Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.

PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:, After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac catheterization suite. The right groin was prepped in the usual sterile fashion. Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta. Next, Judkins left catheter was used to engage the left coronary system. Cineangiography was recorded in multiple views. Next, Judkins right catheter was used to engage the right coronary system. Cineangiography was recorded in multiple views. Next, the Judkins right catheter was used to engage the SVG to OM. Cineangiography was recorded. Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views. Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressures were measured. LV gram was done and a pullback gradient across the aortic valve was done and recorded. Next, an aortogram was done and recorded. At this point, I decided to proceed with percutaneous intervention of the left circumflex. Therefore, AVA 3.5 guide was used to engage the left coronary artery. Angiomax bolus and drip was started. Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres. Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent. Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion. We next attempted a cutting balloon. Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire. Again, we were unable to cross the lesion with the stent. We then try to cross with a noncompliant balloon, which we were unsuccessful. We also try to cutting balloon again, we were unsuccessful. Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted. Final images showed no evidence of dissection, perforation, or further complication. The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results. The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1. The LV. LVEDP was 4. LVES is approximately 50%-55% with inferobasal hypokinesis. No significant MR. No gradient across the aortic valve.,2. Aortogram. The ascending aorta shows no significant dilatation or evidence of dissection. The valve shows no significant aortic insufficiencies. The abdominal aorta and distal aorta shows significant tortuosities.,3. The left main. The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4. Left circumflex. The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch. The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis. The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5. LAD. The LAD is a totally 100% occluded vessel. The LIMA to LAD is patent with only a small-to-moderate caliber LAD. There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%. The diagonal shows proximal 80% stenosis.,6. The right coronary artery: The right coronary artery is 100% occluded. There are retrograde collaterals from left to right to the distal PDA and PLV branches. The SVG to OM is 100% occluded at its take off. The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7. LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon. Final images showed some improvement, however, continued residual stenosis. At this point, the patient will be transferred back to telemetry floor and monitored. We can attempt future intervention or continue aggressive medical management. The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch. Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.

aortogram
balloon
balloon angioplasty
cineangiography
circumflex
coronary artery
coronary system cineangiography
lad
lima to lad
obtuse marginal branch
percutaneous intervention
surgery
svg to om
ventriculogram


Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.

PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure. A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine. A dorsal slit was made, and the prepuce was dissected away from the glans penis. A ** Gomco clamp was properly placed for 5 minutes. During this time, the foreskin was sharply excised using a #10 blade. With removal of the clamp, there was a good cosmetic outcome and no bleeding. The child appeared to tolerate the procedure well. Care instructions were given to the parents.

: 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.


Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.

PREOPERATIVE DIAGNOSIS:, Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:, Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis. Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure. Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion. After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle. The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.

acalculous
acalculous cholecystitis
catheter
cholecystitis
cholecystostomy
cholecystostomy tube
surgery
ultrasound
under ultrasound guidance


Circumcision procedure (neotal)

CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on the papoose board. The external genitalia were prepped with Betadine. A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis. The incision was made. Next, all the adhesions of the inner preputial skin were broken down. The appropriate size bell was obtained and placed over the glans penis. The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco. The bell was then placed and tightened down. Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum. A blade was used to incise circumferentially around the bell. The bell was removed. There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed. The little boy was given back to his mom.,PLAN:, They have a new baby checkup in the near future with their primary care physician. I will see them back on a p.r.n. basis if there are any problems with the circumcision.

bell
circumcision
circumferentially
external genitalia
foreskin
glans
glans penis
gomco
gomco clamp
infant
infection
meatal stenosis
neonatal
penile block
penis
preputial skin
surgery


PREOPERATIVE DIAGNOSIS:, Phimosis.,POSTOPERATIVE DIAGNOSES:, Phimosis.,OPERATIONS:, Circumcision.,ANESTHESIA: , LMA.,EBL:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis. The patient had spraying of urine and ballooning of the foreskin with voiding. The urine seemed to have collected underneath the foreskin and then would slowly drip out. Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed. Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed. The patient's family understood all the complications and wanted to proceed with the procedure. Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in usual sterile fashion. All the penile adhesions were released prior to the prepping. The extra foreskin was marked off, 1 x 3 Gamco clamp was used. Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done. There was excellent hemostasis. Dermabond was applied. The patient was brought to recovery at the end of the procedure in stable condition.

ballooning
ballooning of the foreskin
circumcision
foreskin
gamco clamp
phimosis
spraying
spraying of urine
surgery
urine


Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.

PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: , Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. These dense adhesions were associated with chronic inflammatory edematous changes. The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally. The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally. The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver. There was no evidence of adhesions from the abdominal wall to the liver. The remainder of the abdomen was unremarkable.,BRIEF HISTORY: ,This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain. She had been asked to follow up and scheduled for surgery previously. Her pain had now been intractable associated with anorexia. She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination. Her transaminases were markedly elevated. She also developed pancreatitis secondary to gallstones. Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis. She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis. Following this, she was scheduled for operative laparoscopic cholecystectomy. Her parents were explained the risks, benefits, and complications of the procedure. She gave us informed consent to proceed with surgery.,OPERATIVE PROCEDURE: ,The patient brought to the operative suite and placed in the supine position. Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created. Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty. Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty. The abdomen was then insufflated to 15 mmHg with carbon-dioxide. Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty. Video laparoscope was inserted and the above notable findings were identified in the operative findings. The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed. A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline. The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament. Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line. These were inserted without difficulty. The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder. Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions. Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct. A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch. This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place. Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly. Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor.,Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall. The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery. The abdomen was then irrigated with copious amounts of normal saline. The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port. There was noted to be gallstones within the gallbladder. Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall. Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty. The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia. A #4-0 Vicryl suture was used to approximate all incisions. The incisions were then injected with local injectable 0.25% Marcaine. All ports were then cleaned dry. Steri-Strips were placed across and sterile pressure dressings were placed on top of this. The patient tolerated the entire procedure well. She was transferred to the Postanesthesia Care Unit in stable condition. She will be followed closely in the postoperative course in General Medical Floor.

abdomen
adhesions
anterior abdominal wall
cholecystectomy
cystic duct
gallbladder
gallstone
injectable
laparoscopic
laparoscopic cholecystectomy
omental adhesions
pancreatitis
surgery
veress needle
video laparoscope


Open cholecystectomy (attempted laparoscopic cholecystectomy).

PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.

blake
cholecystectomy
cholecystitis
cholelithiasis
electrocautery
endotracheal
french
gallbladder
gallbladder fossa
gangrenous
hasson
laparoscopic
omentum
subhepatic
surgery


PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE:, After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.


PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:, Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:, The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased. Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening. A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma. The patient had a metastatic workup, which was negative including a brain MRI and bone scan. The bone scan showed only signal positivity in the left 9th rib near the tumor. The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia. He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. The patient was intubated with a double-lumen endotracheal tube. Intravenous antibiotics were given. A Foley catheter was placed. The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion. An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass. The skin and subcutaneous tissues were dissected sharply with the electrocautery. Good hemostasis was obtained. The tumor was easily palpable and clearly involving the 8th to 9th rib. A thoracotomy was initially made above the mass in approximately the 7th intercostal space. Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection. The thoracotomy was extended anteriorly and posteriorly. It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected. The ribs of the chest wall were first cut at their anterior aspect. The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery. Hemostasis was obtained with both electrocautery and clips. The chest wall segment to be resected was retracted laterally and posteriorly. It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement. Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor. The spleen and the stomach were identified and were protected. Inferiorly, the resection of the chest wall was continued in the 10th interspace. The dissection was then carried posteriorly to the level of the spine. The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung. A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection. Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies. The ribs were disarticulated, closed to or at their articulations with the spine. Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery. There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section. The specimen was oriented for the pathologist who came to the room. Hemostasis was obtained. The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures. This produced a satisfactory diaphragmatic repair without undue tension. A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly. This was secured with a #1 silk suture. The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect. A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually. The resulting mesh closure was snug and deemed adequate. The serratus muscle was reapproximated with figure-of-8 0 Vicryl. The latissimus was reapproximated with a two #1 Vicryl placed in running fashion. Of note, two #10 JP drains were placed over the mesh repair of the chest wall. The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl. The wounds were dressed. The patient was brought from the operating room directly to the North ICU, intubated in stable condition. All counts were correct.,

anesthesia
chest
chest wall
chest wall reconstruction
chest wall segment
chest wall tumor
chest wall tumor resection
diaphragm
electrocautery
gore tex mesh
left lower lobe
lower lobe
lung
lung wedge resection
mesh
pleural cavity
resection
surgery
tumor
wall
wedge
wedge resection


PREOPERATIVE DIAGNOSES:,1. Cholelithiasis.,2. Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic cholecystitis.,2. Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with ongoing recurrent episodes of right upper quadrant pain, associated with nausea. Ultrasound revealed cholelithiasis. The patient also had somewhat thickened gallbladder wall. The patient was admitted through emergency room last night with acute onset right upper quadrant pain. Clinically, it was felt the patient had acute cholecystitis. Laparoscopic cholecystectomy with cholangiogram was advised. Procedure, indication, risk, and alternative were discussed with the patient in detail preoperatively and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia, and abdomen was prepped and draped. A small transverse incision was made just above the umbilicus under local anesthesia. Fascia was opened vertically. Stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted and peritoneal cavity was insufflated with CO2.,Laparoscopic camera was inserted, and the patient was placed in reverse Trendelenburg, rotated to the left. A 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Examination at this time showed no free fluid, no acute inflammatory changes. Liver was grossly normal. Gallbladder was noted to be thickened. Gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema, consistent with acute cholecystitis.,The fundus of the gallbladder was retracted superiorly, and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated. It was clipped distally and using C-arm fluoroscopy, intraoperative cystic duct cholangiogram was done, which was interpreted as normal. There was slight dilatation noted at the junction of the right and left hepatic duct, but no filling defects or any other pathology was noted. It was presumed that this was probably a congenital anomaly. The cystic duct was clipped twice proximally and divided beyond the clips. Cystic artery was identified, isolated, clipped twice proximally, once distally, and divided.,The gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port. Specimen was sent for histopathology. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. Trocars were removed under direct vision and peritoneal cavity was evacuated with CO2. Umbilical area fascia was closed with 0-Vicryl figure-of-eight sutures, required extra sutures to close the fascial defect. Some difficulty was encountered closing the fascia initially because of the patient's significant amount of subcutaneous fat. In the end, the repair appears to be quite satisfactory. Rest of the incisions closed with 3-0 Vicryl for the subcutaneous tissues and staples for the skin. Sterile dressing was applied.,The patient transferred to recovery room in stable condition.

acute cholecystitis
cholangiogram
cholecystectomy
cholelithiasis
gallbladder
laparoscopic
laparoscopic cholecystectomy
surgery


Left pleural effusion, parapneumonic, loculated. Left chest tube placement.

PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. The incision was made and deepened through the different layers to reach the intercostal space. The pleura was entered on top of the underlying rib and finger digital palpation was performed. Multiple loculations were encountered. Break up of loculations was performed posteriorly and a chest tube was directed posteriorly. Only a small amount of fluid was noted to come out initially. This was sent for various studies. Soft adhesions were encountered. The plan was to obtain a chest x-ray and start Activase installation.

activase
chest
chest tube
chest tube placement
infiltration
lidocaine
loculated
parapneumonic
pleural
pleural effusion
surgery


Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.

PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:, Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:, No evidence of intramediastinal purulence or hematoma. He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. The previously placed AlloDerm membrane was removed. Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. Both cavities were also irrigated and suctioned. The drains were flushed and repositioned. Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. The sternum was then smeared with a vancomycin paste. The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. The skin was closed with interrupted nylon sutures and a sterile dressing was placed. The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.

chest closure
delayed primary chest closure
hypoplastic left heart syndrome
norwood operation
open chest
stage 1 norwood operation
surgery


Removal of chest wall mass. The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.

PREOPERATIVE DIAGNOSIS:, Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:, Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic. The time-out process was followed and preoperative antibiotics were given. The patient was in the supine position and was prepped and draped in the usual fashion.,The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected. An incision was made directly on the mass and carried down to the ribs. This is where the several chondral cartilages of the lower ribs meet. So I believe they were isolated in 9th rib anteriorly and I was able to encircle it. The medial area was __________. There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs. There was also a separate sharp growth of the mass growing superiorly. Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally. This may be due to an extension towards the inside of his chest. Hemostasis was revised. The internal mammary was intact and there was no obvious penetration of the pleural cavity. The specimen was sent to Pathology and then we proceeded to close the defect. Obviously, the space between the ribs cannot be approximated. So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.,The patient tolerated the procedure well. Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.

cartilages
chest
chest wall
chest wall mass
local anesthetic
lower ribs
mass
ribs
surgery
wall


Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 10 mL,COMPLICATIONS:, None.,SPONGE COUNT: , Correct x2.

barometric trauma
blunt dissection
chest
chest tube
chest tube insertion
chest wall
chest x-ray
insertion
pneumonia
pneumothorax
respiratory failure
sepsis
spontaneous pneumothorax
surgery
thoracic cavity
tube


Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion.

PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion today. Postoperatively from that, she started having a blood tinged pink frothy sputum. Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum. The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion. The area was anesthetized with 1% Lidocaine solution. The patient was given sedation. A #10 blade scalpel was used to make an incision approximately 1.5 cm long. Then a curved scissor was used to dissect down to the level of the rib. A blunt peon was then used to again enter into the right hemithorax. Immediately a blood tinged effusion was released. The chest tube was placed and directed in a posterior and superior direction. The chest tube was hooked up to the Pleur-evac device which was ________ tip suction. The chest tube was tied in with a #0 silk suture in a U-stitch fashion. It was sutured in place with sterile dressing and silk tape. The patient tolerated this procedure well. We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.

carcinoma
chest tube
hemithorax
hemothorax
infuse-a-port insertion
pleur-evac device
surgery


Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound.

PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage. A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures. The patient was agreeable to proceed.,OPERATIVE PROCEDURE: ,The patient was prepped and draped at the bedside over both chest tube sites. The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures. The skin was then cleansed and Vaseline occlusive dressing was applied over the sites. The same procedure was performed on the other side. The chest tubes were removed on full inspiration. Vital signs remained stable throughout the procedure. The patient will remain in the intensive care unit for continued monitoring.,

bilateral pleural effusion
chest
chest tubes
effusion
pleural
pleural effusion
serous drainage
surgery


Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization.

PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:, Spinal/epidural with good effect.,FINDINGS: ,Delivered vigorous male infant from cephalic presentation. Apgars 9/9. Birth weight 6 pounds 14 ounces. Infant suctioned with a bulb upon delivery of the head and body. Cord clamped and cut and infant passed to pediatric team present. Complete placenta manually extracted intact with three vessel cord. Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision. In addition, the bladder was involved in adhesion mass complex. A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions. These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall. Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries. Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT: ,Per anesthesia records. Urine cleared postoperatively.,IV FLUIDS: ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia. She was prepped and draped in the usual manner for repeat cesarean section. A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar. This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife. This incision was extended laterally with Mayo scissors. Dense fibromuscular layer was encountered from the patient's previous surgeries. Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision. Fascia was previously separated superiorly and inferiorly from the muscular layer. A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus. Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall. This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall. Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall. These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection. This was successfully done without anterior entry into the bladder. Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus. The uterus was then incised using a sharp knife and low transverse incision. This was extended with bandage scissors. The infant was delivered easily from a cephalic presentation. Bulb suction was done following delivery of the head and body. The cord clamped and cut and the infant passed to pediatric team present. Cord segment and cord blood was obtained. Complete placenta manually extracted intact with three vessel cord. Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces. Complete placenta with three vessels retrieved. Uterus was exteriorized from the abdominal cavity. Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining. Pennington clamps placed at the uterine incision angles and the inferior incision lip. A #1 chromic suture closed the uterus in running continuous interlocking closure. Good hemostasis upon completion of the closure. Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots. The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion. This was closed with chromic suture in a running continuous interlocking closure with good hemostasis. Attention was then focused on the bilateral tubal ligation. Babcock clamp placed in the mid fallopian tube and elevated. Cautery was used to make a window in the avascular segment of the mesosalpinx. Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed. The ligated proximal and distal stumps were then cauterized with Bovie cautery. This tubal ligation procedure was done in a bilateral fashion. Upon completion of tubal ligation, uterus was returned to the abdominal cavity. Left and right gutters examined and found to be clean and dry. Evaluation of the low uterine segment incision revealed continued hemostasis. Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done. Interceed was then placed on the low uterine incision and the low anterior uterine aspect. The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures. Irrigation of the muscular layer with good hemostasis noted. The fascia was closed with #1 Vicryl in a running continuous closure. Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery. The skin was closed with staples.

abdominal
abdominal cavity
adhesiolysis
adhesions
anterior
anterior uterus
bilateral tubal ligation
cesarean
cesarean section
chromic
chromic suture
hemostasis
infant
low-transverse cesarean section
sterilization
surgery
term pregnancy
tubal ligation
uterine
uterus


Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.

PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:, Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED: ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS: ,50 mL.,NEEDLE AND SPONGE COUNT:, Correct.,SPECIMENS: , None.,TOURNIQUET TIME: ,Approximately 77 minutes.,IMPLANTS USED:,1. Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2. All-poly patella, size 32/8.5 mm thickness.,3. Prolong highly cross-linked polyethylene 12 mm.,4. Stemmed tibial component, size 2.,5. Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability. Surgery was indicated to relieve her pain and improve her functional ability. Goal objectives and the procedure were discussed with the patient. Risks and benefits were explained. No guarantees have been made or implied. Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE: ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion. A nonsterile tourniquet was placed proximally in the thigh. Antibiotics were infused prior to Foley catheter insertion. Time-out procedure was called.,A straight longitudinal anterior midline incision was made. Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia. Deep fascia was exposed. The tourniquet was inflated at 300 mmHg prior to the skin incision. A standard medial parapatellar approach was made. The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion. Incision was then carried down distally and distal arthrotomy was completed. Patellar tendon was well protected. Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair. The knee was exposed very well. Significant tricompartmental osteoarthritis was noted. The osteophytes were removed with a rongeur. Anterior and posterior cruciate ligaments were excised. Medial and lateral meniscectomies were performed. Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity. The medial compartment was more affected than lateral. Medial ligaments were tied. Retropatellar fat pad was excised. Osteophytes were removed. Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur. The trochlear notch was ossified. A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment. The anterior portal was 1 cm anterior to the PCL attachment. The anterior femoral sizer was positioned keeping 3 degrees of external rotation. Rotation was also verified using the transepicondylar axis and Whiteside line. The pins were positioned in the appropriate holes. Anterior femoral cut was performed after placing the cutting guide. Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned. A distal femoral cut was made which was satisfactory. A sizer was positioned which was noted to be D. The 5-in-1 cutting block size D was secured with spring pins over the resected bone. Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer. Then using a reciprocating saw, intercondylar base notch cut and side cuts were made. Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle. Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed. The bone with its attached soft tissue was removed. Once the femoral preparation was completed, attention was placed for the preparation of the tibia. The medial and the lateral collateral ligaments were well protected with a retractor. The PCL retractor was positioned and the tibia was translated anteriorly. Osteophytes were removed. The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle. Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe. Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest. A built-in 7-degree posterior slope was considered with instrumentation. Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site. Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane. The resected thickness of the bone was satisfactory taken 2 mm from the most affected site. The resected surface shows some sclerotic bone medially. Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle. Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed. Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion. Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension. The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia. Size 2 tibial trial plate was positioned. Appropriate external rotation was maintained with the help of the horseshoe alignment rod. Reference to the tibial crest distally and 2nd toe was considered as before. The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle. The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor. At this point, trial femoral and tibial components were reduced using a 12 mm trial liner. The range of motion and stability in both flexion and extension was satisfactory. No further soft tissue release was indicated. I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella. Using a patellar caliper, the thickness was measured to be 21.5 mm. This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact. Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide. Using a caliper, the resected patella was measured, which was noted to be 13 mm. A 32 sizer was noted to accommodate the resected surface very well. Drilling was completed and trial 32 button was inserted without any difficulty. The tracking was satisfactory. There was no evidence of any subluxation or dislocation of the patella. The trial components position was satisfactory. The alignment and the rotation of all 3 components were satisfactory. All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system. The resected surfaces were dried with a sponge. Two batches of Palacos cement were mixed. The cementing was initiated starting with tibia followed by femur and patella. Excess peripheral cement were removed with the curette and knife. The knee was positioned in extension with a 12 mm trial liner. Patellar clamp was placed after cementing the all-poly patella. Once the cement was set hard and cured, tourniquet was deflated. Hemostasis was achieved. The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner. Range of motion and stability was verified at 0 degrees and flexion of 120 degrees. Anterior-posterior drawer test was satisfactory. Medial and lateral stability was satisfactory. Patellar tracking was satisfactory. The wound was thoroughly irrigated. Hemostasis was achieved. A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine. The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion. The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally. The skin was approximated with staples. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient was then transferred to the recovery room in a stable condition. There were no intraoperative complications noted. She tolerated the procedure very well.


Laparoscopic resection of cecal polyp. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.

PREOPERATIVE DIAGNOSIS:, Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA: ,General oral endotracheal intubation.,PROCEDURE:, After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps. A bladed 11-mm port was inserted without difficulty. Pneumoperitoneum was obtained using C02. Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant. There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel. The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve. This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice. The appendix was somewhat retrocecal in position but otherwise looked normal. The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye. There was enough however in the wall to identify the location of the polyp. The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table. The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear. I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon. This new staple line was then opened on the back table and examined. There was some residual polypoid material noted but the margins this time appeared to be clear. The peritoneal cavity was then lavaged with antibiotic solution. There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery. The trocars were removed under direct vision. No bleeding was noted. The bladed trocar site was closed using a figure-of-eight O Vicryl suture. All skin incisions were closed with running 4-0 Monocryl subcuticular sutures. Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing. The patient tolerated the procedure well without any complications.

anesthetic
blunt dissection
cecal polyp
gia stapler
ileocecal valve
infiltrated
kocher clamps
laparoscopic resection
peritoneal cavity
polyp
surgery


Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.

PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1. DePuy Ultima calcar stem, size 3 x 45.,2. Bipolar head 28 x 43.,3. Head with +0 neck length.,4. Distal centralizer and cement restrictor.,5. SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS: ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter. The lesser trochanter was intact. The fracture site was noted to show abnormal pathological tissue with grayish discoloration. The quality of the bone was also pathologically abnormal with soft trabecular bone. The abnormal pathological tissues were sent along with the femoral head to pathology for assessment. Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture. She denied any history of fall or trauma. The presentation was consistent with pathological fracture pending tissue assessment. Indication, risks, and benefits were discussed. Treatment options were reviewed. No guarantees have been made or implied.,PROCEDURE: ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up. The left lower extremity was prepped and draped in a standard sterile fashion. Time-out procedure was called. Antibiotics were infused.,A standard posterolateral approach was made. Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus. This was then incised along the line of the incision. Hemostasis was achieved. Charnley retractor was positioned. The trochanter was intact. The gluteus medius was well protected with retractor. The piriformis and minimus junction was identified. The minimus was also reflected along with the medius. Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion. Similarly, L-shaped capsulotomy was performed. A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair. Fracture site was exposed. The femoral neck fracture was noted to be very low-lying basicervical type. Femoral head was retrieved without any difficulty with the help of a corkscrew. The head size was measured to be 43 mm. Bony fragments were removed. The acetabular socket was thoroughly irrigated. A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability. The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration. This was sent to the pathology. The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem. An L-shaped osteotomy was performed in order to accept the calcar prosthesis. The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter. There was no calcar superior to the lesser trochanter. The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis. Hemostasis was achieved. Now, the medullary canal was entered with a canal finder. The fracture site was well exposed. Satisfactory lateralization was performed. Attention was for the reaming process. Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal. At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted. Appropriate anteversion was positioned. The anteversion was marked with a Bovie to identify subsequent anteversion during implantation. The bony edges were trimmed. The calcar implant with 45 mm neck length was fit in the host femur very well. There was no evidence of any subsidence. At this point, trial reduction was performed using a bipolar trial head with 0 neck length. The relationship between the central femoral head and the greater trochanter was satisfactory. The hip was well reduced without any difficulty. The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory. The shuck was less than 1 mm. Leg length was satisfactory in reference to the contralateral leg. Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation. Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees. After verifying the stability and range of motion in all direction, trial components were removed. The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely. At this point, 2 batches of SmartSet cement with antibiotics were mixed. The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected. Centralizer was positioned. The cement restrictor was inserted. Retrograde cementing technique was applied once the canal was dried. Using cement gun, retrograde cementing was performed. The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured. The excess cement was removed with the help of a curette and Freer elevator. All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head. Once again, 0 neck length trial bipolar head was inserted over the trunnion. It was reduced and range of motion and stability was satisfactory. I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation. There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation. I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable. At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced. Range of motion and stability was as above. Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis. This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster. Satisfactory reinforcement was achieved with the #5 Ethibond. The wound was thoroughly irrigated. Hemostasis was achieved. The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl. The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures. Skin was approximated with staples. Sterile dressings were placed. Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noted.


PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT: ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE: ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.


Insertion of central venous line and arterial line and transesophageal echocardiography probe.

INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including use of gowns, mask, and gloves, etc. The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:, Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin. A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened. Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. There was good venous blood return on the first try. Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm. It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact. There was good blood return from both lumens, which were flushed with heparinized saline. The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:, Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:, Attention was directed to the left wrist, which was placed on wrist rest. The Allen test was normal. A Cook 2.5-French 5 cm long arterial catheter kit was opened. A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact. There was pulsatile blood return and the catheter was flushed with heparinized saline solution. It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure. The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion. Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. There was good visualization of the heart. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. The probe was removed at the end. There was no trauma and there was no blood tingeing.,

arterial
arterial line
aseptic technique
atrial septectomy
blood return
catheter
central
central venous
central venous line
glenn procedure
insertion
open-heart surgery
probe
pulsatile blood
surgery
transesophageal echocardiography probe


Central line insertion. Empyema thoracis and need for intravenous antibiotics.

PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty. The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline. The catheter was fixed to the skin with sutures. The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.

catheter
central line insertion
empyema
intravenous
surgery
thoracis


Cauterization of epistaxis, left nasal septum. Fiberoptic nasal laryngoscopy. Atrophic dry nasal mucosa. Epistaxis. Atrophic laryngeal changes secondary to inhaled steroid use.

PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1. Atrophic dry cracked nasal mucosa.,2. Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess. The patient was taken to the operating room for incision and drainage. Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis. Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery. The patient does report of having endotracheal tube intubation during anesthesia. The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:, After the procedure was described, the patient was placed in the seated position. The fiberoptic nasal laryngoscope was then inserted into the patient's left naris. The nasal mucosal membranes were dry and atrophic throughout. There was no evidence of any mass lesions. The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity. There was no evidence of mass, ulceration, lesion, or obstruction. The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes. There was no evidence of any local mass lesion, nodule, or ulcerations. There was no evidence of any erythema. Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric. The airway was stable and patent throughout the entire examination. The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx. The eustachian tube was completely visualized and was patent without obstruction. The scope was then further removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris. At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma. If this becomes possible in the future, this may provide her some relief of her chronic dysphonia. The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.

atrophic
cauterization
dry nasal mucosa
dysphonia
epistaxis
fiberoptic
fiberoptic nasal laryngoscopy
inhaled steroid use
laryngeal
laryngoscope
lesions
mucosa
nasal mucosa
supraglottic
surgery


PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:, Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,PROCEDURE IN DETAIL: , The ultrasound was used to localize the left femoral vein and to confirm it's patency and course. The left inguinal area was then prepped and draped in a sterile manner. The overlying soft tissues were anesthetized with 1% plain lidocaine. Under direct ultrasound visualization, the femoral vein was cannulated without difficulty, and a guidewire advanced. This was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself. Finally, the multilumen catheter itself was inserted over the guidewire. Once the catheter was fully inserted, the guidewire was completely withdrawn. Placement was confirmed by the withdrawal of dark venous blood from all ports; all ports were then flushed, the catheter sewn into place, and the dressing applied. He tolerated the procedure very well, without complications.

access
catheter
femoral
femoral vein
guidewire
placement
plain lidocaine
surgery
ultrasound
vein
venous


Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.

PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.

auricular
auricular region
cheek
cheek neck
cheek neck facelift
dissection
facelift
incision
lipotosis
neck
neck facelift
neck skin ptosis
post auricular
postoperative
pre and post auricular
rhytides
submental
submental suction assisted lipectomy
surgery


Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed

PREOPERATIVE DIAGNOSIS:, Refractory priapism.,POSTOPERATIVE DIAGNOSIS:, Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE: ,This is a 34-year-old African-American male who is known to our service with a history of recurrent priapism. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed and then subsequently underwent _______ procedure. The patient's priapism did return following this and he was scheduled for cavernosaphenous shunt.,PROCEDURE:, Informed written consent was obtained. The patient was taken to the operative suite and administered anesthetic. The patient was sterilely prepped and draped in the supine fashion. A #15 French Foley catheter was inserted under sterile conditions. Incision was made in the left base of the penile shaft on the lateral aspect, approximately 3 cm in length. Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum. The fascia was incised in elliptical fashion for approximately 2 cm. A #14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted.,Attention was then turned to the left groin and the superficial saphenous vein was harvested. Due to incisions brought up into the initial incision after gauging enough length, this was then spatulated with Potts scissors for approximately 2 cm. Vein was irrigated. One branching vessel was noted to be leaking, this was tied off and repeat injection with heparinized saline showed no additional leaks. Tunnel was then created from the superior most groin region to the incision in the penile shaft. Saphenous vein was then passed through this tunnel with the aid of a hemostat. Anastomosis was performed using #5-0 Prolene suture in a running fashion from proximal to distal. There were no leaks noted. There was good flow noted within the saphenous vein graft. Penis was noted to be in a flaccid state. All incisions were irrigated copiously and closed in several layers. Sterile dressings were applied. The patient was cleaned, transferred to recovery room in stable condition.,PLAN: ,We will continue with antibiotics for pain control, maintain Foley catheter. Further recommendations to follow.

aspiration
cavernosaphenous shunt
corpora cavernosum
corporal
corporal aspiration
foley catheter
priapism
refractory priapism
saphenous vein
surgery
winter's shunt


Normal cataract surgery.

NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized. A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic. A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome. A 5- to 5.5-mm anterior capsulorrhexis was created. The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag. The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique. Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification. Peripheral cortex was removed with the irrigation and aspiration handpiece. The posterior capsule was polished. The capsular bag was expanded with viscoelastic. The implant was inspected under the microscope and found to be free of defects. The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag. The trailing haptic was positioned with the cartridge system. Residual viscoelastic was removed from the anterior chamber and from behind the implant. The corneal wound was hydrated with balanced salt solution. The anterior chamber was fully re-formed through the side-port incision. The wound was inspected and found to be watertight. The intraocular pressure was adjusted as necessary. The lid speculum was removed. Topical Timoptic drops, Eserine and Dexacidin ointment were applied. The eye was shielded. The patient appeared to tolerate the procedure well and left the operating room in stable condition. Followup appointment is with Dr. X on the first postoperative day.

: 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.


PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, left eye.,PROCEDURE PERFORMED: ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion. A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber. It was then filled with viscoelastic. A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis. The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision. The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees. The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic. A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag. The trailing loop was placed inside the bag. The viscoelastic was removed with the irrigation-aspiration handpiece. The lens centered well. A single 10-0 nylon suture was placed to close the wound. It was checked and ascertained to be watertight. Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally. Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.

anterior chamber
capsular
cataract
cataract extraction
chamber
extracapsular
intraocular
intraocular lens
keratome
limbus
phacoemulsification
surgery