SURGICAL OP REPORT # 14
DIAGNOSIS: T12-L1 fracture dislocation.
OPERATIONS:1. Left thoracoabdominal exposure, T11-L2.2. Resection left 10th rib.3. Placement of chest tube (Blake drain).
DRAINS: 24 French Blake drain into the pleural cavity.
DETAILS:Patient was brought to the operating room, positioned supine. General anesthesia was induced. Patient was then placed into the lateral decubitus position with the left side up.An incision was made in oblique fashion overlying the 10th rib and taken down onto the abdominal wall. The musculature was divided with electrocautery and the 10th rib was resected subperiosteally. The pleural cavity was entered under direct vision and the lung was packed away.The abdominal wall musculature was then divided allowing entry into the extraperitoneal space. The visceral sac was mobilized and retracted medially. The diaphragm was taken down circumferentially. The pleura was incised and intercostals to the lower thoracic vertebrae were clamped, divided and ligated. Additional diaphragmatic attachments were taken down as were several segmental levels allowing visualization down to L2.The anterior and lateral aspect of the spine was then exposed from T11-L2. The area of the fracture dislocation was obvious.
At this time Neurosurgery performed their portion of the procedure. On completion of the neurosurgical portion, hemostasis was checked and found to be adequate though there was some venous oozing from the bone edges.The diaphragm was closed with interrupted #1 Polysorb suture. The pleura was closed with a 3-0 Polysorb suture. A 24 Blake drained was placed into the pleural cavity and secured at the skin with a 2-0 nylon. The ribs were then approximated with several #1 Polysorb pericostal sutures with the suture placed through a drill hole.The chest and abdominal wall musculature was then closed in layers using Polysorb suture. The subcutaneous tissue was closed with a running 3-0 Polysorb and skin with a 4-0 Biosyn subcuticular stitch.Steri-Strips were applied as was a dry dressing. An occlusive dressing was placed to the chest tube site. Patient tolerated procedures well without complications.
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SURGICAL OP REPORT # 33
Diagnosis: Hypertensive renal failure requiring hemodialysis
Operation: Insertion of left arteriovenous Gore-tex graft for dialysis access
This patient has a history of end stage renal disease secondary to hypertension. She is taken to the O/R for a left arteriovenous Gore-Tex graft placement in the forearm for permanent dialysis access.
Procedure: The patient was brought to the operating suite, placed in the supine position, and fitted with EKG leads and a blood pressure cuff. An IV had been started in the surgery center. An interscalene block is performed. Anesthesia was obtained in the left upper extremity. The patient was prepped and draped in the usual sterile fashion over the left upper extremity.
Through a transverse incision one finger breadth below the left antecubital fossa crease, the skin was incised. The brachial artery and the cephalic vein were dissected out, and vascular loupes placed about them. The counter incision at the distal one-third of the forearm was made and a tunneling device was used to swing a 4.0 millimeter to 7.0 millimeter tapered Gore-tex graft through the subcutaneous tunnel. Then with the use of 6.0 double armed Prolene times two the end of graft side of the cephalic vein anastomosis was performed.
Prior to the initiation of anastomoses, the patient was heparinized. After completion of the arterial anastomosis, the graft was allowed to fill with blood and this was then flushed with heparinized saline as well. An arteriotomy was then made and an end graft to side of brachial artery anastomosis was made using one double armed 6-0 Prolene. Care was taken to ensure that the alignment of the Gore-tex graft was normal prior to anastomosis.
Upon opening the vessel loupes on the artery, a thrill was appreciated in the proximal, medial upper arm indicating adequate flow throughout the graft. Hemostasis was obtained about the anastomosis with the use of Surgicel. The wounds were then closed.
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SURGICAL OP REPORT # 34
DIAGNOSIS: Multiparous female desires permanent sterilization.
OPERATION: Laparoscopic tubal ligation with Falope ring on the right and bipolar cautery on the left.
FINDINGS AT OPERATION: At the time of surgery, the patient was found to have a normal-size uterus, but it was densely adherent to the posterior surface of the anterior abdominal wall in its entirety. The round ligaments were also densely adherent. The left tube was quite phimotic. The right tube appeared normal. Both ovaries appeared normal. The patient's appendix was noted to be in the cul-de-sac, but was not adherent.
PROCEDURE: The patient was taken to the operating room, where she was laid supine on the operating table, and general endotracheal anesthesia was administered. She was then placed in the dorsal lithotomy position and examination under anesthesia revealed her to have normal-size uterus. The patient's vagina, perineum, and abdomen were sterilely prepped and draped for surgery in the usual fashion. The cervix was visualized and grasped with a single-tooth tenaculum, and Kahn's cannula was placed.
The urinary bladder was drained with a Foley catheter. A #11 blade was then used to make an infraumbilical stab incision, and Veress needle was placed. After testing for adequate intraperitoneal placement, pneumoperitoneum was obtained with 2.5 liters of carbon dioxide gas. The Veress needle was then removed, and the 10-mm trocar and trocar sheath were placed. The trocar was removed, and the operative laparoscope was placed, and the patient's pelvic contents were visualized with findings, as noted above.
The Falope ring applicator was used to place a Falope ring at the avascular midportion of the patient's right tube without difficulty. A large knuckle of tube was performed. The patient's left tube was then located and identified by the fimbriated end, and a Falope ring was placed, but the knuckle of tube was judged to be insufficient. Therefore, the Kleppinger bipolar forceps were used to cauterize the tube in four segments until loss of ammeter resistance was found. When this was completed, the tube was basically cauterized in its entirety. No bleeding was seen.
The procedure was terminated. The instruments were removed. The pneumoperitoneum was released, and the trocar sheath was removed under direct visualization. The fascia and subcuticular tissue were closed with 3-0 Vicryl. A sterile dressing was placed. The Foley catheter and vaginal instruments were also removed, and the patient was returned to the recumbent position, and taken from the operating room to the recovery room in stable condition.
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SURGICAL OP REPORT # 32
DIAGNOSIS: Head and neck carcinoma with nodal metastases; need for long-term intravenous access.
Procedure: Left subclavian Port-A-Cath insertion (9.6-French) under fluoroscopy.
INDICATIONS: Fifty-year-old woman recently diagnosed with right tonsillar cancer with nodal metastases needing long-term IV access for chemotherapy. She is also going to get radiation therapy.
PROCEDURE: The patient was taken to the operating room and placed in the supine position and given intravenous sedation. The chest was prepped and draped in the usual sterile fashion. Using the Seldinger technique, the left subclavian vein was cannulated, and a needle was passed into the superior vena cava under fluoroscopic guidance. The needle was removed. A field block was then performed in the left subclavian region with a 50/50 mixture of 1% Xylocaine with 0.5% Marcaine with epinephrine.
A dilator and introducer sheath were then passed over the wire under fluoroscopy. The wire and dilator were removed leaving the sheath in place. A Port-A-Cath catheter pre-flushed with heparinized saline was inserted to 20 cm from the skin through the introducer sheath. The sheath was cracked and pulled out leaving the catheter in place. The catheter was positioned using fluoroscopy in the superior vena cava proximal to the right atrium. A reservoir pocket was created on the chest lower down from the insertion site. The tunneler was attached to the catheter. The catheter was brought out to the reservoir pocket site, and the catheter was cut to the appropriate length, attached to the reservoir which had been previously flushed with heparinized saline. The reservoir was placed into the pocket, and again under fluoroscopy the tip of the catheter was confirmed to be in the superior vena cava. The reservoir was secured to the pectoral fascia with a 2-0 Prolene suture. The wound was irrigated with warm normal saline and aspirated dry. Hemostasis was assured.
The skin was closed at both sites with subcuticular 4-0 Monocryl. Benzoin, Steri-Strips, and sterile dressings were applied. There were no complications. Prior to closing the wound, the reservoir was aspirated easily of blood and then flushed with heparinized saline solution.
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SURGICAL OP REPORT #36
DIAGNOSIS: 1. Retained T-tubes. 2. Chronic tympanic membrane perforations. 3. Adenoid hypertrophy with chronic adenoiditis.
OPERATION: 1. Bilateral T-tube removal. 2. Bilateral fat pad myringoplasty. 3. Adenoidectomy.
ANESTHESIA: General, endotracheal.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old who had T-tubes placed by another physician at a young age. He has had persistent problems with reactions to the T-tubes and now has large perforations surrounding the T-tubes. The T-tubes were unable to be removed in the office because of lack of cooperation. He also had chronic adenoiditis with adenoid hypertrophy.
PROCEDURE: The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion. From the right earlobe a #15 blade was used to make a posterior earlobe incision, and fat was obtained and harvested and set aside for a later portion of the case. The initial incision was closed with 3-0 Monocryl sutures.
The patient was then repositioned, and first the right ear was approached. The T-tube was removed from the right ear. Then the edges of the perforation were freshened. Gelfoam was placed into the middle ear site for a base to apply the fat patch. The fat was then placed into the perforated site, and Gelfoam was placed on the lateral aspect. The same procedure and findings were noted on the left side. With the T-tube removed, the edges of the tympanic membrane perforation were freshened. The Gelfoam was placed in the middle ear, the fat patch was placed, and Gelfoam was placed lateral to the fat patch.
The patient was then repositioned, and the Crowe-Davis mouth gag was inserted into the oral cavity and positioned allowing full visualization of the oropharynx. The soft palate was palpated for any submucosal cleft; there was none. A red rubber catheter was inserted through the nose and out through the mouth to provide retraction of the soft palate. The adenoid curet was used to remove hypertrophied and very inflamed adenoid tissue. A tonsil pack was placed in the nasopharynx for hemostasis effect. The pack was removed, and any obvious bleeding points were controlled with the suction Bovie apparatus.
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