Samples of Transcribed Documents
RADIOLOGY AND OPERATIVE REPORTS ONLY ON THIS PAGE
DIAGNOSIS: STAGE IV, T4, N1, M0 SQUAMOUS CELL
CARCINOMA OF THE OROPHARNYX. RADIATION TREATMENT WAS
COMPLETED 10/2/99
Dear Dr. X:
INTERVAL HISTORY: Mr. John Doe returned yesterday. It
has been a month since he was last seen here. He is
status post osteonecrosis of his right mandible. He
has seen Dr. X. He has had some of the exposed bone
removed. He has been feeling a lot better since then.
Very little pain remains. Last night when he was
eating popcorn, he developed some swelling and
discomfort over his right cheek. I told him that his
salivary gland probably was swollen. He is having no
difficulties swallowing. He is eating garnishes,
breakfast with protein enhancers, and some soft foods.
His weight has dropped about 2˝ pounds since last
month. No other complaints or problems were offered;
no suggestion of a new primary.
PHYSICAL EXAMINATION: Weight 244˝ lbs.
Mr. Doe
appears about the same as the last time I saw him. He
is in no apparent distress. Neck was supple without
lymph node. Lungs were clear to auscultation
bilaterally. Inspection of oral cavity and oropharynx
shows he has some small area of exposed bone in the
right posterior mandible. There are two separate areas
of some bridging of the gingiva covering partially
over those areas. It is smooth to feel. I do not feel
any rough edges or jagged edges. View of the thyroid
scope, supraglottic and glottic structures are readily
visualized. They appeared to be normal. The oropharynx
is also visible and palpably normal.
IMPRESSION:
1. No evidence of disease recurrence.
2. Osteonecrosis of the right mandible.
PLAN: I will ask Mr. Doe to return to see me in one
month. If he continues to heal, that would be great.
If there is some delay in his healing, our concern for
progression is osteonecrosis. I think he should have
hyperbaric oxygen. Once again, thank you very much for
allowing us to participate in Mr. Doe's oncology care.
---------------------------------------------------------------------------------
EYE SURGERY
Description of Procedure: The patient was taken to the
operating room, anesthetized with a peribulbar
anesthetic, 5 cc, and prepped and draped in the
prescribed manner. A wire lid speculum was then placed
beneath the lid of the left eye and a 4-0 silk suture
was placed beneath the belly of the superior rectus
muscle. A peritomy was made at the limbus at 12
o'clock. Superficial episcleral bleeders were
cauterized with wet-field cautery. With a Beaver #69
blade, a groove was made 1.5 mm posterior to the
limbus. A crescent knife was used to dissect the
scleral tunnel to clear cornea.
The chamber was entered with a sharp keratome. Healon
was used to deepen the chamber. A capsulotomy was
performed with the can-opener technique and the lens
nucleus rocked loose. A phacoemulsification tip was
introduced and a large bowl sculpted. The remaining
nucleus was brought into the anterior chamber, and
with the pulse mode and phacoemulsification with high
vacuum, the remaining nucleus was removed without
complication. With the irrigation and aspiration, the
cortical material was removed. The posterior capsule
was polished. The chamber was deepened with
viscoelastic and a posterior chamber lens implant of
the appropriate power was placed in the capsular bag.
The lens was centered with a Sinskey hook. The Healon
was removed and Miochol injected. The pupil was noted
to be round and small. A single 10-0 nylon suture was
used to close the wound. The wound was checked for
leakage and found to be secure. The conjunctiva was
closed with wet-field cautery and antibiotic and
steroid combination injected sub-Tenon. The superior
rectus suture was removed and the lid speculum was
removed. A patch and shield were placed over the eye
and the patient returned to the recovery room in good
condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Radical retropubic prostatectomy.
Bilateral pelvic lymph node dissection.
INDICATIONS FOR SURGERY:
This 64-year-old gentleman was recently found to have
a PSA elevation to 4.1 which prompted a biopsy of the
prostate, which then showed prostate cancer. A
metastatic workup was negative for disease spread. He
was counseled regarding treatment options and desired
to undergo a radical prostatectomy. He was well
informed regarding all risks, alternatives, and
expectations, and provided his adequate informed
consent prior to surgery.
PREOPERATIVE DIAGNOSIS:
Prostate cancer, stage T1c.
POSTOPERATIVE DIAGNOSIS:
Prostate cancer, stage T1c.
ANESTHESIA:
Regional.
SPECIMEN:
Prostate with seminal vesicles and bilateral pelvic
lymph nodes.
DESCRIPTION: The patient was brought to the operating
room and regional anesthesia was achieved. He was
placed supine on the operating table. His lower
abdomen and genitalia were prepped and draped in a
sterile manner. The operating room table was flexed.
Routine antibiotic prophylaxis was provided. A
20-French Foley catheter was inserted per urethra at
the beginning of the case and connected to straight
drainage. A lower midline abdominal incision between
the umbilicus and the symphysis pubis was then made
dividing the rectus abdominis muscle bellies. The
Space of Retzius ( retropubic space) was entered. Routine bilateral
pelvic
lymph node dissections were performed. The lymph node
packets were not thought to be suspicious for disease
spread, and thus they were sent for final
histopathologic diagnosis. Surgery continued. The fat
overlying the endopelvic fascia was then removed. The
endopelvic fascia was then incised bilaterally at
reflections with the lateral pelvic side walls. The
dorsal vein complex was isolated. This was oversewn
initially with a running 3-0 Monocryl suture.
Thereafter, the complex was divided distal to the
apex. Monocryl suture was used to complete hemostasis.
Dissection of the prostate was then performed from the
apex to the base of the prostate, preserving
neovascular tissue bilaterally. At the base of the
prostate, seminal vesicles were dissected free and the
vas deferens were clipped and divided. The prostate
was divided from the bladder neck circumferentially
while avoiding injury to the ureters. The specimen was
removed intact from the operative field. It was also
sent for final histopathologic diagnosis. Hemostasis
was achieved and irrigation performed. Reconstruction
of the bladder neck was then performed. This was done
in a standard tennis-racket-type closure using both
2-0 and 4-0 chromic suture which formed a handle and
racket respectively. The mucosa of the bladder neck
was everted and the reconstructed bladder neck
measured approximately 22-French in size. Five
separate 2-0 Monocryl sutures were originally placed
within the urethral stump and were then used to
complete an anastomosis with the reconstructed bladder
neck. The anastomosis was completed over an 18-French
Foley catheter reinserted per urethra. The
reconstruction was shown to be watertight. The
catheter was connected to straight drainage.
Percutaneous drains were placed bilaterally with
inward ports directed toward the obturator fossae.
They were secured at the skin level with 3-0 nylon
suture and connected to Hemovac suction. Irrigation
was then performed. Closure was then performed at the
fascial level with a #1 PDS suture and at the skin
level with staples. A dry sterile dressing was
applied. This completed the procedure. There were no
apparent complications. At the conclusion of the
procedure, all needle, sponge, and instrument counts
were noted to be correct. Estimated blood loss was
1700 ml. Replacement consisted of 5.5 liters
crystalloid and 2 U autologous blood. The patient was
transferred to a stretcher and taken to the recovery
room in satisfactory condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Right stereotactic percutaneous trigeminal glycerin
rhizotomy under fluoroscopic control.
PREOPERATIVE DIAGNOSIS:
Recurrent resistant right-sided trigeminal neuralgia.
POSTOPERATIVE DIAGNOSIS:
Recurrent resistant right-sided trigeminal neuralgia.
ANESTHESIA:
Light general intravenous sedation.
DESCRIPTION: The patient was brought to the general
operating room, placed on the table in the supine
position, and light general intravenous sedation was
established by anesthesia. A lateral fluoroscopic
image of the skull was established, and then the right
cheek was prepared and draped in the usual sterile
fashion for glycerin rhizotomy. The cheek was
infiltrated with 1% Xylocaine, and then utilizing
external stereotactic landmarks and an internal finger
in the lateral pterygoid wing, a long 20-gauge spinal
needle was passed to the level of the foramen ovale.
This was done with some degree of difficulty, but
eventually it was possible to guide the tip of the
needle to the level of the clivus under fluoroscopic
control.
The stylette was withdrawn with no initial return of
cerebrospinal fluid, and then advanced until there was
some cerebrospinal fluid. The head of the bed was then
elevated to 60 degrees, and 0.4 cc of anhydrous
glycerin slowly injected. There was no bradycardia.
The needle was withdrawn and the patient was left in
the 60-degree head-up position and taken to the
recovery room in satisfactory condition.
---------------------------------------------------------------------------------
CIRCUMCISION:
DESCRIPTION: With the patient in the supine position
and under general anesthesia, the lower abdomen and
genitalia were prepped and draped appropriately. A
hemostat was used to bluntly take down adhesions
between the foreskin and glans. A circumferential
incision was made on the outer prepuce at the level of
the corona. A second incision was made on the inner
prepuce 4 mm beneath the corona and carried straight
across the frenulum. A plane of dissection was
established dorsally and the dorsal foreskin was
divided. Attachments between the foreskin and penis
were then taken down sharply. Bovie electrocautery was
used for hemostasis. Then 5-0 chromic interrupted
sutures were used to complete the procedure. A sterile
Tegaderm dressing was applied. The patient tolerated
the procedure well and was taken to the recovery room
in satisfactory condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Extracapsular cataract extraction, right eye, by
phacoemulsification with implantation of posterior
chamber intraocular lens.
INDICATIONS FOR SURGERY:
Slow, painless decreased vision, right eye, secondary
to cataract formation, interfering with the patient's
ability to perform daily activities.
PREOPERATIVE DIAGNOSIS:
Cataract, right eye, with impaired function.
POSTOPERATIVE DIAGNOSIS:
Cataract, right eye, with impaired function.
ANESTHESIA:
Local with intravenous sedation.
DESCRIPTION: Following instillation of dilating and
antibiotic eye drops, the patient was brought to the
operating room where anesthesia was induced through
neuroleptic along with peribulbar injection. Following
onset of anesthesia and akinesia, the patient was
prepared and draped for ophthalmic surgery. A wire lid
speculum was placed in the right eye and a 5-0 black
silk stay suture was placed beneath the superior
rectus muscle. A fornix-based conjunctival flap was
formed with Westcott scissors and hemostasis was
achieved with electrocautery. Clear-cornea
paracentesis wound was made with a Supersharp blade. A
#7 blade was used to make a superior scleral incision
2 mm posterior to the surgical limbus. From this
point, the crescent blade was used to fashion a
scleral tunnel through which the anterior chamber was
entered with a 3.2-mm keratome. Viscoelastic was
injected into the anterior chamber to deepen it, and
an anterior capsulotomy performed with a
capsulorrhexis technique. The nu cleus was
hydrodissected with balanced salt solution and
emulsified with the phacoemulsification device. The
remaining cortex was removed using irrigation and
aspiration. Additional viscoelastic was reintroduced
into the anterior chamber to deepen it. The scleral
tunnel was enlarged with a 5.2-mm keratome. The
posterior chamber intraocular lens was inspected and
irrigated with balanced salt solution. Using a smooth
lens forceps, we introduced the lens into the eye and
placed it in the appropriate pos ition. Following
rotation, it was noted to be well centered and well
positioned with the loop in the horizontal position.
The viscoelastic was removed using irrigation and
aspiration, and Miochol was injected into the anterior
chamber, producing a small round pupil. The scleral
wound was closed with an interrupted 10-0 nylon
suture. The wound was found to be watertight, as was
the paracentesis wound. The anterior chamber was deep
and well formed with a well-centered intraocular lens.
The conjunctiva was closed with electrocautery. The
wire lid speculum and stay suture were removed from
the eye which was then dressed with topical antibiotic
and steroid drops followed by a patch and shield. The
patient tolerated the procedure well and was taken to
the recovery room in alert and stable condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Right breast needle-localization biopsy.
PREOPERATIVE DIAGNOSIS:
Right breast mammographic abnormality.
POSTOPERATIVE DIAGNOSIS:
Right breast mammographic abnormality.
ANESTHESIA:
Local with sedation.
DESCRIPTION: The patient was first taken to the
mammography suite where the right breast mammographic
abnormalities were needle localized in a routine
fashion. She was then brought to the operating room
and placed on the operating room table in the supine
position. The patient's right breast was then prepared
and draped in the usual sterile fashion. Local
anesthesia was then infiltrated in the proposed
incision site. A small circumareolar incision was then
made over the area in question. The incision was
carried down to the subcutaneous tissue to the breast
tissue proper. The area in question was then grasped
with an Allis clamp and dissected free using Bovie
electrocautery. The specimen was then removed and sent
to mammography which confirmed removal of the
mammographic abnormality.
Attention was now turned back to the breast tissue
proper. Hemostasis was obtained with Bovie
electrocautery. The wound was irrigated with bibiotic
solution. At this point, there was good hemostasis and
sponge and needle counts were correct. The
subcutaneous tissue was then reapproximated with
several interrupted 3-0 Vicryl sutures. The skin was
then closed with a running subcuticular 4-0 Prolene
suture. At the end of this portion of the case, there
was good hemostasis and the sponge and needle counts
were correct. The incision was then cleaned with a wet
and a dry, and then benzoin and Steri-Strips were
applied. A dry sterile dressing was applied. The
patient tolerated the procedure well. Estimated blood
loss was approximately 10 cc.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Right orchidopexy.
PREOPERATIVE DIAGNOSIS:
Undescended right testis.
POSTOPERATIVE DIAGNOSIS:
Undescended right testis.
ANESTHESIA:
General mask anesthesia.
DESCRIPTION: With the patient in the supine position
after a suitable level of general mask anesthesia had
been obtained, the penis and genitalia were prepared
and draped in the usual manner. A transverse incision
was made in the suprapubic skin fold on the right with
a #15 blade. Bleeding was controlled with
electrocautery. The subcutaneous tissues were incised
and the testis was noted just emerging from the
external inguinal ring. The external oblique fascia
was opened with a #15 blade and Metzenbaum scissors.
The testis was grasped and freed up from the
surrounding fibers. This was freed up to the level of
the internal inguinal ring. The hernia sac was then
opened and the hernia sac dissected up to the level of
the internal ring where it was twisted and transfixed
with 4-0 Vicryl. With this maneuver, quite adequate
testis length was obtained.
Dr. X then returned to the operating room, rescrubbed
and regowned and joined the operation. The testis was
brought down to the subcutaneous dartos pouch created
in the manner of Latimer in the scrotum. The testis
was brought into the pouch and 3-0 silk suture was
placed in the connective tissue of the testis, brought
out through the scrotal wall and tied over a cotton
pledget. The scrotal incision which had been made with
a #15 blade was then closed with a 5-0 Vicryl. Careful
search for bleeding was undertaken. None was seen in
the scrotum or in the groin. The external oblique
fascia was then closed with running 4-0 Vicryl. The
subcutaneous tissue was closed with 4-0 Vicryl. The
skin was closed with running subcuticular 3-0 Prolene
suture. There were no intraoperative complications.
The child was discharged from the operating room in
satisfactory condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Cystourethroscopy, left retrograde ureteropyelogram
and left dismembered pyeloplasty.
PREOPERATIVE DIAGNOSIS:
Left ureteropelvic junction obstruction.
POSTOPERATIVE DIAGNOSIS:
Left ureteropelvic junction obstruction.
ANESTHESIA:
General endotracheal anesthesia.
DESCRIPTION: The patient was brought to the operating
room and underwent general anesthesia. He was placed
in the dorsal lithotomy position. He was prepared and
draped in the usual manner. The 9.5 pediatric
cystoscope was placed in the bladder and a #3 ureteral
catheter was placed through the torquing channel. A
left retrograde ureteropyelogram was obtained. This
showed a clear obstruction at the junction of the left
ureteropelvic junction. The cystoscope and stent were
then removed.
The patient was then placed in the left-flank-up
position. An incision was made off the tip of the 12th
rib with a #15 blade. Bleeding was controlled
utilizing electrocautery. The muscle fibers were all
incised in the flank with electrocautery. Two
Richardson retractors were placed. Gerota's fascia was
opened in a vertical fashion and the kidney was
delivered. The ureter was found in the retroperitoneal
space and dissected out to the level of the renal
pelvis. There was clear obstruction and kinking at the
level of the ureteropelvic junction. Markings sutures
were placed in the ureter and the renal pelvis with
6-0 Vicryl. The obstructive segment was excised and
the tenth renal pelvis was then decompressed. An
oblique anastomosis was then effected between the
upper ureter which had been spatulated and the renal
pelvis. This was accomplished with two sutures of 6-0
Vicryl at the apices and then running sutures on the
anterior and posterior wall with 6-0 Vicryl. Prior to
completing the anterior anastomosis, a 10-French
Malecot catheter was used as a nephrostomy tube and
brought with the nephrostomy needle through the
substance of the kidney and was brought out through
the flank, and it was sewn to the flank with 4-0
Prolene. The anterior aspect of the anastomosis was
then completed after a #3 pediatric feeding tube was
placed through the anastomosis andÔ to be watertight.
The kidney was returned to the renal space. Gerota's
fascia was left open in the caudad portion. A Penrose
drain was placed through a stab wound and brought down
to the inferior portion below the anastomosis. This
was sewn to the skin with 4-0 nylon. The muscle layers
were then closed with running 3-0 Vicryl. The
subcutaneous layer was closed with 4-0 Vicryl and the
skin was closed with a running subcuticular 3-0
Prolene suture. There were no intraoperative
complication. The patient was discharged to the
recovery room in satisfactory condition.
---------------------------------------------------------------------------------
EYE SURGERY: MEDIAL RECTUS RECESSION
PREPARATION: Both eyes were prepared with Ioprep and
draped in the usual sterile manner.
DESCRIPTION: After appropriate draping, a lid speculum
was placed between the lids of the right eye. An
incision was made supertemporally to expose the right
medial rectus muscle. This was hooked with a muscle
hook and secured with 6-0 Vicryl sutures and
disinserted from the globe. It was reattached to the
globe in hang-back, adjustable suture fashion,
recessing it 6 mm from the original insertion. A 5-0
Mersilene suture was placed for traction purposes
during the adjustment process.
The right superior rectus muscle was then approached
through the same supranasal incision, hooked to the
muscle hook and cleared of surrounding tissue far
backwards over the top surface of the muscle, and was
disinserted from the globe after being secured with a
double-armed 6-0 Vicryl suture. It was reattached to
the globe in hang-back adjustable suture fashion,
recessing it 4 mm from the insertion site, and 5-0
mersilene traction suture was placed.
The left medial rectus muscle was then recessed in a
similar manner, 5.5 mm on an adjustable suture. Both
eyes were dressed with Pred-G ointment. The patient
was returned to her room in good condition, having
tolerated the procedure well.
---------------------------------------------------------------------------------
EYE SURGERY: TRABECULECTOMY WITH BIOPSY:
The patient was brought to the operating room and
placed in the supine position. Local anesthesia was
induced with a retrobulbar injection of 2% Xylocaine
mixed 1:1 with 0.75% Marcaine with Wydase. The eye was
prepared and draped in the usual sterile fashion. A
lid speculum was placed between the lids. Conjunctival
incisions were made nasally and temporally, and a 4-mm
infusion cannula was sutured into the inferotemporal
quadrant 4 mm posterior to the limbus using a 4-0
Vicryl suture. After cannula tip placement in the
vitreous cavity had been verified, infusion was begun.
Supranasal and superotemporal sclerotomies were
performed, and the trocar and cannula system was
introduced. The vitrectomy was performed. The
posterior vitreous was not detached. It was elevated
from the posterior pole and trimmed back into the far
periphery.
We then selected a biopsy site inferiorly and cut out
a 2 x 2-mm piece of retina at 6 o'clock at the border
of infected and noninfected retina. There was no
significant bleeding. We then performed a fluid-gas
exchange, flatting the retina through the biopsy site.
Laser was placed around the biopsy for 360 degrees to
demarcate the peripheral retinitis. We then filled the
eye with silicone oil. The sclerotomies were sutured
shut with 7-0 Vicryl, and the conjunctiva was closed
with 6-0 plain. Sub-Tenon's Ancef and Decadron were
injected. The patient tolerated the procedure well and
was returned to the recovery room in stable condition.
---------------------------------------------------------------------------------
CATARACT SURGERY:
Description of Procedure: The patient was brought to
the operating room where the anesthesiologist
established I.V. lines and cardiac monitoring leads.
Mild intravenous sedation was administered. Using a
solution containing 0.75% Marcaine and 2% lidocaine
with Wydase, a peribulbar block was administered to
the right eye. Gentle digital pressure was applied to
the eye for approximately 2 minutes to help diffuse
the anesthetic. The patient was then prepared with a
5% solution of povidone-iodine to the conjunctival fornix
and lashes, and a 10% solution of
povidone-iodine to the lids and periorbital skin. The
patient was then draped in the usual sterile fashion.
A lid speculum and 4-0 silk superior rectus bridle
suture were then placed in the operative eye. A
keratome blade was then used to create a biplanar
incision into the anterior chamber. Healon was then
instilled into the anterior chamber.
A capsulorrhexis was then fashioned with a cystotome
blade. BSS and a cannula were then used to
hydrodissect and hydrodelineate the lens.
Aparacentesis incision was made at 3 o'clock with a
Supersharp blade. The phacoemulsification unit, after
being properly tuned and tested, was then used to
emulsify the nucleus. Residual cortical material was
aspirated from the capsular bag with the irrigation
and aspiration unit. Healon was then instilled into
the anterior chamber, severing the anterior and
posterior sections of the capsular bag. The corneal
wound was then enlarged to the size of the optic with
the keratome blade. The intraocular lens was then
inspected and thought to be satisfactory. Then the
lens was gently placed in the capsular bag.
Positioning within the capsular bag was confirmed by
direct visualization. Optic centration was
accomplished with a Sinskey hook. Residual Healon was
removed from the anterior chamber using the irrigation
and aspiration unit. Miostat was then instilled into
the anterior chamber, producing myosis without optic
capture. The corneal wound was then tested for leaks
and none were found. The conjunctiva was closed using
bipolar cautery. Subconjunctival injections of Ancef
and dexamethasone were then given inferiorly with the
needle tip visible at all times. The bridle suture and
lid speculum were then removed. Betoptic-S and Pred-G
ointment was then placed in the conjunctival fornix.
Sponge and needle counts were correct. An eye patch
and shield were placed over the operative eye. The
patient was taken to the recovery room in stable
condition. There were no complications. The patient
tolerated the procedure well. Dr. X performed the
entire procedure.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Extracapsular cataract extraction.
Lens implantation, right eye.
PREOPERATIVE DIAGNOSIS:
Cataract, right eye.
POSTOPERATIVE DIAGNOSIS:
Cataract, right eye.
ANESTHESIA:
Local with sedation.
PREPARATION: Soap and Ioprep.
DESCRIPTION: The patient was placed on the operating
room table in the supine position. After adequate
local anesthesia was achieved, the right face was
prepared and draped in the usual fashion. A lid
speculum was placed between the right lids. A stay
suture of 4-0 black silk was placed beneath the
insertion of the superior rectus muscle and the eye
retracted downward. A peritomy was then performed from
the 9 o'clock to the 3 o'clock position at the limbus.
Hemostasis was achieved using biopolar cautery. A
groove was then made from the 10 o'clock to the 2
o'clock position using a Beaver blade. A suture of 8-0
black silk was then preplaced in a mattress fashion at
10 o'clock and 2 o'clock. The sutures were removed
from the groove. The anterior chamber was entered at
the 12 o'clock position using a Supersharp blade. The
anterior chamber was reformed using Healon.
An anterior capsulotomy was then performed using a
bent 30-gauge needle. The wound was then opened to its
entire extent using straight corneoscleral scissors.
Lens nucleus was expressed without complication.
Previously placed 8-0 black silk sutures were
temporarily tightened and tied. Irrigation and
aspiration tip was entered into the anterior chamber
and the cortical remnants were removed. The lens was
then inserted without complication. The previously
placed 8-0 black silk sutures were permanently
tightened, tied and cut. Miochol was introduced into
the anterior chamber in such a fashion that the Healon
was irrigated free. The pupil came down nicely and was
round. The wound was secured using multiple simple
placed 10-0 nylon stitches at 11 o'clock, 1 o'clock.
These sutures were tightened, tied and cut. The
patient received subconjunctival injection of Decadron
and Ancef. The stay suture and the lid speculum was
removed. The eye was dressed and patched. The patient
was returned to the recovery room, having tolerated
the procedure well without complication.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Direct laryngoscopy, bilateral modified neck
dissection and total laryngectomy.
INDICATIONS FOR SURGERY:
This is a 37-year-old white male who has a bulky
supraglottic cancer with bilateral nodal metastases.
He is to undergo surgical treatment with curative
intent.
PREOPERATIVE DIAGNOSIS:
T3, N2c squamous cell carcinoma of the supraglottic
larynx.
POSTOPERATIVE DIAGNOSIS:
T3, N2c squamous cell carcinoma of the supraglottic
larynx.
ANESTHESIA:
General endotracheal anesthesia.
FINDINGS: There were large, greater-than-2-cm nodes in
both the jugular sheaths in level 2 and 3. There were
small nodes in the left level 5. The tumor in the
larynx extended along the entire length of the left
false cord and eroded the arytenoid and the thyroid
cartilage with extension into the base of tongue and
the base of the left piriform. Frozen section was
taken from the left base of tongue and left piriform
and were negative for tumor.
DESCRIPTION: In the supine position, general
anesthesia was induced and the patient was intubated
without difficulty. The Dedo laryngoscope was
introduced and the larynx, hypopharynx were inspected,
noting the extent of the tumor. The neck was
prepared with alcohol and 1% Xylocaine with
epinephrine 1:100,000; a total of 10 cc was injected
into the planned apron-flap incision. The decision was
made to elevate a platysma flap on the right side, and
so a football-shaped skin paddle, approximately 5 x 4
cm, was outlined. The superior edge of the paddle was
incised and taken down to platysma, and the skin
overlying the platysma was elevated. Then the inferior
edge was incised and the subplatysmal flap was
elevated on the right side. The subplatysmal flap was
kept moist in saline, and it was kept until the end of
the case.
A right-sided, modified neck dissection, sparing
jugular, exposed, dissecting on its superficial and
deep surface, and identifying the spinal accessory
nerve as it emerged from the deep surface up to the
skull base. The spinal accessory nerve was admitted
identified leaving Erb's point and was traced to the
trapezius and dissected away from surrounding tissues.
Then the omohyoid muscle was cut in its midpoint and
the jugular sheath opened. The vagus and carotid were
identified and spared. Dissection continued along the
floor of the posterior triangle, clamping the
transverse cervical vessels and ligating them with
silk ties. The phrenic nerve was identified and
spared, and the fat superficial to it was swept
upward, clamped and tied. Dissection then continued
along the posterior extent of the dissection following
the trapezius to the levator scapulae and up to the
sternomastoid. The fat in the posterior triangle was
then elevated from posterior to anterior, taking care
to cut the branches of the cervical plexus high on the
specimen to avoid injury to the phrenic nerve. The
posterior facial vein was identified and dissected
from surrounding tissue, leaving it as drainage
outflow for the platysmal flap. The anterior jugular
vein was clamped, divided and ligated. The hypoglossal
nerve and digastric muscle were used as the floor of
the anterior border of dissection, sweeping the
fibrofatty tissue downward from here. The spinal
accessory nerve was again dissected from surround
tissue superiorly and the specimen was taken in one
piece as a posterior neck dissection.
The anterior jugular sheath contents were left
pedicled to the larynx. Then the right thyroid lobe
was exposed, sparing the superior thyroid artery,
leaving it intact at the carotid. The midportion of
the inferior neck flap was then incised and a
tracheotomy performed. The strap muscles were split in
the midline and the thyroid isthmus divided with a
Shaw scalpel. A horizontal opening into the trachea
was made below ring three and beveled upward one ring
to allow placement of the anode tube. The endotracheal
tube was removed and the anode placed, and it was
stitched in place.
A left modified neck dissection ensued. Again the
sternomastoid and jugular vein, as well as the 11th
nerve were spared. Dissection was done in the same way
as before, except on the left side the submandibular
gland was included in the specimen. It was dissected
from the undersurface of the mandible, clamping an
dividing the facial vein but leaving the facial artery
in place. The mylohyoid muscle was identified and
retracted anteriorly, exposing the lingual nerve. The
branch to the submandibular gland was clamped, divided
and ligated, as was the duct. The gland was then
dissected off of the digastric muscle, moving it
inferiorly.
Once again, dissection then began inferiorly,
splitting the omohyoid, identifying the contents of
the carotid sheath and the phrenic nerve in the floor
of the triangle. Here structures that were candidates
for the thoracic duct were clamped, divided and
ligated. Once again, the spinal accessory nerve was
dissected from surrounding tissue both it its
posterior triangle extent and at the skull base. The
fibrofatty tissue was moved from posterior to
anterior, taking branches of the jugular vein but
leaving the main internal jugular intact. The specimen
in this way was completely mobilized and left attached
to the larynx.
Then the laryngeal tumor was visualized by entering
the right piriform sinus. The constrictor muscles were
divided off of the thyroid laminae and the hyoid bone
was skeletonized in its right portion. The
perichondrium of the thyroid was incised and elevated
on its undersurface, sparing the piriform mucosa. The
piriform was entered sharply. Using a Babcock, the
incision was extended across the right vallecula and
the tumor in the left base of tongue was visualized. A
Shaw scalpel was used to cut through the tongue base,
keeping one fingerbreadth's distance from the tumor,
as we moved across the base of tongue. This allowed
good visualization of the tumor, and it was finally
determined that a total laryngectomy would be needed
because of arytenoid erosion and involvement at the
junction of the false and true vocal cords.
Thus the strap muscles were divided inferiorly and the
left thyroid gland was mobilized, leaving it attached
to its pedicle. Once again, the constrictor muscles on
the left thyroid lamina were incised, but here the
piriform mucosa was not elevated at first until the
incisions could be made internally, going around the
portion of the tumor in the piriform. The superior
laryngeal artery and vein were clamped, divided and
ligated bilaterally. The larynx was mobilized upward,
allowing visualization of the piriform. The left
piriform was then incised below the tumor, leaving 2
cm of normal mucosal margin and extending across the
postcricoid area. Dissection into the party wall
allowed mobilization of the specimen and the
tracheotomy was completed below, going up the next
tracheal ring as well in a steeple or chimneylike
fashion.
The specimen was removed in one piece and sent for
permanent pathologic analysis. Frozen sections were
taken, as noted above, and returned negative for
tumor. Specimens were taken for the head and neck
tumor biology laboratory. Gloves and sharp instruments
were then changed and the pharyngotomy was closed in a
T-fashion using running canal stitch, beginning
inferiorly and from the right and left tongue base. A
second Lembert layer of 3-0 Vicryl was then placed,
and the wound was irrigated with bibiotic solution.
Three 10-0 Jackson-Pratt drains were placed, two on
the right and one on the left side. The stoma was
matured using 2-0 Prolene first to the clavicular
heads, splitting the anterior portion of the tracheal
rings down two rings and creating a V-shaped
advancement flap from the inferior neck skin to place
in this split. Vertical 2-0 Prolene sutures were then
placed around the stoma. Then the neck skin was closed
in layers using 3-0 Vicryl for the subcutaneous and
platysma closure. On the right side, the platysmal
flap pedicle was excised and discarded, but the
platysma was kept in place, and the skin was closed
without difficulty. Staples were placed on the skin.
Prior to closure of the pharynx, a #12 EntriFlex
feeding tube had been placed, and this was sewn in
place with 3-0 nylon in the nasal septum. The patient
was then awakened and extubated. He was taken to the
ACU where he arrived in stable condition, having
tolerated the procedure well without complication.
Estimated blood loss was approximately 800 cc.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Phacoemulsification with intraocular lens, right eye.
PREOPERATIVE DIAGNOSIS:
Cataract, right eye.
POSTOPERATIVE DIAGNOSIS:
Cataract, right eye.
ANESTHESIA:
Local with standby.
DESCRIPTION: After the patient was given a peribulbar
block consisting of 0.75% Marcaine with 2% Xylocaine
and Wydase, she was routinely prepared and draped for
right cataract surgery. A lid speculum was placed in
the eye and a superior rectus suture on the superior
rectus muscle. A fornix-based flap was raised and any
bleeding vessels were cauterized. A sharp knife was
used to make a side port and partial-scleral-thickness
incision which was dissected anteriorly. A 3-Mm
keratome was used to enter the anterior chamber.
Under Provisc, an anterior capsulotomy was performed
and hydrodissection occurred.
Phacoemulsification was performed, and irrigation and
aspiration of any remaining cortical material. The
wound was enlarged under Provisc to 5.5 mm so that a
#8191 IOLab lens could be placed in the bag and
switched to the 3 and 9 o'clock position with a
Sinskey hook. The remaining Healon was removed.
Miochol was placed in the eye. The wound was found to
be watertight. The fornix-based flap was closed with
cautery. Ancef and Decadron solution was injected
subconjunctivally. Pred-G ointment was place in the
eye. The eye was patched and shielded, and the patient
was taken to the recovery room in excellent condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Extracapsular cataract extraction.
Placement of posterior chamber intraocular lens
implant, right eye.
PREOPERATIVE DIAGNOSIS:
Visually significant immature cataract, right eye.
POSTOPERATIVE DIAGNOSIS:
Visually significant immature cataract, right eye.
ANESTHESIA:
Neuroleptic with I.V. sedation combined with local
consisting of 2% Xylocaine mixed half-and-half with
0.75% Marcaine by retrobulbar and Nadbath.
PROSTHETIC DEVICE/IMPLANT:
Posterior chamber intraocular lens.
DESCRIPTION: After satisfactory local and neuroleptic
anesthesia, the right eyelids and face were prepped
and draped in the usual fashion for sterile ophthalmic
surgery. A lid speculum was placed between the lids of
the right eye and traction suture of 4-0 black silk
was placed superiorly and attached to the drape. A
coelastic material, a capsulotomy of 360 degrees was
performed using the can-opener technique. The capsular
material was then removed from the center and the lens
was gently freed. The corneoscleral wound was then
extended to 10 mm and the lens nucleus was expressed
intact without difficulty. The cortical material was
then removed with aspiration. Following this,
additional viscoelastic material was placed and a
posterior chamber intraocular lens implant, 15
diopters, #MC60, was inserted. This was centered. Each
of the haptics was checked for positioning and
appeared to be tight.
The wound was closed with multiple interrupted 10-0
nylon sutures. Each of the sutures was buried. The
viscoelastic material was removed with aspiration.
Following this, the traction suture was removed and
the conjunctiva was closed with subconjunctival
gentamicin and Decadron. Maxitrol ointment and
Betoptic drops were placed and a pad and shield were
placed. The patient tolerated the procedure well and
was sent to the recovery room in satisfactory
condition.
---------------------------------------------------------------------------------
EYE SURGERY: After preoperative evaluation, Mr. X was
transported to the operating room. After
administration of intravenous sedation by
anesthesiology, a left retrobulbar block was then
performed using a 1.21 mixture of 4% lidocaine and
0.75% bupivacaine with Wydase without complication.
The fellow unoperated right eye was covered with a Fox
shield for the duration of the surgery. On
satisfactory akinesia and anesthesia were
demonstrated, the left eye was then prepped and draped
in the usual sterile fashion. A Maumenee lid speculum
was then placed between the lids of the left eye to
expose the left globe. A limited fornix-based
conjunctival peritomy was then performed to expose the
superior, inferotemporal, and superonasal sclera. A
caliper was used to measure 3 mm inferior to the
limbus in the inferotemporal quadrant, and the globe
was penetrated with a 19-blade MVR blade. An infusion
was placed. After visualizing deep in the vitreous
cavity, it was turned on. Sclerotomies were then made
superonasally and superotemporally 3 mm posterior from
the limbus. The MVR blade was then used to penetrate
the equator of the lens. Fragmentation of the lens was
performed, keeping the anterior capsule of the lens
intact. Following this, the trocar and cannula system
was introduced and the vitrectomy was performed,
letting the previous silicone oil out of the eye. The
posterior pole was visualized using the flat lens
followed by the quartz prism lens followed by the AVI
lens. Because of extensive anterior Postvoiding
residual, membrane peeling was performed anteriorly
followed by retinotomy for 360 degrees.
Perfluorocarbon was used to flatten the retina which
flattened nicely. The endolaser was applied in 360
degrees around the retinotomy. Following this, a
fluid-air exchange was performed and 5000 centistokes
of silicone oil was injected. It should be noted that
during the procedure there was leakage of fluid from
the superonasal sclerotomy which was lacerated. It was
then sutured with 8-0 nylon sutures and an additional
sclerotomy was performed more superiorly. Further
sclerotomies in these areas should be avoided.
Following the silicone oil injection, the sclerotomies
were closed with 7-0 Vicryl sutures. The conjunctiva
was closed with 6-0 plain gut. Subconjunctival
dexamethasone and Ancef were injected. The eye was
patched and shielded and the patient was returned to
the floor in good condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Phacoemulsification of cataract with intraocular lens
implantation, OS, clear-cornea approach.
PREOPERATIVE DIAGNOSIS:
Cataract, OS.
POSTOPERATIVE DIAGNOSIS:
Cataract, OS.
ANESTHESIA:
Local/MAC.
PROSTHETIC DEVICE:
Intraocular lens, Alcon model #MA60BA, 22 diopters,
serial #427252.090.
DESCRIPTION: After informed consent was obtained and
all questions were answered, the patient was brought
to the operating room and placed in the supine
position. After adequate I.V. sedation, a retrobulbar
block of 5 cc of a 50:50 mixture of 2% lidocaine with
Wydase and 0.75% Marcaine was given. The Honan balloon
was then applied to the left eye at 40 mmHg for 5
minutes. The left eye was prepped and draped in the
usual sterile fashion. A lid speculum was placed
between the lids of the left eye. A clear-corneal
incision was made at the temporal limbus. Healon was
used to reform the anterior chamber. A continuous-tear
capsulorrhexis was performed. Hydrodissection of the
lens nucleus was performed. The lens nucleus was then
removed using the phacoemulsification handpiece. The
I/A handpiece was used to remove the residual cortex.
The capsular bag was reinflated with Healon. The
intraocular lens was folded and placed into the
capsular bag under direct inspection. The I/A hand
piece was used to remove residual Healon. Miochol was
injected. The wound was closed with a single 10-0
Vicryl suture. Ancef and Decadron were injected
beneath the conjunctiva. The lid speculum was removed
and Pred-G ointment applied. A patch and shield were
applied. The patient left the operating room in stable
condition and there were no complications. Dr. X was
present and assisted for the entire procedure.
---------------------------------------------------------------------------------
DESCRIPTION: After obtaining adequate witnessed
informed consent from Ms. X regarding the indications,
current methods, potential risks including complete
loss of the eye, as well as the possible significant
limitations of cataract surgery, she was brought to
the operating room area. She was administered several
drops of topical proparacaine 0.5% in the left eye as
well as tetracycline 0.5%. She was administered some
intravenous sedation. The left face and eyelid regions
were then thoroughly prepared with povidone-iodine 10%
solution. A few drops of dilute povidone-iodine 5%
solution were placed directly into her left eye. She
was then draped in the usual sterile fashion for
ocular surgery. A wire lid speculum was placed between
the left eyelids. There were no superior or inferior
rectus sutures utilized. The distance of 3 mm was
marked along the superonasal limbal zone. Using a
diamond blade, an initial perpendicular groove of
approximately 500-micron depth was created. The
diamond blade was then used to create a corneal tunnel
perpendicular to the initial groove, extending
approximately 1.5 mm into clear cornea. The diamond
keratome was then directed perpendicular to the plane
of the iris in order to enter the anterior chamber and
create a self-sealing corneal-valve incision. The
anterior chamber was then reformed with Healon GV. The
operating microscope was brought in; the light was
initially on low power and then gradually intensified.
A 27-gauge needle was entered through the corneal
valve incision and a nick created in the anterior
capsule. A continuous 360-degree curvilinear
capsulorrhexis was then carried out without
difficulty. Balanced salt solution was injected
beneath the capsule to achieve both hydrodissection
and hydrodelineation. The lens nucleus was then
emulsified without difficulty using the Alcon Masters
Series 10,000 unit. Any remaining cortical debris was
removed with the automated irrigation/aspiration unit.
The posterior capsule was then vacuum polished clean.
The anterior chamber and capsular bag were reinflated
with Healon GV. The AcrySof +19.5-diopter PC IOL was
then carefully folded using the folding forceps and
grasped with the direct-action forceps. The PC IOL was
then introduced through the corneal-valve incision and
delivered into the anterior chamber and capsular bag.
The lens was centered into position within the
capsular bag using the Sinskey hook. Any remaining
Healon GV was then removed with the automated
irrigation/aspiration unit.
Miochol was instilled to achieve pupillary myosis. The
corneal valve incision was then closed with a single
interrupted 10-0 Vicryl suture. The suture was cut and
the knot buried in the wound. The wound was tested and
found to be free of any leaks. Subconjunctival
cefazolin, gentamicin, and dexamethasone were then
injected superonasally. The left eye was then dressed
with Pred-G ophthalmic ointment and Pilopin gel. A
sterile eye patch and fox metallic shield were placed
over her left eye. Ms. X tolerated the procedure
extremely well and the operation went without
difficulty. She was transported to her room in stable
condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Exploratory laparotomy.
Omental biopsy.
Cholecystectomy.
Gastrojejunostomy.
Alcohol splanchnicectomy.
INDICATIONS FOR SURGERY:
The patient is an 86-year-old lady who began having
pain six months ago and developed jaundice four months
ago. She had a percutaneous transhepatic stent placed,
and subsequently had a metallic endoprosthesis placed.
Afterwards she developed acute cholecystectomy and
required percutaneous cholecystostomy. She has had
considerable pain from the gallbladder tube, but
attempts to sclerose the gallbladder have not been
successful. A CT scan recently showed extensive tumor
encasing blood vessels without occlusion, and no
obvious metastatic disease. The spread of the tumor
was somewhat reminiscent of a lymphoma. Therefore a
biopsy was recommended, but a tissue diagnosis could
not be established. In addition, the patient has
recently begun to have problems with vomiting.
Therefore exploration was undertaken to establish a
diagnosis, remove the gallbladder, consider doing a
gastrojejunostomy and probably an alcohol
splanchnicectomy.
PREOPERATIVE DIAGNOSIS:
Pancreatic tumor.
POSTOPERATIVE DIAGNOSIS:
Metastatic adenocarcinoma of the pancreas.
ANESTHESIA:
General endotracheal anesthesia.
SPECIMEN:
From omentum, gallbladder, and ascitic fluid for
culture and cell count.
DESCRIPTION: The patient was brought to the operating
room where general endotracheal anesthesia was
induced. The abdomen was prepared with Betadine and
draped in the usual sterile fashion. A midline
incision was made from the xiphoid to the umbilicus.
Hemostasis was achieved with cautery. The falciform
ligament was divided and tied with 2-0 silk. Chylous
ascites was present and totalled about 750 cc. Fluid
was sent for aerobic and anaerobic cultures as well as
cell count. Exploration of the abdomen revealed
adhesions around the gallbladder and around the liver
on the right. Tumor was present on the diaphragmatic
peritoneum. The liver was relatively normal in size,
shape and consistency. It had some tiny nodules but no
definite metastases.
The spleen was slightly enlarged. The stomach, small
intestine, colon, bladder and kidneys were grossly
normal. The gallbladder was shrunken and surrounded by
inflammatory tissue. The pancreas was enlarged and
consistent with a primary. Tumor nodules were present
in the omentum around the gallbladder, and some of
these were excised and sent for frozen section, and
found to be metastatic adenocarcinoma. Tumor was also
present on a small uterus as well as in the pouch of
Douglas and along the right paracolic gutter.
Adhesions around the gallbladder were taken down, and
the percutaneous catheter from was cut off and removed
the gallbladder. The gallbladder was dissected from
the surgeon tissues, and the cystic artery was doubly
ligated with 2-0 silk and divided. The cystic duct was
suture ligated with 2-0 silk and the specimen was sent
for permanent section. Once the gallbladder was
removed, tumor involvement of the duodenum was
apparent. For this reason, a gastrojejunostomy was
performed. A defect was made in the greater omentum
and in the left transverse mesocolon. The proximal
jejunum was brought up in a retrocolic, isoperistaltic
fashion and a side-to-side gastrojejunostomy was done
to the posterior layer of the stomach in two layers
with an outer layer of 3-0 silk and an inner layer of
running 3-0 Vicryl. The mesenteric defect was closed
by attaching the mesocolon to the posterior wall of
the stomach. An alcohol splanchnicectomy was performed
by injected 20 cc of 50% alcohol on either side of the
aorta at the level of the celiac axis. The abdomen was
irrigated with bibiotic solution and hemostasis was
felt to be adequate. A 3/16-inch Duvol drain was
placed through a stab incision in the right upper
quadrant and secured to the skin with 0-silk suture.
The fascia was closed with interrupted 2-0 wire
sutures. A layer of running 0-Prolene was placed over
to try to get a seal to prevent leakage of ascites.
The skin was approximated with staples. Xeroform and a
dry sterile dressing was applied. Sponge and needle
counts were correct. Estimated blood loss was less
than 100 cc. The patient tolerated the procedure
without difficulty and returned to the intensive care
unit in stable condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Transurethral resection of the bladder tumor.
PREOPERATIVE DIAGNOSIS:
Bladder carcinoma.
POSTOPERATIVE DIAGNOSIS:
Bladder carcinoma.
ANESTHESIA:
Spinal.
DESCRIPTION: The patient was taken to the operating
room and after induction of anesthesia and the
administration of intravenous antibiotics, he was
prepared and draped in the usual relaxed dorsal
lithotomy position.
The anterior urethra was sounded to 30-French, and
then the Iglesias resectoscope was placed and
cystopanendoscopy was performed with the results noted
below. The urethra was within normal limits. The
outlet nonocclusive bladder capacity was adequate.
The orifices were normal in position and morphology,
and the left orifice was adjacent to a large fungating
bladder carcinoma which was obviously necrotic. The
tumor extended to the entire surface of the left
lateral wall and was sequy resected into deep muscle
using the Iglesias resectoscope. No other lesions were
identified. A separate biopsy of the prostatic urethra
was obtained. Electrocautery was used to achieve
hemostasis. The chips were removed and the bladder was
once again inspected and found to be free of evidence
of injury, and the ureteral orifices were intact at
the conclusion of the procedure. No evidence of
perforation was identified. The scope was withdrawn
and a 24-French 30-cc bag, three-way Foley catheter
was placed to continuous bladder irrigation with clear
efflux of urine noted. The patient was taken to the
recovery room in stable condition, having tolerated
the procedure well.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Exploration of radial artery with embolectomy.
PREOPERATIVE DIAGNOSIS:
Embolus, left radial artery.
POSTOPERATIVE DIAGNOSIS:
Embolus, left radial artery.
ANESTHESIA:
Local with intravenous sedation.
DESCRIPTION: The patient was brought to the operating
room and given intravenous sedation. The left arm was
prepared with an iodine-containing solution and draped
in a sterile fashion. Local anesthesia was provided.
An incision was made in the proximal third of the
forearm over the course of the radial artery. The
pulse became nonpalpable. Dissection was carried down
until the artery was identified. It was freed of
surrounding tissues and controlled with vessel loops.
It was open in a transverse direction for
approximately one-half its circumference. There was
good inflow with very poor backbleeding. A size #2
embolectomy catheter was passed distally multiple
times, retrieving several clot fragments. At the end
of the procedure, there was good backbleeding. The
catheter was passed for a total distance of
approximately 40-50 cm, which would have extended well
into the palm of the hand. The artery was flushed with
heparinized saline. It was allowed to flush at the
inflow site and was flushed with heparinized saline.
The arteriotomy was then closed with interrupted 7-0
Prolene sutures. Hemostasis was assured. The wound was
irrigated and closed in layers using Vicryl suture.
Sterile dressings were applied. At the end of the
procedure, there was a dopplerable pulse at the wrist,
and the hand was warm. The patient was sent from the
operating room in satisfactory condition. Estimated
blood loss was minimal.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Orthotopic liver transplant including total
hepatectomy, cholecystectomy, venovenous bypass, open
liver biopsy and cholangiogram.
Cadaveric renal transplant into the right iliac fossa.
PREOPERATIVE DIAGNOSIS:
Liver failure secondary to recurrent hepatitis B and
kidney failure presumed secondary to FK-506 toxicity.
POSTOPERATIVE DIAGNOSIS:
Liver failure secondary to recurrent hepatitis B and
kidney failure presumed secondary to FK-506 toxicity.
ANESTHESIA:
General endotracheal anesthesia.
DESCRIPTION: The patient was brought to the operating
room and induced with general endotracheal anesthesia.
She was prepared with an iodine-containing solution
and draped in a standard fashion. A standard
transplant incision was made and dissection was
carried down until the peritoneal cavity was
identified. There were dense adhesions of the
intestine to the liver, and also the liver to the
diaphragm. Dissection was carried out to mobilize the
liver fully. Vascular structures were identified. The
artery and bile duct were divided between ties. The
portal vein was mobilized adequately until the
suprahepatic and infrahepatic cavae were dissected
free.
Next the donor liver was prepared on the back table.
Venovenous bypass was instituted by cannulating the
left femoral vein with a percutaneous 19-French
cannula. This was then brought to bypass pump and
returned to a Cordis in the jugular vein. It was
determined after dissection of the recipient hepatic
artery that this would be too small for anastomosis;
therefore, an arterial graft was fashioned from the
cadaveric iliac artery. This was anastomosed to the
aorta using supraciliac position. The recipient's
aorta was very friable and buttressing of the
anastomosis with Teflon pledgets was required. It
should be noted that on the dome of the liver there
was a 3-cm firm nodule. There was no evidence of any
adenopathy or spread of the lesion outside the
confines of the liver. The donor liver was brought to
the operative field. It was kept cold during the
period of anastomosis. Suprahepatic caval anastomosis
was performed in standard fashion using a running 3-0
Prolene suture. Infrahepatic caval anastomosis was
then performed in standard fashion using a running 4-0
Prolene suture. Next a portal venous anastomosis was
performed using a running 6-0 Prolene suture finished
with a growth knot. The suprahepatic caval clamp was
removed and the portal venous clamp. During the period
of anastomosis, the liver was flushed with cold
lactated Ringer's solution through the portal vein.
Hemostasis was assured. The patient tolerated the
procedure well. The liver was well perfused and the
infrahepatic caval clamp was removed. Next an
end-to-end anastomosis of the donor hepatic artery to
the arterial bypass graft was performed using a
running Prolene suture. Vascular control was released.
There was an excellent thrill through the arterial
anemia. The liver was well perfused. The liver biopsy
was obtained and hemostasis was assured. The bile duct
anastomosis was then performed in end-to-end fashion
using interrupted PDS sutures over a 8-French T-tube.
Cholangiogram was obtained and there was no leak.
Hemostasis was again assured. The wound was irrigated
copiously. Three closed suction drains were placed
through separate stab incisions. The fascia was then
closed using a running Prolene stitch. Subcutaneous
tissues were irrigated. Hemostasis was assured. The
skin was closed with staples.
Next a standard right iliac fossa incision was made.
Dissection was carried down through the
retroperitoneal space until the iliac vessels were
identified. These were mobilized. Overlying lymphatics
were ligated between individual silk ties. Vascular
clamps were applied to the vessels. The kidney which
had been prepared previously on the back table was
brought to the operative field. A venotomy was made
and an end-to-side venous anastomosis was performed
using a running Prolene suture. Arteriotomy was then
made and a running anastomosis was performed for an
end-to-side arterial anastomosis. Vascular control was
released and the kidney was well perfused. The patient
began making some urine. The bladder was exposed with
the mucosa over an appropriate length. A
ureteroneocystostomy was made after the ureter had
been trimmed to the appropriate length. The
musculature was then reapproximated over this
anastomosis for a distance of approximately 3 cm using
PDS sutures. The wound was irrigated. The fascia was
closed with a running Prolene suture and the skin was
closed with staples. The venovenous bypass catheter
was removed. All drains were secured at their exit
sites as well as the T-tube. The patient was sent to
the operating room in satisfactory condition. All
needle, instrument and sponge counts were correct.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Direct laryngoscopy with excision of vallecular cyst.
INDICATIONS FOR SURGERY:
This is a 73-year-old white female with a history of
dysphagia and lump-in-throat sensation. The patient
was evaluated by Dr. X who noted a left-sided
vallevular cyst. The patient was counseled and agreed
to undergo the above procedure. The risks,
alternatives and potential complications were
discussed. Witnessed informed consent was signed.
PREOPERATIVE DIAGNOSIS:
Left-sided vallecular cyst and dysphagia.
POSTOPERATIVE DIAGNOSIS:
Left-sided vallecular cyst and dysphagia.
ANESTHESIA:
General endotracheal anesthesia.
FLUIDS: 600 cc crystalloid.
FINDINGS: 4-mm, left-sided vallecular cyst.
description: The patient was taken to the operating
room where she was placed on the table in the supine
position. General endotracheal anesthesia was
administered. The patient was then prepared and draped
in the usual sterile fashion using the Holinger
laryngoscope, the oral cavity, oropharynx, piriform
sinuses, vallecula, epiglottis, true vocal cords,
false vocal cords were all examined. She was noted to
have a left-sided vallecular cyst. The Holinger scope
was then removed and the Dedo laryngoscope inserted to
visualize the cyst. Using the upbiting cup forceps and
straight scissors, the cyst was excised. There was
some bleeding which was controlled with direct
pressure. Exploration of the vallecula was carried out
to make sure she did not have any others. The patient
was then awakened and taken to the recovery room in
satisfactory condition, having tolerated the procedure
well. Dr. X was present for the entire procedure.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Adenotonsillectomy.
INDICATIONS FOR SURGERY:
The patient is a 10-year-old white female child with a
history of chronic tonsillitis refractory to medical
therapy. She was taken to the operating room for
adenotonsillectomy. Witnessed informed consent was
obtained prior to the procedure.
PREOPERATIVE DIAGNOSIS:
Chronic tonsillitis.
POSTOPERATIVE DIAGNOSIS:
Chronic tonsillitis.
ANESTHESIA:
General endotracheal anesthesia.
SPECIMEN:
Tonsils and adenoids.
FLUIDS: Crystalloid.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 20 cc.
FINDINGS: Large cryptic tonsils and moderate adenoids.
Palate normal.
DESCRIPTION: The patient was brought to the operating
room and general anesthesia was established via
endotracheal tube. Intravenous ampicillin and Decadron
were administered. She was placed in the rose
position. A Crowe-Davis mouth gag was inserted. The
adenoids were removed with the adenoid curet. The
nasopharynx was packed. The tonsils were removed using
electrocautery to dissect between the superior
constrictor muscle and the tonsillar capsule.
Hemostasis was achieved with suction cautery. With
adequate hemostasis, the pharynx was irrigated and
suctioned free of secretions. The stomach was emptied
free of secretions. She was awakened from anesthesia
without difficulty.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Adenotonsillectomy.
INDICATIONS FOR SURGERY:
The patient is a 5-1/2-year-old white female child
with a history of chronic tonsillitis and tonsillar
adenoidal hypertrophy with nocturnal breathing
disturbance which was very mild. She was brought to
the operating room for adenotonsillectomy. Witnessed
informed consent was obtained prior to the procedure.
PREOPERATIVE DIAGNOSIS:
Tonsillar and adenoidal hypertrophy.
POSTOPERATIVE DIAGNOSIS:
Tonsillar and adenoidal hypertrophy.
ANESTHESIA:
General endotracheal anesthesia.
SPECIMEN: Tonsils and adenoids.
FLUIDS: Crystalloid.
FINDINGS: Large tonsils and adenoids and a normal
palate.
ESTIMATED BLOOD LOSS: Less than 20 cc.
DESCRIPTION: The patient was brought to the operating
room and general anesthesia was established via
endotracheal tube. Intravenous ampicillin and Decadron
were administered. She was placed in the rose
position. A Crowe-Davis mouth gag was inserted. The
adenoids were removed with the adenoid curet. The
nasopharynx was packed. The tonsils were removed using
electrocautery to dissect between the superior
constrictor muscle and the tonsillar capsule.
Hemostasis was achieved with suction cautery. With
adequate hemostasis, the pharynx was irrigated and
suctioned free of secretions. She was awakened from
anesthesia without difficulty.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Reduction osteoplasty of craniofacial bones with
contouring bur.
Revision of scar, 17 cm of scalp, unusual, extended.
PREOPERATIVE DIAGNOSIS:
Cranial deformity secondary to previous reconstruction
and cranial growth abnormality.
POSTOPERATIVE DIAGNOSIS:
Cranial deformity secondary to previous reconstruction
and cranial growth abnormality.
ANESTHESIA:
General endotracheal anesthesia.
DESCRIPTION: The patient was placed on the operating
table in the supine position. After adequate induction
of general anesthesia, the patient was prepared and
draped in the usual sterile fashion. This was
accomplished after an appropriate removal of hair and
prescrubbing. Dr. X then reopened the vertical portion
of the incision and repaired the defect with a piece
of titanium mesh. Once this was complete, the
secondary procedure was begun.
Attention was directed to the segments. We extended
the vertical incision transversely to the left side in
order to allow exposure of the prominent right frontal
or right parietal thickened bone. This was contoured
with a pineapple bur. This was reduced in sized down
to the minimal amount in view of the thickness of the
bone. This gave a smoother overall contour. Other
areas were difficult to reach to correct any more
extensive irregularity. I discussed the case with Dr.
X regarding the extension of the temporal region. He
agreed that since there was extensive tension on the
wound repair that extending down into the frontal
region with the associated swelling could compromise
the skin closure which was extraordinarily difficult,
and would not have otherwise allowed for the scar
revision. Therefore we elected to proceed with the
scar revision. This was discussed with the family.
The old scar was removed down to the area where there
appeared to be hair growth. This was trimmed
appropriately and hemostasis was achieved with
electrocautery. Closure was then accomplished with 2-0
Vicryl interrupted sutures followed by 3-0 Vicryl on
the periphery, followed by a running 3-0 nylon. A
sterile dressing was applied. The patient tolerated
the procedure well, anesthesia was reversed and the
patient was transferred to the recovery room in good
condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Removal of varied irritating plates and screws.
Reduction osteoplasty of craniofacial bones.
Scar revision (bicoronal).
INDICATIONS FOR SURGERY:
This patient underwent a craniofacial reconstruction
in the past. This resulted in a good overall extension
of the skull. He had a smooth forehead but with some
irregularity in the temporal parietal region. He had
some irregularities of the overlying bone with a
slight temporal hollow. Iliotibial was elected to
proceed with revision of the scar, removal of the
prominent hardware and contouring of the bone,
possibly reconstructing a temporal fossa.
PREOPERATIVE DIAGNOSIS:
Loosening of plate and screws following craniofacial
reconstruction.
Prominent hypertrophic scar.
Prominent reconstructive craniofacial bones.
POSTOPERATIVE DIAGNOSIS:
Loosening of plate and screws following craniofacial
reconstruction.
Prominent hypertrophic scar.
Prominent reconstructive craniofacial bones.
ANESTHESIA:
General endotracheal anesthesia.
DESCRIPTION: The patient was placed in the supine
position. After adequate induction of general
anesthesia, a small episode. We then proceeded with
preparation and draping in the usual sterile fashion.
The old incision was excised. Old scar was excised and
the incision opened. Subperiosteal dissection with
some supraperiosteal dissection proceeded without
difficulty. We then extended all the way down to the
forehead where the plates, screws and wires were all
removed.
Attention was directed to the frontotemporal orbital
region where some of the excess bone was contoured
down. This was also accomplished in the upper sagittal
and parietal region. This appeared decrease the
prominence of this area and diminished the temporal
hollow. This allowed for a good overall shape, and
therefore the area was copiously irrigated with
saline. Closure was accomplished with 3-0 Vicryl and a
running 4-0 nylon. The patient tolerated the procedure
well and was reversed from anesthesia and transferred
to the recovery room in good condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Right groin exploration; neurolysis.
INDICATIONS FOR SURGERY:
Right groin pain in the ilioinguinal nerve
distribution, status post open right inguinal
herniorrhaphy with Marlex mesh. The patient is a
28-year-old male who underwent a right incisional
herniorrhaphy with Marlex mesh in the past at an
outside institution. He developed pain postoperatively
in the right groin in the distribution of the
ilioinguinal nerve. His pain failed to improve with
multiple therapies, and he was referred to X Hospital
and seen by Dr. X and his pain group for appropriate
intervention. I also had the opportunity to examine
him preoperatively and felt that his pain was most
likely related to an ilioinguinal nerve injury.
Appropriate operative consent was obtained.
PREOPERATIVE DIAGNOSIS:
Right ilioinguinal nerve entrapment secondary to past
inguinal herniorrhaphy.
POSTOPERATIVE DIAGNOSIS:
Right ilioinguinal nerve entrapment secondary to past
inguinal herniorrhaphy.
ANESTHESIA:
General endotracheal anesthesia.
SPECIMEN: Portion of ilioinguinal nerve with attached
Marlex
mesh and scar.
DESCRIPTION: The patient was brought to the operating
room and placed on the operating room table in the
supine position. After the successful induction of
general endotracheal anesthesia, the right groin was
prescrubbed, shaved, prepared and draped in the
routine fashion using Prepodyne. We reopened the
previous right inguinal hernia incision superficially
and extended it up laterally and cephalad up around
toward the anterosuperior iliac spine. We divided the
subcutaneous tissue using the electrocautery, and
identified the external oblique muscle lateral to the
previousÔ stinct branches running in the proper
position. This position was on top of the internal
oblique muscle down toward the groin.
We dissected these two nerves out nicely down toward
the groin and found that the nerve itself became
entrapped in the area of scar tissue right at the
lateralmost edge of the previously placed Marlex mesh.
At this site, there appeared to be scar, and perhaps
even neuroma formation. We dissected out the nervous
at the level of this Marlex mesh, taking out a button
of mesh approximately the size of a nickel. We did not
disrupt the remainder of the herniorrhaphy, nor did we
divide down medially toward the pubic tubercle. We
then dissected out the ilioinguinal nerve laterally up
toward the anterosuperior spine and performed a
neurolysis at this level, cutting the nerve at
approximately the level of the anterosuperior iliac
spine, although we were several centimeters medial.
The specimen included the ilioinguinal nerve as well
as the Marlex mesh and the presumed neuroma. We
irrigated the wound copiously with bibiotic solution.
Hemostasis was insured. The external oblique was run
closed using 2-0 Vicryl. Scarpa's fascia was closed
using 3-0 Vicryl and the skin was closed using 4-0
Vicryl on a subcuticular needle. The patient tolerated
the procedure well and was taken from the operating
room to the recovery room in satisfactory condition. I
was present for the entire procedure. All counts were
reported as correct.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Exploratory laparotomy.
Cholecystectomy and en bloc resection of the
extrahepatic biliary tree.
Drainage of noninfected peripancreatic necrosis.
Roux-en-Y hepaticojejunostomy.
Placement of two 16-French Silastic stents.
INDICATIONS FOR SURGERY:
The patient is a 55-year-old white male who became ill
several weeks ago after eating crabs. He developed
obstructive jaundice and eventually his imaging
studies revealed dilated intrahepatic ducts and a
decompressed gallbladder. Cholangiography showed a
stricture of the common hepatic duct and proximal
common bile duct consistent with either
cholangiocarcinoma, gallbladder cancer or unlikely
sclerosing cholangitis. Percutaneous transhepatic
stenting was performed on both the right and left
sides. Angiography showed no evidence of arterial or
venous encasement or occlusion. A routine bowel
preparation was performed and preoperative consent
obtained.
PREOPERATIVE DIAGNOSIS:
Adenocarcinoma of the extrahepatic biliary tree
involving the gallbladder infundibulum as well as the
common hepatic duct and common bile duct.
POSTOPERATIVE DIAGNOSIS:
Adenocarcinoma of the extrahepatic biliary tree
involving the gallbladder infundibulum as well as the
common hepatic duct and common bile duct.
ANESTHESIA:
General endotracheal anesthesia.
SPECIMEN:
En bloc resection specimen including gallbladder and
extrahepatic biliary tree; portion of necrotic
pancreas.
PROSTHETIC DEVICE/IMPLANT:
Two 16-French Silastic stents and four 3/16-inch
drains.
DESCRIPTION: The patient was brought to the operationg
room and placed on the operating room table in the
supine position. After the successful induction of
general endotracheal anesthesia, the abdomen was
prescrubbed and shaved. A Foley catheter was placed
and the abdomen was prepared and draped in routine
fashion using Prepodyne. The previous Ring catheter
which exited the right flank and the epigastrium were
prepared into the wound. The abdomen was open ed using
a skin knife from the xiphoid to below the umbilicus,
and carried down using electrocautery. On entry into
the abdomen, there was no evidence of carcinomatosis
or omental implants. The gallbladder was shrunken and
had a mass palpable near the i nfundibulum. There was
thickening and scar formation in the porta hepatis.
There was also evidence of recent acute pancreatitis
with some necrotic material and inflammation around
the head of the pancreas which was debrided. The
mesentery of the small bowel was markedly
foreshortened. There was no ascites and only a small
amount of blood up around the right Ring catheter.
Attention was turned first to performing a Kocher
maneuver and debriding a bit of the head of the
pancreas. The remainder of the pancreas, the body and
tail felt firm, but there was no evidence of any
pancreatic neoplasm. We took the gallbladder down ou t
of the gallbladder fossa using electrocautery. This
was accomplished without incident. We left the
gallbladder in place, however, and then at the level
of the superduodenal portion of the common bile duct,
we encircled it with a vessel loop. There wa s a
significant amount of scar and inflammation here, and
this was quite a difficult dissection. We were
eventually able to completely encircle the common bile
duct at this level and elevate it with a vessel loop.
We then divided the common bile duct wi th
electrocautery. We removed the previously placed
endoprosthesis which had been occluded and the left
the Ring catheters exiting out from the proximal
common bile duct. We performed a biopsy of the distal
common bile duct at this level, and this retur ned
negative for tumor. The distal common bile duct was
then oversewn using 3-0 Prolene sutures in a running
fashion. We then elevated the specimen up off the
portal vein up towards the hilum, taking care to avoid
any injury to major vascular structures. In
particular, we avoid injury to the common hepatic
artery and proper hepatic artery into the portal vein.
We eventually dissected up to the level of the left
hepatic duct and right hepatic duct, and took these up
as high as was possible which was ap proximately 1 cm
above the bifurcation. The left and right hepatic
ducts were divided using electrocautery. The specimen
was removed, including the right hepatic duct, left
hepatic duct, hepatic duct bifurcation and the entire
extrahepatic biliary tree with the gallbladder
attached down to the level of the intrapancreatic
portion of the common bile duct. Hemostasis was
assured at this point. The Ring catheters were exiting
from both the right and left hepatic ducts.
At one point, we thought there was perhaps a posterior
segment branch of the biliary tree, but this did not
materialize. It was tied with 2-0 silk. During the
cholecystectomy, we did note a small branch of the
right posterior segment draining into the bile duct.
Attention was next turned to the reconstruction. We
used the Ring catheters to pull Silastic stents
through the liver, first using a guide wire followed
by a 12-French coude catheter, a 14-French coude
catheter and subsequently a 16-French Silastic stent.
We positioned the Silastic stent exiting the hepatic
duct sites with no side holes within the liver to
tamponade any bleeding. We then went down below the
ligament of Treitz and felt it would be very difficult
to create a Roux-en-Y limb, but we made this effort.
Approximately 25 cm below the ligament of Treitz,
which is a bit further than I usually go, I divided
the mesentery of the small bowel and pedicled the
blood supply of the Roux-en-Y limb on a more distal
jejunal arcade. This was accomplis hed with some
difficulty as the mesentery was quite foreshortened.
Numerous clamps and ties were placed along the
mesentery and we made every effort to preserve the
arterial circulation to the Roux-en-Y limb. We then
divided the jejunum with a GIA stapl er and oversewed
its distal end using 3-0 silk sutures. The Roux-en-Y
limb would not come up in the antecolic position
because of its foreshortened mesentery and short
length. We therefore were obliged to put the Roux-en-Y
limb in the retrocolic position which brought it very
close to the necrotic area of pancreatitis. We
debrided the pancreatitis, and there was absolutely no
way to bring the limb antecolic, and therefore we had
to bring it up retrocolic up to the porta hepatis. It
was with some diffi culty and a bit of tension that we
actually got the Roux-en-Y limb up to the porta
hepatis. We then made a longitudinal jejunotomy
approximately 3 cm downstream from the cut end of the
jejunum. We performed one hepaticojejunostomy to both
of the limbs of the right and left hepatic bile ducts
using interrupted 4-0 Vicryl sutures, first doing the
posterior row in interrupted single-layer fashion and
subsequently doing the anterior row in interrupted
single-layer fashion. We placed Silastic stents into
th e jejunal limb to decompress our biliary-enteric
anastomosis. The anastomosis was quite difficult, and
we found we were sewing well up into the liver.
Nonetheless we tested the anastomosis, and apart from
one small leaking area which was oversewn using three
interrupted 3-0 Vicryl sutures. We appeared to have a
watertight anastomosis without evidence of bile leak.
Then 60 cm downstream from the hepaticojejunostomy, we
then reimplanted the proximal jejunum as an
end-to-side jejunojejunostomy using an outer layer of
interrupted 3-0 silk and an inner layer of running 3-0
Vicryl. The mesenteric trap was closed using
interrupted 3-0 silk. We irrigated the abdomen
copiously using 3 L of warm bibiotic solution. We
brought the Silastic stents out the anter ior abdomen
and sewed them in place with 4-0 steel wire. We pulled
the side holes back to allow at least one side hole to
be up into the liver to drain bile.
Four 3/16-inch drains were placed through separate
stab incisions, two on the left, two on the right side
and sewn in place using 4-0 steel wire. We then
brought one of the drains on each side up to the
hepatotomy site and the second drain was placed to the
hepaticojejunostomy. We again irrigated with bibiotic
solution and closed using skin clips. All counts were
reported as correct. I was present for the critical
portion of this operation defined as from the opening
to the closing, and I was immediately present for the
entire surgery. All counts were reported as correc t.
The patient tolerated the procedure well and came from
the operating room to the anesthesia care unit in
satisfactory condition.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Hysteroscopy and dilatation and curettage.
PREOPERATIVE DIAGNOSIS:
Dysfunctional uterine bleeding.
POSTOPERATIVE DIAGNOSIS:
Dysfunction uterine bleeding.
ANESTHESIA:
Local sedation.
DESCRIPTION: The patient was brought to the operating
room and placed in the supine position and given
intravenous sedation. She was placed in the dorsal
lithotomy position and examined. Examination revealed
an enlarged uterus with a suspected posterior wall
leiomyomata in the cul-de-sac. There was no evidence
of adnexal masses. The rectovaginal examination was
confirmatory.
The patient was then prepared and draped in the usual
manner for hysteroscopy and possible dilatation and
curettage. A Wolf carbon dioxide hysteroscope was
utilized. The cervix was inspected and found to be
normal. A paracervical block was placed with a total
of 18 cc of 1% Xylocaine plain, 9 cc in each lateral
paracervical area. The endocervical canal was normal.
The uterine cavity: The right and left uterotubal
ostia and cornua were identified. They appeared
normal. The anterior, posterior and lateral walls were
smooth, although the posterior wall was somewhat
extrinsically compressed. No lesions were noted. The
hysteroscope was reinserted to verify sampling of the
cavity. All instruments were then removed. Tissue
specimen was submitted to pathology.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Operative hysteroscopy with lysis of adhesions, tubal
cannulation, intrauterine device insertion and
diagnostic laparoscopy.
PREOPERATIVE DIAGNOSIS:
Severe Asherman's syndrome.
POSTOPERATIVE DIAGNOSIS:
Severe Asherman's syndrome.
ANESTHESIA:
General endotracheal anesthesia.
PROSTHETIC DEVICE:
Paragard T380 intrauterine device inserted.
DESCRIPTION: The patient was brought to the operating
room and placed in the supine position, and given
general anesthesia and intubated. She was placed in
the dorsal lithotomy position and examination under
anesthesia revealed a normal-sized anteverted uterus,
no evidence of adnexal masses. She was then prepared
and draped in the usual manner for simultaneous
operative hysteroscopy and laparoscopy. These
procedures were performed simultaneously after the
bladder was catheterized and drained of about 200 cc
of urine. A stab incision was made within the
umbilicus through which a Veress needle was placed and
2 liters of carbon dioxide gas infused. Laparoscopic
trocar and sleeve were inserted. Eventually a
secondary puncture was created above the symphysis
pubis. Vaginally a speculum was inserted into the
vagina uterine cavity was explored. The scope was
inserted a few centimeters into the endocervical canal
into the lower uterine segment and was met with a wall
of dense adhesions. Using blunt probes and flexible
and rigid scissors, a cavity was eventually created
and the limits of the uterotubal ostium or the cornua
were determined by the use of a blunt probe,
visualizing the movement of the probe in the cornual
region of the uterus through the laparoscope, passed
through the umbilicus. The left fallopian tube was
actually cannulated with a Miles Novy cannula. Dye
spill from the left tube was observed. Following the
creation of the uterine cavity. Adhesions were dense
and the procedure was involved. A Paragard T380 IUD
was inserted and the position within the cavity
verified by reinsertion of the hysteroscope.
Laparoscopically the uterus appeared to be normal in
size. An old perforation site near the right cornua
was identified. The left ovary was normal in size,
oval in shape, white in coloration. Smooth surface was
apparent. No adhesions or lesions were noted. The
right ovary was normal in size, oval in shape, white
in coloration. No adhesions or lesions noted. The left
tube was normal in length, normal surface appearance,
normal in size. The fimbria were delicate. As
previously mentioned, this tube was cannulated and dye
spill was seen. No adhesions or lesions noted. The
right tube was normal in length. Normal surface
appearance. Normal in size. This tube was not
cannulated. The fimbria were delicate. No dye spill
was seen. No adhesions were noted.
Following the procedure, the pelvis was irrigated.
Hemostasis was found to be complete. Instruments were
removed. Carbon dioxide gas was expelled. Incisions
were closed with 4-0 Vicryl. The patient was reversed
from anesthesia, extubated and transferred to the
recovery room in satisfactory condition. She will
receive Premarin therapy for the next morning prior to
removing the IUD.
---------------------------------------------------------------------------------
TITLE OF OPERATION:
Wide local excision of malignant melanoma and left
axillary sentinel lymph node biopsy.
PREOPERATIVE DIAGNOSIS:
Malignant melanoma, intermediate depth, left posterior
shoulder.
POSTOPERATIVE DIAGNOSIS:
Malignant melanoma, intermediate depth, left posterior
shoulder.
ANESTHESIA:
General endotracheal anesthesia.
SPECIMEN:
Wide local excision of melanoma after shave biopsy,
and left axillary lymph nodes.
DESCRIPTION: Under general anesthesia, the axilla was
prepared and draped in the usual sterile fashion.
Using a gamma probe, the axillary lymph node was
noted. A 3- to 4-cm incision was made sharply. The
skin and subcutaneous tissues were dissected down
sharply through the clavipectoral fascia. The probe
then located a small lymph node along the
thoracodorsal vessels. This was excised with sharp and
blunt dissection, taking care to tie off the
lymphatics with 3-0 Vicryl suture. In addition, two
other small specimens were also taken. The wound was
irrigated copiously with normal saline. Bleeding
vessels were cauterized and the wound was closed with
interrupted 3-0 Vicryl suture and a running 4-0 Vicryl
subcuticular suture. Benzoin, Steri-Strips and a dry
sterile dressing were applied.
New gowns, instruments and gloves were used to perform
the wide local excision on the left posterior
shoulder. An elliptical incision was made to allow a
2-cm margin around the lesion in question. The skin
and subcutaneous tissues were dissected down sharply
to the level of the fascia. The fascia and tissue were
then removed with electrocautery. The wound was
irrigated copiously with normal saline. Bleeding
vessels were cauterized. The wound was closed with
interrupted 3-0 Vicryl suture and interrupted 3-0
nylon vertical mattress sutures. The patient tolerated
the procedure well and was sent to the recovery room
in stable condition.