Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.

PREOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy with decompression C6-C7.,2. Arthrodesis with anterior interbody fusion C6-C7.,3. Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4. PEEK implant 7 mm.,5. Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS: ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS: ,Round French 10 JP drain.,SPECIMENS,: None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:, This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped. The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07. This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow. She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear. She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level. Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level. Operation, expected outcome, risks, and benefits were discussed with her. Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma. There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function. Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics. However, the patient may develop deeper-seated infection, which may require return to the operating room. Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft. There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery. There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid. There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. There is also the risk of pseudoarthrosis and hardware failure. She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case. The EMGs were silent and there was no evidence of any stimulation. After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension. The head was supported on a foam doughnut. The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side. A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm. The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision. The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles. Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath. The prevertebral fascia was identified and cut sharply. A localizing x-ray verified the marker to be at the C6-C7 interspace. Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7. Self-retaining retractor was then laid out. The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr. The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7. There was note of a new osteophyte on the left C6-C7 foramen. This was carefully drilled down. After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders. They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam. After this was completed, Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant was then tapped into placed after its interior was packed with Vitoss. The plate was then applied and secured in place with four 12 x 4.7 mm screws. Irrigation of the area was done. A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis. The wound was reinforced with Dermabond. The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site. C-collar was placed and the patient was transferred to Recovery after extubation.


Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.

PREOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Anterior cervical fusion, C5-C6.,3. Anterior cervical instrumentation, C5-C6.,4. Allograft C5-C6.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS:, None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months. Nonoperative measures failed to relieve her symptoms and surgical intervention was requested. We discussed reasonable risks, benefits, and alternatives of various treatment options. Continuation of nonoperative care versus the risks associated with surgery were discussed. She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery. Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite. General anesthetic was administered. The patient was placed in the supine position. All prominences and neurovascular structures were well accommodated. The patient was noted to have pulse in this position. Preoperative x-rays revealed appropriate levels for skin incision. Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed. The patient was then prepped and draped in sterile fashion. Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease. Subcutaneous tissue was dissected down to the level of the omohyoid which was transected. Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally. This was taken down to the prevertebral fascia which was bluntly split. Intraoperative x-ray was taken to ensure proper levels. Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures. Inferior spondylosis was removed with high-speed bur. A scalpel and curette was used to remove the disc. Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally. Disc herniation was removed from the right posterolateral aspect of the interspace. High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion. Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura. No further evidence of compression was identified. Hemostasis was achieved with thrombin-soaked Gelfoam. Interspace was then distracted with Caspar pin distractions set gently. Interspace was then gently retracted with the Caspar pin distraction set. An 8-mm allograft was deemed in appropriate fit. This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit. The graft was stable to pull-out forces. Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws. Plate and screws were then locked to the plate. Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft. Wounds were copiously irrigated with normal saline. Omohyoid was approximated with 3-0 Vicryl. Running 3-0 Vicryl was used to close the platysma. Subcuticular Monocryl and Steri-Strips were used to close the skin. A deep drain was placed prior to wound closure. The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition. There were no intraoperative complications. All needle and sponge counts were correct. Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.

allograft
anterior
anterior cervical
anterior cervical discectomy
cervical
cervical discectomy
cervical fusion
cervical spondylosis
decompression
discectomy
fusion
herniated disc
instrumentation
surgery


Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.

PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,PROCEDURES,1. Anterior cervical discectomy, C3-C4, C2-C3.,2. Anterior cervical fusion, C2-C3, C3-C4.,3. Removal of old instrumentation, C4-C5.,4. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position. The neck was prepped and draped in the usual fashion for anterior cervical discectomy. A high incision was made to allow access to C2-C3. Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate. We placed in self-retaining retractors. With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5. After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal. In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4. We then placed the ABC 55-mm plate from C2 down to C4. These were secured with 16-mm titanium screws after excellent purchase. We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin. Blood loss was about 50 mL. No complication of the surgery. Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation. At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.

abc plates
anterior
anterior cervical discectomy
cervical
cervical discectomy
cervical fusion
discectomy
fusion
herniated nucleus pulposus
instrumentation
nucleus pulposus
osteophyte
osteophyte formation
spinal stenosis
stenosis
surgery
vertebral
vertebral bodies


Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.

PREOPERATIVE DIAGNOSIS: ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:, Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position. Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position. A preoperative x-ray was obtained to identify the operative level and neck position. An incision was marked at the C4-C5 level on the right side. The incision was opened with #10 blade knife. Dissection was carried down through subcutaneous tissues using Bovie electrocautery. The platysma muscle was divided with the cautery and mobilized rostrally and caudally. The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection. The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia. This was opened with scissors and dissected rostrally and caudally with the peanut dissectors. The operative level was confirmed with an intraoperative x-ray. The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator. The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5. Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted. We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes. Operating microscope was draped and brought into play. Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went. We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally. Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch. There was a transligamentous disc herniation, which was removed during this process. We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent. Cord was seen to be pulsating freely behind the dura. There appeared to be no complications and the decompression appeared adequate. We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body. An 8 mm lordotic trial was used and appeared perfect. We then used a corticocancellous 8 mm lordotic graft. This was tapped into position. Distraction was released, appeared to be in excellent position. We then positioned an 18 mm Vector plate over the inner space. Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position. We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion. All of the screws locked to the plate and this was confirmed on visual inspection. Intraoperative x-ray was again obtained. Construct appeared satisfactory. Attention was then directed to closure. The wound was copiously irrigated. All of the self-retaining retractors were removed. Bleeding points were controlled with bone wax and bipolar electrocautery. The platysma layer was now closed with interrupted 3-0 Vicryl sutures. The skin was closed with running 3-0 Vicryl subcuticular stitch. Steri-Strips were applied. A sterile bandage was applied. All sponge, needle, and cottonoid counts were reported as correct. The patient tolerated the procedure well. He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.

acf spacer
anterior
anterior cervical discectomy
arthrodesis
cervical
corticocancellous
discectomy
herniated nucleus pulposus
lordotic
screws
spacer
surgery
synthes vector plate


Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.

ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:, This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs. She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted. Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. She was interested in participating in the artificial disk replacement study and was entered into that study. She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. She has done well postoperatively with a sensation of right arm pain and numbness in her fingers. She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment. She will contact our office prior to her appointment if she has problems. Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill.

anterior cervical discectomy
artificial disk replacement
cervical
discectomy
herniated nucleus pulposus
nucleusnote
surgery


Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr. 7. Microscopic dissection.

PREOPERATIVE DIAGNOSIS:, Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1. Anterior cervical discectomy, C4-C5 and C5-C6.,2. Arthrodesis, C4-C5 and C5-C6.,3. Partial corpectomy, C5.,4. Machine bone allograft, C4-C5 and C5-C6.,5. Placement of anterior cervical plate with a Zephyr C4 to C6.,6. Fluoroscopic guidance.,7. Microscopic dissection.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:, This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. We then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C4 and in to the body of C6. The disc was then completely removed at C4-C5. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments were noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed. The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area. Again part of the body at C5 was removed to make sure that there was no additional constriction. Both nerve roots were then widely decompressed. Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition.

anterior
anterior cervical discectomy
arthrodesis
bone allograft
cervical
cervical discectomy
cervical plate
corpectomy
disc herniations
discectomy
fluoroscopic guidance
machine bone allograft
microscopic dissectio
surgery
zephyr


Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.

PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1. Anterior cervical decompression, C5-C6.,2. Anterior cervical decompression, C6-C7.,3. Anterior spine instrumentation.,4. Anterior cervical spine fusion, C5-C6.,5. Anterior cervical spine fusion, C6-C7.,6. Application of machined allograft at C5-C6.,7. Application of machined allograft at C6-C7.,8. Allograft, structural at C5-C6.,9. Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE: ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness. Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left. The patient has failed epidural steroid injections. Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position. After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion. A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body. It was taken down through the subcutaneous tissues exposing the platysmus muscle. The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine. An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level. Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed. The disk was very degenerated and brown in color. There was an acute disk herniation through posterior longitudinal ligament. The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed. Approximately, 5 mm of the nerve root on both the right and left side was visualized. A ball-ended probe could be passed up the foramen. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place. There was good bony apposition both proximally and distally. Next, attention was placed at the C6-C7 level. Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed. The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left. The posterior longitudinal ligament was removed. A bilateral foraminotomy was performed. Approximately, 5 mm of the C7 nerve root was visualized on both sides. A micro nerve hook was able to be passed up the foramen easily. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place. There was good bony apposition, both proximally and distally. Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws. Intraoperative x-ray confirmed appropriate positioning of the plate and the graft. The wound was then copiously irrigated with normal saline and bacitracin. There was no active bleeding upon closure of the wound. A small drain was placed deep. The platysmal muscle was closed with 3-0 Vicryl. The skin was closed with #4-0 Monocryl. Mastisol and Steri-Strips were applied. The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events. The patient was awoken and taken to the recovery room in satisfactory condition.

allograft
anterior
anterior cervical decompression
anterior cervical spine
cervical
cervical spine
herniated nucleus pulposus
spine fusion
surgery


Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy.

PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1. C5-C6 arthrodesis, anterior interbody technique.,2. C5-C6 anterior cervical discectomy.,3. C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4. Implantation of machine bone implant.,5. Microsurgical technique.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS: ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain. The pain has become more and more severe. It runs to the thumb and index finger of the right hand and it is accompanied by numbness. If he tilts his neck backwards, the pain shoots down the arm. If he is working with the computer, it is very difficult to use his mouse. He tried conservative measures and failed to respond, so he sought out surgery. Surgery was discussed with him in detail. A C5-C6 anterior cervical discectomy and fusion was recommended. He understood and wished to proceed with surgery. Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR. There general endotracheal anesthesia was induced. He was positioned on the OR table with an IV bag between the scapulae. The neck was slightly extended and taped into position. A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle. The incision was extended through skin, subcutaneous fat, and platysma. Hemostasis was assured with Bovie cautery. The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath. The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine. A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space. An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure. A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space. The operating microscope was then brought into the field and used throughout the case except for the closure. Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible. Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body. A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament. A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina. A small amount of disk material was found at the right neural foramen. After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated. A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate. So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk. The wound was thoroughly irrigated and inspected for hemostasis. A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated. The patient was valsalved. There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers. The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin. The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins. Sterile dressing was placed on the patient's neck. He was extubated in the OR and transported to the recovery room in stable condition. There were no complications.

anterior
anterior cervical discectomy
arm radiculopathy
bone implant
cervical
cervical discectomy
disc herniation
discectomy
disk
disk space
herniation
interbody
mystique
mystique plate
neural foramina
radiculopathy
surgery
wound


Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.

PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1. Anterior cervical discectomy of C3-C4.,2. Removal of herniated disc and osteophytes.,3. Bilateral C4 nerve root decompression.,4. Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. Grafting of fibular allograft bone for creation of arthrodesis.,6. Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain. Conservative therapy has failed to improve the problem. Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck. Dissection was carried down through the platysmal musculature and the anterior spine was exposed. The medial borders of the longus colli muscles were dissected free from their attachments to the spine. A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space. Castoff self-retaining pins were placed into the body of the C3 and C4. Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed. Quite a bit of overhanging osteophytes were identified and removed. As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs. A high-speed diamond bur was used to slowly drill these spurs away. I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen. The dura was extremely thin and I could see through it in several areas. I removed the bony compression in the foramen and identified soft tissue and veins overlying the root. All of these were not stripped away for fear of tearing this very tissue-paper-thin dura. However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis. As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally. Under distraction the graft was placed and fit well. An x-ray showed good graft placement.,Attention was turned to spinal instrumentation. A Synthes Short Stature plate was used with four 3-mm screws. Holes were drilled with all four screws were placed with pretty good purchase. Next, the locking screws were then applied. An x-ray was obtained which showed good placement of graft, plate, and screws. The upper screws were near the upper endplate of C3. The C3 vertebral body that remained was narrow after drilling off the spurs. Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure. A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied along with a rigid Philadelphia collar. The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.

allograft
anterior
anterior cervical discectomy
anterior technique
arthrodesis
autologous
bone
cervical
cervical discectomy
cord compression
creation of arthrodesis
discectomy
fibular allograft bone
grafting
harvesting
herniated
instrumentation
nerve root decompression
osteophytes
spinal
spinal cord
spinal cord compression
spinal instrumentation
surgery
vertebral
vertebral bodies
vertebral body


C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.

PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.

allograft
anterior
anterior cervical discectomy
bank allograft
cervical
cervical discectomy
cervical radiculopathy
discectomy
foramen
radiculopathy
surgery


Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.

PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:, Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:, C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy. After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees. A shoulder roll was placed and the head supported on a donut support. The cervical region was prepped and draped in the standard fashion. A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle. In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done. Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly. Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy. Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly. A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint. On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect. This was done under the microscope. A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus. A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level. This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen. Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released. Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right. This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots. With this done, the wound was irrigated. Hemostasis was ensured with bipolar coagulation. Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites. Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed. A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7. The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7. With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated. Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down. A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site. Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient remained hemodynamically stable throughout the procedure. Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling. In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure. The patient remained stable throughout the procedure.

anterior
anterior cervical discectomy
cervical
cervical disk protrusions
cervical pain
cervical plate fixation
cervical radiculopathy
decompression
discectomy
disk
fluoroscopy
intraoperative
radiculopathy
sofamor danek titanium window plate
surgery
vertebral
vertebral body


Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.

PREOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1. Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2. Bilateral C6 nerve root decompression.,3. Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4. Bilateral C5 nerve root decompression.,5. Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6. Bilateral C4 nerve root decompression.,7. Harvesting of autologous bone from the vertebral bodies.,8. Grafting of allograft bone for creation of arthrodesis.,9. Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12. Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6. There was a herniated disk with cord compression and radiculopathy at C4-C5. C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels. Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives. He clearly understands and has no further questions and requests that I proceed.,PROCEDURE: ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease. Dissection was carried down through the platysma musculature and the anterior spine was exposed. The medial borders of the longus colli muscle were dissected free from their attachments to the spine. Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained. A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space. The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies. The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament. The ligament was incised and the underlying dura was exposed. I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen. There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact. However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right. The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5. I worked down through bony osteophytes and identified the posterior longitudinal ligament. The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces. The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen. The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it. Again the microscope was angled to the left side where similar decompression was achieved. Central decompression was achieved here where there was a moderate amount of spinal cord compression. This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space. Here there were large osteophytes projecting posteriorly against the cord. I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord. This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord. I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right. The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis. A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration. Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis. Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4. Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge. I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks. The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described. An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation. Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate. The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush. The holes were drilled and the screws were placed. Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6. All eight screws had good purchase. The locking screws were tightly applied. An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure. The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained. A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct. There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.


INDICATION:, Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:, Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.,2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.,2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.,3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months.

acute coronary syndrome
angiographic
angiographic stenosis
angiography
angioplasty
artery
arthrectomy
catheterization
circumflex artery
coronary
coronary angiography
coronary artery
femoral
femoral angiography
hemostasis
lad
perclose hemostasis
proximal
rca
selective coronary angiography
stenting
surgery
ventricular angiography
ventricular catheterization
wire


PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:, Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron. She was placed supine on the operating room table. General endotracheal anesthesia was induced without difficulty. In the holding area, her allergies were reviewed. It is unclear whether she is actually allergic to penicillin. Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine. She might be allergic to BACTRIM and SULFA. After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand. There was no bifid uvula or submucous cleft. She had 3+ cryptic tonsils with significant debris in the tonsillar crypts. Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume. The left superior tonsillar pole was then grasped with curved Allis forceps. _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3. Mouthgag was released, reopened, no bleeding was seen. The right tonsil was then removed in the same fashion. The mouthgag released, reopened, and no bleeding was seen. Small red rubber catheter in the nasal passage was used to retract the soft palate. She had mild-to-moderate adenoidal tissue residual. It was removed with Coblation Evac Xtra gently curved Wand on 9/5. Red rubber catheter was then removed. Mouthgag was again released, reopened, no bleeding was seen. Orogastric suction carried out with only scant clear stomach contents. Mouthgag was then removed. Teeth and lips were inspected and were in their preoperative condition. The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:, Family will be counseled postoperatively. Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain. _______ and promethazine if needed for nausea and vomiting.

adenotonsillectomy
adenotonsillitis
coblation evac xtra wand
endotracheal anesthesia
forceps
hypertrophic adenotonsillitis
lortab elixir
mouthgag
red rubber catheter
surgery
total blood loss


Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.

PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED: ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction. The nasopharynx was inspected with the laryngeal mirror. Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx. The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit. The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris. The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.

adenoidectomy
cavity
hypertrophy
mcivor
mcivor mouth gag
nasal
nasal passage
nasopharynx
oral
oral cavity
oropharynx
palate
surgery
tongue


The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed.

PROCEDURE IN DETAIL: ,While in the holding area, the patient received a peripheral IV from the nursing staff. In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes. The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines. Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain. Approximately 3 mL were administered. The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye. During the draping process, care was taken to isolate the lashes. A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva. Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus. Blunt dissection was carried out in the superotemporal quadrant. Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness. This flap was cut forward to clear cornea using a crescent blade. The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. The tube was then cut to an appropriate length to enter the anterior chamber. The anterior chamber was then entered after a paracentesis wound had been made temporally. A trabeculectomy was done and then the tube was threaded through the trabeculectomy site. The tube was sutured in place with a multi-wrapped 8-0 nylon suture. The scleral flap was then sutured in place with two 10-0 nylon sutures. The knots were trimmed, rotated and buried. A scleral patch was then placed of an appropriate size over the two. It was sutured in place with interrupted 8-0 nylon sutures. The knots were trimmed. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle. The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft. A good flow was established with irrigation into the anterior chamber. Homatropine, Econopred, and Vigamox drops were placed into the eye. A patch and shield were placed over the eye after removing the draping and the speculum. The patient tolerated the procedure well. He was taken to the recovery in good condition. He will be seen in followup in the office tomorrow.

: 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.


Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.

PREOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA: ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION: ,In the right flank-up position, table was flexed. He had a Foley catheter in place. Incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. The vena cava was identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down. The edges were freshened up. Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well. All sponge and instrument counts were correct. Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.

adrenalectomy
hernia
hernia repair
laparoscopic
laparoscopic hand-assisted
renal vein
surgery
umbilical
umbilical hernia repair
vena cava


Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.

PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculography.,4. Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was flushed. Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire. The catheter was then guided into the left ventricle. The guidewire and dilator were then removed. The catheter was then flushed. LVEDP was measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material. LVEDP was then remeasured. Pullback was performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary was unable to be engaged with this catheter. Thus it was removed over a guidewire. Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Left main coronary artery was then engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. The catheter was then removed from the ostium of the right coronary artery and then removed. The sheath was then flushed. Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization. Thus an #18 gauge Argon needle was used to cannulate the right femoral vein. A steel guidewire was inserted through the needle into the vascular lumen. The needle was removed over the guidewire. Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, a Swan-Ganz catheter was advanced to the level of 20 cm. The balloon was inflated. Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position. Hemodynamics were measured along the way. PA saturation, right atrial saturation, femoral artery saturation were all obtained. Once adequate study has been performed, the catheter was then removed. Both sheaths were flushed and found fine. The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection. There is no LVAO. There is no mitral regurgitation. There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY: ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart. There is a proximal 60% to 70% stenotic lesion. There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion. The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease. The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY: ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout. There is no evidence of any critical disease. The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS: ,Pulmonary artery pressure equals 61/23 with a mean of 44. Pulmonary artery wedge pressure equals 32. Right ventricle pressure equals 65/24. The right atrial pressure equals to 22. Cardiac output by Fick is 4.9. Cardiac index by Fick is 2.3. Hand calculated cardiac output equals 7.8. Hand calculated cardiac index equals 3.7. On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%. Femoral artery saturation equals 99.1%. Pulse oximetry is 99%. Right atrial saturation is 76.3%. Systemic blood pressure is 166/58. Body surface area equals 2.12. Hemoglobin equals 12.6.,IMPRESSION:,1. Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2. Normal left ventricular function with an estimated ejection fraction of 60%.,3. Biventricular overload.,4. Moderate pulmonary hypertension.,5. There is no evidence of shunt.,PLAN:,1. The patient will be admitted for IV diuresis in light of the biventricular overload.,2. The findings of the heart catheterization were discussed in detail with the patient and the patient's family. There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history. We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3. The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4. The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5. The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.


Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.

PREOPERATIVE DIAGNOSES:,1. Left superficial femoral artery subtotal stenosis.,2. Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Left superficial femoral artery subtotal stenosis.,2. Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1. Left lower extremity angiogram.,2. Left superficial femoral artery laser atherectomy.,3. Left superficial femoral artery percutaneous transluminal balloon angioplasty. ,4. Left external iliac artery angioplasty.,5. Left external iliac artery stent placement.,6. Completion angiogram.,FINDINGS: ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed. We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery. We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire. A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery. Because of the findings as noted above, this became more involved than initially hoped for. Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout. He had good palpable dorsalis pedis pulses bilaterally on completion. He was taken to the recovery room in satisfactory condition. Protamine was given to partially reverse the heparin.


Grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary - Omentectomy, pelvic lymph node dissection, and laparoscopy.

PREOPERATIVE DIAGNOSES,1. Incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2. Status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,POSTOPERATIVE DIAGNOSES,1. Incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2. Status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,OPERATIONS PERFORMED,1. Robotic-assisted omentectomy.,2. Robotic-assisted pelvic lymph node dissection.,3. Attempted laparoscopy.,4. Exploratory laparotomy with bilateral pelvic bilateral periaortic lymph node dissection with multiple biopsies.,ANESTHESIA:, General/epidural anesthesia.,ESTIMATED BLOOD LOSS:, 200 mL.,COMPLICATIONS:, None.,FINAL SPONGE AND NEEDLE COUNTS: , Correct, confirmed by x-ray JP drain x1.,INDICATIONS FOR SURGERY: , Mrs. A is a pleasant 66-year-old female who was diagnosed with an unsuspected grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary. The patient is status post laparoscopic-assisted vaginal hysterectomy BSO. The patient was referred to me by Dr. X. Because of the incomplete staging, the patient was advised to undergo a robotic-assisted surgical staging. Risks, benefits, and rationale of these procedures were reviewed. The patient has understanding of these risks and wishes to proceed with the surgery as planned.,INTRAOPERATIVE FINDINGS,1. No evidence of ascites.,2. At the time of the exploratory laparotomy, the diaphragm was well palpated. They were clear. The low attachments were removed. The lesser omentum was unremarkable. The pancreas, spleen, and liver were unremarkable. The gallbladder was unremarkable. The stomach appeared grossly normal. The small bowel was inspected from the ligament which starts to the ileocecal valve. There is no evidence of disease. Paracolic gutter and peritoneum was free. The omentum was grossly normal.,3. In the pelvis, uterus, tubes, and ovaries were absent. There was no evidence seeding along the bladder, pelvic, cul-de-sac, and peritoneum.,4. Retroperitoneally, pelvic lymph nodes were mostly normal; however, at the right aortic, there are nodes. These nodes were extremely fibrotic and they were densely adherent to the anterior wall of the vena cava which precluded me from performing a robotic periaortic lymph node dissection. There was some area that was suspicious right at the low right periaortic lymph node. They were sent for frozen section and they came back as benign. It is unclear to me why did the lymph nodes were quite fibrotic and firm, but we will wait for the pathology report.,PROCEDURE IN DETAIL: , The patient was given IV antibiotics prior to our incision site, sequential compression device was placed as part of the DVT prophylaxis. I have requested an epidural catheter be placed for purpose of the periaortic lymph node dissection. With this in mind, we proceeded as such.,We initially began with the robotic portion of the procedure.,A 1-cm supraumbilical incision made. A Veress needle was inserted without difficulty. Pneumoperitoneum was achieved to the abdominal pressure of 15 mmHg. A 12mm trocar was inserted without difficulty. After completion of this, a 12mm trocar was placed in the left lower quadrant 2 fingerbreadths medial to the anterior superior iliac spine under direct laparoscopic visualization. After completion of this, a laparoscope was then placed in the left lower quadrant port to assist in the placement of the remainder of the da Vinci ports. Two 8-mm ports were placed in the right upper quadrant 8 cm apart while one 8-mm port was placed in the left upper quadrant 8 cm apart. After completion of this, the patient was placed in steep Trendelenburg position. The robotic system was then docked and after docking the robotic system, the instrumentation was inserted under direct laparoscopic visualization to ensure that there was no injury to the abdominal contents. Once this was completed, the robotic camera was then docked. We then proceeded with our daVinci portion of the procedure.,I then proceeded now with the omentectomy. The omentum was taken off the transverse colon with the harmonic scalpel. The entire omentum was removed and placed in the pelvis. After completion of this, I then proceeded now with the pelvic lymph node dissection.,An incision was made parallel along the peritoneum overlying the psoas muscle. All the lymph node bearing tissues along the external iliac artery and vein were subsequently skeletonized off the vessels and resected. The lymph node bearing tissues interposed between the external iliac vein and psoas muscle were mobilized into the obturator fossa and subsequently removed off the accessory obturator vein, artery and nerve. In the process of removing the lymphoid tissues, the genitofemoral nerve along with the accessory obturator vein, obturator artery and nerve were all preserved. The lymphoid tissues interposed between the external iliac vein and psoas muscle along with the common iliac vessels were also subsequently removed. The lymph node bearing tissues bifurcating at the hypogastric and the external iliac vein were likewise removed in addition to the hypogastric lymph nodes. All the lymph node tissues were placed in an Endobag and removed and submitted as pelvic nodes on the right side and subsequently the left side. Boundaries of the pelvic nodal dissection distally were the external circumflex iliac vein, laterally the psoas muscle along with the obturator internus fascia, medially the superior vesical artery along with the ureter, and inferiorly below the obturator nerve.,At this point in time, we have attempted the periaortic lymph node dissection. I did open up the peritoneum overlying the bifurcation of the aorta. This peritoneum was incised up to the level of the duodenal recess. It was at this point in time that the periaortic lymph node dissection was extremely difficult. I was unable to get a tissue plane as the lymph nodes were apparently very fibrotic. I was concerned that I would tear off the anterior wall of the cava in the process of trying to perform the right periaortic lymph node. For this reason, I aborted the robotic procedure or in after nearly attempting for about an hour and a half for the periaortic lymph nodes. Once this was unsuccessful, the robotic system was then dedocked. I then placed additional ports. A 5-mm port was placed in the suprapubic region, two fingerbreadths above. A right lower quadrant 12-mm port was placed. After completion of this, I had attempted to see whether we could do the remainder of the periaortic lymph node dissection via laparoscopically. Despite an attempt for a nearly 35 minutes, I was not able to get adequate exposure. The small bowel kept on falling in the operative field which precluded us to perform the procedure safely. For this reason, I converted to an open procedure.,A midline incision was made from suprapubic bone and extended above the umbilicus. The abdominal cavity was entered without injuring the bell. After entering the abdomen, omentum was removed. Ray-Tec sponges were removed. We covered for the Ray-Tec sponges. After completion of this, Thompson retractor was placed. The patient was placed in C-Trendelenburg position. The bowel was packed cephalad. Retroperitoneum space was entered right and left ureters were identified. I then meticulously resected the lymphoid-bearing tissues anterior and lateral to the cava. This dissection was quite difficult as the lymph nodes were extremely fibrotic and adherent to the caval wall. I was able to freed up these lymph nodes without injuring of the cava. Likewise, the left periaortic lymph node dissection was carried out from the level of the bifurcation to 1 cm above the IMA. All the periaortic lymph node dissection was then carried out. After completion of this, I then took washings. Random biopsies were obtained of the cul-de-sac and right and left pelvic side wall along with the right and left paracolic gutter. After completion of this, the patient appears to have tolerated the procedure well. There was no obvious gross disease. The bowel was inspected meticulously to ensure that there was no evidence of injury. Once this was completed, the bowel was placed back to its normal position. Several film solutions were placed. We counted for sponges, needles, and instruments. Once this was counted for, the fascia was then closed with #2 Vicryl suture in a mass closure fashion. The subcutaneous route was copiously irrigated with water. The JP drain was brought to the right lower quadrant incision. All the incision ports were then closed with 3-0 Monocryl suture. Likewise, the midline incision was closed with 3-0 Monocryl sutures.,At the conclusion of the procedure, there was no obvious gross disease left.,


Adenoidectomy procedure

ADENOIDECTOMY,PROCEDURE:, The patient was brought into the operating room suite, anesthesia administered via endotracheal tube. Following this the patient was draped in standard fashion. The Crowe-Davis mouth gag was inserted in the oral cavity. The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril. Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer. The adenoid pad was removed without difficulty. The nasopharynx was packed. Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated. The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.


Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.

POSTOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy.,OPERATION PERFORMED: Adenotonsillectomy.,ANESTHESIA: General endotracheal.,INDICATIONS: The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE: The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion. A McIvor mouth gag was applied. The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand. A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly. The adenoids were removed with suction electrocautery under mere visualization. The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion. The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion. The inferior, middle and superior pole vessels were further cauterized with suction electrocautery. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.


Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.

PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE: ,Adenotonsillectomy.,COMPLICATIONS:, None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed. A similar procedure was performed on the contralateral tonsil. Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted. The patient was then allowed to awaken and was brought to the recovery room in stable condition.

adenoid
adenotonsillectomy
curettes
curved allis
hypertrophied
surgery
tonsillar
tonsillitis