. The patient is to be nonweightbearing on the left lower extremity with crutches. The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d. The patient is to follow-up with Dr. X as directed.

ankle
fascia
fasciotomy
fascitis
foot
medially
plantar
plantar fascia
plantar fasciotomy
plantar fascitis
surgery


PREOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,PROCEDURE:,1. Conscious sedation.,2. Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:, None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:, After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.

chest
chest tube
chest tube talc pleurodesis
decubitus position
effusion
lateral decubitus position
pleural
pleural effusion
pleurodesis
recurrent
surgery
talc
talc pleurodesis
tube


Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.

PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:, Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma. He did not return for followup or radiotherapy as instructed, and the tumor has regrown. For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible. The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him. Many risks including CSF leak and blindness were discussed in detail. After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE: ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position. Care was taken to pad all pressure points appropriately. The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space. Clear and colorless CSF issued forth. A catheter was inserted to a distance of 40 cm, and the needle was removed. The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas. Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor. This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed. He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder. Care was taken to pad all pressure points appropriately. The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection. The metallic arm was then connected to the table for the use of the endoscope. The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use. Hemostasis was obtained. The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril. The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium. Needle Bovie electrocautery was used to clear mucosa away from the ostium. The perpendicular plate of the ethmoid had already been separated from the sphenoid. I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this. I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of. The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized. Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma. A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor. I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free. The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right. There appeared to be cavernous sinus invasion on the left. It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter. A large amount of this was removed. There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor. While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus. In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression. Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained. I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction. I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air. Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation. The middle turbinates were then restored to their anatomic position. There was no significant intranasal bleeding, and for this reason, an open nasal packing was required. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition. The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.


S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old. He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face. He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet. He has redness of the right toes 2, 3 and 4. Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1. Plantar fasciitis.,

fasciitis
heel
plantar
plantar fasciitis
surgery
tinea pedis
tinea purpura


External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.

PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,BLOOD LOSS: ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:, None.,INDICATION FOR OPERATION: ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. Risks and benefits of procedure were discussed in detail with the patient and her husband. All questions were answered, and consent was obtained. The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1. There was a comminuted distal tibia fracture with a fibular shaft fracture. Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. As the reduction was stable with buddy taping, no pinning was performed.,3. Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL: ,The patient was identified in the preoperative holding area. The left leg was identified and marked at the surgical site of the patient. She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. She received Ancef for antibiotic prophylaxis. A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. At this point, the pins were cut short and capped to protect the sharp ends. The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. Please note there was no break in sterile technique throughout the case.,PLAN: ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. She will maintain her buddy taping in regards to her great toe fracture.

external fixation
fixation
fracture
phalanx
phalanx fracture
pilon
pilon fracture
proximal
proximal phalanx
reduction
schantz pins
surgery
tibia
tibia fracture
toe
toe fracture


Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.

PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:, Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.

abscess
cyst
excision
hemostasis
infected
pilonidal cyst
surgery


PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL: ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A small bump was placed underneath her right buttock. The right upper thigh was then prepped and draped in standard surgical fashion. The upper aspect of the incision was reincised. The dissection was carried down to the crew, which was easily found. A guidewire was placed inside the screw with subsequent removal of the previous screw. The previous screw measured 65 mm. A 60 mm screw was then placed under direct visualization with fluoroscopy. The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion. The guidewire was removed. The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat. The skin was closed with 4-0 Monocryl. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape. The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery. She should continue toe touch weightbearing on her leg. The wound may be wet in approximately 5 days. The patient should follow up in clinic in about 10 days. The patient is given Vicodin for pain. Intraoperative findings were relayed to the mother.

capital femoral epiphysis
femoral epiphysis
guidewire
intraarticular protrusion
pinning
screw
surgery


Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.

PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.

chest
empyema
hemothorax
insertion
pigtail catheter
pleural space
surgery


Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

PROCEDURE CODES: 64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA: MAC.,COMPLICATIONS: None.,DESCRIPTION OF TECHNIQUE: Informed consent was obtained from the patient's mom. The patient was brought to minor procedures and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation. Approximately 4 mL of 5% phenol was injected in this location bilaterally. Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. After injections were performed, bilateral short leg fiberglass casts were applied. The patient tolerated the procedure well and no complications were encountered.

active emg
bilateral
botulinum
botulinum toxin
botulinum toxin injection
botulinum toxin injection bilateral
casts
cerebral palsy
emg stimulation
femoris medial
fiberglass
fiberglass casts
gastrocnemius
gastrocnemius soleus
gastrocnemius soleus muscles
hamstrings
injection
leg fiberglass
muscles
muscles phenol neurolysis
nerves
neurolysis of bilateral obturator
obturator
obturator nerves
phenol
phenol neurolysis
rectus femoris
short leg fiberglass
short leg fiberglass casts
soleus muscles
surgery
toxin
toxin injection
toxin injection bilateral rectus


PROCEDURES PERFORMED:, Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:, Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.

active emg
botulinum
botulinum toxin
botulinum toxin injection
brain injury
emg
emg stimulation
extensors
injection
knee extensors
musculocutaneous
musculocutaneous nerve
neurolysis
obturator nerves
pectoralis major
phenol
phenol neurolysis
spastic quadriparesis
stimulus
surgery
toxin
toxin injection
traumatic brain
wrist flexors


Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.

PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.

anesthesia
anterior chamber
capsular bag
capsule
cataract
chamber
cornea
cornea tunnel
cornea tunnel wound
implantation
intraocular
intraocular lens
intraocular lens implantation
lens
lens implantation
phacoemulsification
phacoemulsification of cataract
surgery


PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:, Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient. She was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse. Approximately 6 mL of 5% phenol was injected in this location. At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.

active emg
botulinum
botulinum toxin
botulinum toxin injection
cerebral palsy
emg stimulation
femoris and vastus medialis
injection
intermedius and right pectoralis
major muscles
medialis intermedius
obturator nerve
pectoralis
pectoralis major
phenol
phenol neurolysis
rectus femoris
rectus femoris and vastus
surgery
toxin
toxin injection
vastus medialis intermedius


Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE: ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA: ,Topical.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,The patient was identified. The operative eye was treated with tetracaine 1% topically in the preoperative holding area. The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye. The lashes were tapped using Steri-Strips to prevent blinking. A lid speculum was placed to prevent lid closure. Anesthesia was verified. Then, a 3.5-mm groove was created with a diamond blade temporarily. This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat. A paracentesis was made. A round capsulorrhexis was performed. The anterior capsular flap was removed. Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. The irrigating-aspirating machine was used to clear residual cortex. The Provisc was instilled. An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified. The viscoelastic was removed. Intraocular lens remained well centered. The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. The anterior chamber remained deep, and there was no wound leak. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment. A tight patch and Fox shield were placed. The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.

anterior
cataract
chamber
eye
hydrodelineation
intraocular
intraocular lens
lens
phacoemulsification
phacoemulsification of cataract
posterior chamber
surgery


PICC line insertion

PROCEDURE PERFORMED:, PICC line insertion.,DESCRIPTION OF PROCEDURE:, The patient was identified by myself on presentation to the angiography suite. His right arm was prepped and draped in sterile fashion from the antecubital fossa up. Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein. A guidewire was then threaded through the vein and advanced without difficulty. An introducer was then placed over the guidewire. We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram. What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein. It was very tortuous area. We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that. Decision was made at that point then to just do a midline catheter. The catheter was cut to 20 cm, then we inserted back to the introducer. The introducer was removed. The catheter was secured by two #3-0 silk sutures. Appropriate imaging was then taken. Sterile dressing was applied. The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor. We may make another attempt in the near future using a different approach.,

: 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.


TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child. He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract. He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained. All questions were answered. The patient was brought to preoperative holding area where the operative right eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced by the anesthesia service. A time-out was called to confirm the procedure and operative eye. The right operative eye was disinfected and draped in a standard fashion for eye surgery. A lid speculum was placed. The vitreoretinal team placed the infusion cannula after performing a peritomy. At this point in the case, the patient was turned over to the cornea service with Mrs. Jun. A paracentesis was made at the approximately 3 o'clock position. Healon was placed into the anterior chamber. The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis. This incision was then shelved anteriorly and used to enter the anterior chamber. The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome. Hydrodissection was performed. The lens nucleus was removed using phacoemulsification and irrigation and aspiration. Lens cortex also was removed using irrigation and aspiration. Viscoelastic was placed to inflate the capsular remnant. The diamond knife was used to enlarge the phaco incision. Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty. The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed. The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber. This was done without difficulty. The anterior chamber was secured and watertight at the end of the procedure. Intraocular pressure was satisfactory. The patient tolerated the procedure well and then was turned over to the retina service in good condition. They will dictate a separate note.

chamber
eye
intraocular
intraocular lens implant
lens
phacoemulsification
posterior chamber
surgery