Operative Note

Angioplasty

PROCEDURE: Left carotid endarterectomy with Dacron patch angioplasty.

 SUMMARY:  The patient was taken to the operating room and after adequate induction of general endotracheal anesthesia, the patient's left neck and chest was sterilely prepped and draped in the usual manner. 

A longitudinal incision was made along the anterior border of the sternocleidomastoid muscle.  The underlying skin and the platysma muscle were divided using electrocautery.  The underlying carotid sheath was identified.  The left common carotid, internal and external carotid arteries were dissected free from their surrounding structures and encircled with vessel loops.  The left internal carotid artery was dissected free above the left internal carotid lesion. The patient was systemically heparinized.  Proximal and distal control was obtained and then a longitudinal arteriotomy was made beginning in the distal common carotid artery and extending into the left internal carotid artery beyond the lesion.  A Sundt shunt was placed for intraoperative cerebral profusion.  A standard carotid endarterectomy was performed removing the large amount of internal carotid artery plaque.  The distal end point was tacked with interrupted 7-0 Prolene sutures. The loose fibrointimal debris was removed.  Prior to proximal and distal control, the patient was systemically heparinized.  The arteriotomy was closed using a Dacron patch angioplasty.  The patch was placed using a running 6-0 Prolene suture.  Prior to completion of the patch angioplasty the shunt was removed. The internal carotid artery was noted to have good backbleeding and there was good flow via the left common carotid artery.  Once the shunt was removed, the patch angioplasty was closed.  The Doppler was used to confirm good flow signals within the common carotid and internal and external carotid arteries.  Thrombin and Gelfoam were used for hemostasis. 

A 7 mm flat Jackson-Pratt drain was placed in the wound and the wound was closed in multiple layers using running 2-0 and 3-0 Vicryl sutures.  The skin was reapproximated with staples. 

A sterile dressing was then applied. At the conclusion of the procedure the patient extubated and transported to the recovery room for further care and monitoring.

Artery bypass

Operative NotePROCEDURE:  Left femoral to above-knee popliteal artery bypass utilizing a 7 mm ring reinforced PTFE Distaflo Graft.

SUMMARY:   The patient was taken to the operating room.  After adequate induction of general endotracheal anesthesia, the abdomen and left lower extremity was sterilely prepped and draped in the usual manner.  An oblique left groin incision was made in the underlying subcutaneous tissues were divided using electrocautery.  The common femoral artery was then dissected free from its surrounding structures, as the inguinal ligament was mobilized.  The distal external iliac artery was also dissected free from surrounding structures.  There was some posterior plaquing.  However, the vessel appeared overall soft. The distal external iliac and distal common femoral artery was then encircled with vessel loops. Through a distal left medial thigh incision, the above-the-knee popliteal artery was exposed and encircled with vessel loops.  A subsartorial tunnel was created and the patient was administered 5000 units of intravenous heparin.  The activated clotting times were monitored during the procedure. Proximal distal control of the above-the-knee popliteal artery was achieved and then a longitudinal arteriotomy was made with an 11 blade scalpel.  This was extended proximally and distally with Potts scissors.  A 4 mm and 5 mm vessel dilator easily passed through the lumen of the above-the-knee popliteal artery.  The distal anastomosis was first created utilizing a running HS7 Prolene suture, secured with horizontal mattress sutures at the heel and the tail of the anastomosis.  Once this anastomosis was complete, the graft was passed through the tunnel and the attention was turned to the left groin.  Proximal and distal left common femoral artery control was established.  Longitudinal arteriotomy was then made, and the graft was tailored to an appropriate length for spatulated end-to-side anastomosis utilizing a running HS7 Prolene suture.  Once the proximal anastomosis is complete, arterial flow was first reestablished to the distal common femoral artery followed by the graft.  The Doppler was used to confirm good arterial flow signals within the common femoral artery as well as the above-the-knee popliteal artery and the posterior tibia and dorsalis pedis arteries. Hemostasis was achieved with hemostatic Weck clips and thrombin soaked Gelfoam.  The wounds were then irrigated with antibiotic irrigation and then closed in multiple layers using interrupted 2-0 and 3-0 Vicryl sutures.  The skin was reapproximated with staples.  A sterile dressing was then applied.  The patient tolerated the procedure well and was extubated and transported to the recovery room in stable condition.

bladder tumor

Operative NoteDIAGNOSIS:     Bladder tumor.

SUMMARY:   Under adequate spinal anesthesia, the patient was put in lithotomy position and area prepped and draped in the usual sterile manner.  A #22-French Olympus cystoscope was introduced in the urethra, advanced under direct vision into the bladder.  With the 8-French cone-tip urethral catheter, bilateral retrograde pyelograms were performed. No abnormalities were noted on the retrograde pyelogram.  Following that, bladder was left full and the cystoscope removed.

A #24-French continuous flow resectoscope was then introduced in the urethra, advanced under direct vision into the bladder. 

Above-mentioned findings on cystoscopy were confirmed.  Following that, the bladder tumors which were found were resected down to the base of the bladder tumor and hemostasis was achieved with spot cauterization of the bleeding points. Following that, bladder was emptied along with the bladder tumor pieces.  Bladder was once again examined.  Hemostasis was adequate.  Urethral orifices were normal and there was clear efflux noted from both of them.  The bladder was left full, resectoscope removed, replaced with a 20-French Foley catheter, balloon of which was inflated with 10 cc of water.

Bimanual exam performed at the end of procedure failed to reveal a pelvic mass.  The prostate felt firm and benign in consistency. Continuous bladder irrigation was started in the operating room.  The patient tolerated the procedure well, left the operating room in satisfactory condition.

cystoscopy

Operative NotePROCEDURE:    Cystoscopy with bladder biopsy.

SUMMARY:   The patient was taken to the operating room and placed in the lithotomy position, and prepped and draped in the usual sterile fashion.  A 22 French cystoscope was then placed into the urethra and advanced into the urinary bladder showing mildly enlarged trilobed view of the prostate.  Upon entry to the urinary bladder, the bladder was examined with 30 and 70 degree lenses.  A small foreign like projection was found distal to the right ureteral orifice.  Biopsy forceps were used to biopsy this lesion and Bugbee cautery was used for hemostasis. Upon completion of the biopsy, the rest of the bladder was examined showing no further lesions.  Ureteral orifices were in the normal anatomic position with clear urine.  The cystoscope was then removed.  An 18 French catheter was placed.  The patient was taken to recovery in stable condition.  The patient went home with the catheter since we will see him tomorrow morning. The patient will follow up for pathology results.    

hernia repair

Operative NotePROCEDURE:    Umbilical hernia repair. 

SUMMARY:  The patient was taken to the operating room and prepped and draped in the usual sterile fashion.  Supraumbilical curvilinear incision was made and carried down to the fascia using blunt dissection.  Once this was done, hernia site was identified.  The hernia sack was dissected free from the fascia and dropped back to the preperitoneal space.  Once the fascia was clear circumferentially, the defect was closed with interrupted Ethibond sutures.  Once closure was adequate, the wound was checked for hemostasis.  After this, it was irrigated with sterile saline. 

 Next, 10 cc of 0.25% Marcaine plain was used for postoperative analgesia.  The wound was then closed in 2 layers with interrupted deep dermals as well as a running subcuticular Vicryl suture.  A sterile dressing was then applied.  The patient was awakened, extubated, and taken to post-anesthesia care unit in stable condition. Instrument and needle counts were correct as reported to me.    

laparoscopic cholecystectomy

Operative NotePROCEDURE:      Laparoscopic cholecystectomy. 

SUMMARY:   The patient was brought to the operating room and after proper identification. With the patient awake, a Foley catheter was placed and the patient was intubated after the induction of appropriate anesthesia.  The patient remained under general anesthesia for the duration of the case. The patient was prepped with DuraPrep over the abdomen in the usual fashion and then he was draped in the usual sterile fashion. Following the draping, the pneumoperitoneum was established via direct access over the peritoneum via a supraumbilical incision. After direct visualization of the peritoneum, the trocar was introduced and insufflation was begun. 

After appropriate insufflation a 10 mm scope was inserted and the abdomen was visually inspected to be benign in gross visualization. Next, another 11 mm port was placed in the right midepigastric region through the rectus abdominus muscle.  This was then followed by the placement of two 5 mm ports in the usual manner on the patient’s right hand side just below the costal margin.  The gallbladder was easily identified.  There were a few adhesions.  No intraabdominal fluid.  A generous amount of omental fat was present. Upon retraction of the gallbladder, the infundibulum was identified.  After some blunt dissection, the cystic duct was identified and then skeletonized using the small grasper.  After appropriate identification of the cystic duct, it was clipped 3 times with 2 clips staying, 1 clip going.  It was then transected with scissors.  This was performed without any complication. Next, a cystic artery was identified and 2 surgical clips on the proximal end and 1 surgical clip on the distal end were applied and this was transected using the laparoscopic scissors.  Following this, the gallbladder was easily retracted back and electrocautery was used to dissect the gallbladder fossa.  There was a well-established plane.  We came across one small arterial bleeder, approximately half way up the gallbladder fossa.  This was dealt with surgical clips. After application of the clips, no further bleeding from this site was appreciated.  Hemostasis was attained on the gallbladder fossa using a small amount of electrocautery. Following the removal of the gallbladder from the gallbladder fossa, it was placed in an endobag and subsequently removed from the supraumbilical port site.  Next, the gallbladder was thoroughly irrigated with approximately 1 liter of normal saline and then sucked dry after returning the patient to the supine position.  The supraumbilical fascia was closed directly with 0 Vicryl and then the dermis was closed at all 4 incision sites with a 4-0 Monocryl absorbable monofilament in a running subcuticular manner. The fascia was closed in a simple interrupted manner.  Steri-Strips and dressings were placed over the incision sites. The patient was awakened from anesthesia.  The Foley catheter was removed prior to him being awakened from anesthesia. The patient was returned to post-anesthesia care unit in a stable condition.

rhinoplasty

Operative NotePROCEDURE:      Rhinoplasty. 

SUMMARY: After adequate informed consent was obtained, the patient was brought to the operating room.  After induction of general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion.  The very bulbus nose was first infiltrated using 1% Xylocaine with epinephrin.  After giving adequate time for the epinephrine and having it taken its completed effect, the area was resected sharply using a scalpel.  This was then followed by contouring using dermabrader.  Hemostasis was maintained with electrocautery along with topical application of epinephrine.  The patient tolerated the procedure well and was awakened from anesthesia without difficulty and was transferred to recovery in satisfactory condition.

trigger finger release

Operative NotePROCEDURE:      Trigger finger release from long finger of the left hand.

SUMMARY:   The patient was taken to the operating room and placed in the supine position on the operating table where, after adequate IV regional anesthetic effect had been obtained, the left arm was prepped and draped in a sterile manner.  A 1 cm long transverse incision was made in line with the proximal palmar crease and carried by sharp dissection through the subcutaneous tissue.  Blunt dissection was used to expose the flexor tendon and the proximal edge of the A1 pulley. Using a #11 knife blade, the A1 pulley was incised from proximal to distal.  The finger was then put through a full range of motion with no triggering and I could see the small bump on the flexor tendon appear and disappear, and there was no triggering.  The wound was irrigated copiously with normal saline and the incision closed with 4 interrupted simple sutures of 3-0 nylon.  A sterile pressure dressing was placed over the hand, and the tourniquet was deflated.  The patient was awakened and returned to recovery in apparently good condition. Tourniquet time was 30 minutes.

meatotomy

Operative NotePROCEDURE:     Urethral meatotomy. 

SUMMARY:   Under satisfactory general anesthesia, the patient was placed in a supine position and prepped and draped in the usual fashion.  A bougie à boule was used to identify the caliber of the urethral meatus at this time it was type 2 12-French.  A 14-French bougie à boule was introduced in an incision made over the bougie à boule and extended.  Sutures were placed at the apex and laterally to reapproximate the mucosa. Hemostasis was good.  The urethra was recalibrated to 18 french at this point without difficulty.  Neosporin ointment was applied and the patient was sent from the operating room to the recovery room in satisfactory condition. 

Operative NotePROCEDURE:    Abdominoplasty with fascial plication.

SUMMARY:   After the induction of general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion.  Skin incision had been previously marked with a marking pen.  First, the umbilicus was sharply excised and freed from the dermis.  This was then marked with a 2-0 Vicryl stitch for later use.  Next, the lower transverse incision was sharply made and dissection was carried down to the fascial plane with electrocautery.  Hemostasis was achieved with electrocautery throughout the case.  The soft tissue was then elevated off the fascial plane in the cephalad direction up to the costal margin laterally and to the xiphoid process medially. The flap was split up to the level of the umbilicus and dissection was carried around, thus leaving a generous umbilical stock. The abdomen was then irrigated with antibiotic solution and rechecked for hemostasis.  Next, approximately 4 cm of fascial plication were carried out with interrupted figure-of-eight 0 Nurolon followed by running 2-0 Vicryl.  The rectus sheath was then injected with 20 mL of 0.25% Marcaine with 1:200,000 epinephrineon each side for a total of 40 mL.  The abdomen was then re irrigated. Two 19 French drains were placed through separate inferolateral stab incisions and secured with 4-0 nylon drain stitches.  The drains were shortened, leaving approximately 20 cm of white drain inside the wound.  Next, the table was flexed at the waist until closure above the level of the umbilicus could be achieved.  The amount for excision was then estimated with a marker. The excess tissue was then sharply excised and removed with electrocautery.  After achieving hemostasis, the abdomen was re irrigated. The midline was then brought together with the deep dermal 3-0 Polysorb.  In addition, a small amount of soft tissue was left over the mons pubis and this was advanced in the cephalad direction with several 2-0 Polysorb.  Scarpa was then closed, tacking this to the fascial plane with multiple interrupted 2-0 PDS stitches.  Next, the dermis was reapproximated with multiple

interrupted deep dermal 3-0 Polysorb followed by running subcuticular 3-0 Monocryl.  A small dog ear was excised from the left side. Next, a T-shaped incision was made over the umbilical stock. This was 1.5 by 1.5 cm.  Dissection was carried down through the subcutaneous tissue to reveal the umbilicus which was delivered through the wound.  Two small side nicks were placed in the belly button to match the T-shaped incision.  This was then secured with multiple half-buried 4-0 Prolene stitches with knots on the umbilical side.  Prior to complete closure of the bellybutton, additional antibiotic solution was irrigated in the wound. A strip of Xeroform gauze was then placed in the umbilicus.  The abdominal closure was dressed with benzoin, Steri-Strips, Hypafix tape, followed by dry gauze dressing.  Abdominal binder was then placed. 

Operative NoteDIAGNOSIS:   Acute perforated appendicitis. 

SUMMARY: The patient was brought into the operating room and prepped and draped in the usual sterile fashion.  A 10 mm trocar was placed through a curvilinear incision in the supraumbilical region through the umbilical hernia defect.  Next, a 12 mm trocar was placed in the left lower quadrant under direct visualization after insufflation of the pneumoperitoneum.  A 5 mm trocar was placed in the suprapubic region. Upon inspection, the appendix was seen adherent to the right lateral pelvic wall.  It was seen to be perforated on the inferior margin with pus present. This was irrigated.  The appendix was then dissected free from the lateral abdominal wall.  Once the appendix was free from the abdominal wall, the appendix and mesoappendix were dissected free from the base of the colon to allow adequate transection. Next, the window was established through the base of the mesoappendix and the mesoappendix was then divided with a vascular load on the endovascular stapler.  During further dissection, there was a small amount of bleeding that was encountered from the mesoappendix. This was controlled with a 1 cm hemoclip.  After this was done, the appendix was then taken using a blue load on a 45 endovascular stapler.  After the appendix was transected, it was placed in an endobag and brought out through the left lateral incision. Once this was done, the abdomen was irrigated copiously with 3 liters of sterile saline.  After copious irrigation and clear return of fluid, the trocars were removed and the pneumoperitoneum was evacuated along with the fluid and the midline supraumbilical fascia was reapproximated with a figure-of-eight Vicryl sutures.  Once this was done, all skin sites were closed with interrupted Vicryl subcuticular sutures.  Sterile dressing was applied, the patient was awakened, and extubated and taken to post-anesthesia care unit in stable condition.  Lap and needle counts were correct X2 as reported to me.

Operative NotePROCEDURE:   Kelman phacoemulsification with posterior chamber intraocular lens implant.

SUMMARY:   History, physical, and consent were obtained and identified on the chart. The patient was taken to the operating room where he was sedated by Anesthesia and a retrobulbar block was given with a mixture of 2% lidocaine and Wydase.  The eye was prepped and draped in the usual sterile manner.  A lid speculum was put into place.  A paracentesis was made at the 11 o'clock limbus and Viscoat was used to deepen the anterior chamber.  A 2.75 mm steel keratome was used to create a wound at the 9 o'clock limbus. A continuous curvilinearcapsulorrhexis was performed with a cystotome and Utrata forceps. Hydrodissection and hydrodelineation were performed with balanced salt solution on a 27-gauge cannula.  The nucleus was emulsified and aspirated using a modified stop and chop technique.  Cortical cleanup was performed with the irrigation and aspiration handpiece.  Healon was placed into the capsular bag.  The wound was slightly enlarged with a crescent blade.  A lens was loaded into the Monarch injection system and delivered to the capsular bag without difficulty.  The remaining Viscoat and Healon were removed with the irrigation and aspiration handpiece.  The wound was checked for water tightness and no leakage was found.  The eye was patched with Maxitrol ointment.  The patient tolerated the procedure well.  There were no complications.  

Operative NoteDIAGNOSIS:     Supraglottic mass, rule out pharyngeal cancer.

SUMMARY:  The patient was taken to the operating room, appropriate monitors were placed and general endotracheal anesthesia was induced by the anesthesia team. Examination of the head and neck under anesthesia was performed.  There were no neck masses.  There were no masses of the base of the tongue, and there were no masses of the preepiglottic space.  However, the epiglottic lesion was palpable and firm. He was turned and a shoulder roll was placed to put the patient’s neck in extension.  The Dedo laryngoscope was then introduced into the mouth after padding the gums with a moist 4X4.  The patient was noted to be edentulous on the maxillary segment and had 5 chipped teeth on the mandibular segment.  The Dedo laryngoscope was then advanced to the level of the cords which were found to be normal.  It was then gently retracted to view the surface of the epiglottis which was normal.  It was then further withdrawn to provide excellent visualization of the lingual surface of the epiglottis which is found to be grossly involved with the mass which appeared consistent with squamous cell carcinoma. Of course the mass extended into the left aryepiglottic fold and likely into the right aryepiglottic fold as well.  The preepiglottic space was not involved, nor was the base of the tongue. The perform sinuses were then inspected with the Dedo; both

were found to be normal, as well as the postcricoid space.  At this point, attention was turned to the esophagus.  The Dedo was removed and the flexible esophagogastroduodenoscopy scope was inserted. Using insufflation, the scope was gently advanced throughout the length of the esophagus to the GE junction.  There were no lesions found in the esophagus so the scope was gently and atraumatically removed.  The Dedo was then reinserted to expose the lesion.  The biopsy forceps were then used to take multiple biopsies, the first of which was sent for frozen section diagnosis. The remainder was sent for permanent pathology.  A pledget was soaked in 1% lidocaine with epinephrine and placed over the biopsy site while we awaited the results of the frozen section.  The Dedo was then withdrawn while awaiting this.  The pledget was then removed. The area was inspected one final time for hemostasis and found to be dry.  The shoulder roll was removed and the patient was returned to the care of the anesthesia team for wake up.  This proceeded uneventfully and he was extubated in stable condition.    

perative NotePROCEDURE:     Total knee arthroplasty.

SUMMARY:   The patient was brought to the operating room and placed supine on the operating table.  He was given a spinal anesthetic with Duramorph in the spinal. 

 A Foley catheter was inserted.  He was given 2 grams of Ancef and a tourniquet was placed about the thigh.  The extremity was prepped and draped in the usual manner.  The limb was elevated, exsanguinated, and the tourniquet inflated to 300 mm/Hg initially for 70 minutes.  It was then deflated for 10 and reinflated for another 15 minutes. 

 An anterior midline incision was made with the distal end just distal to the tibial tubercle.  Incision was made with the knife.  Medial parapatellar incision was made thereafter.  Pin was placed in the tibia tubercle to prevent inadvertent avulsion and was removed at the end of the case.  Patella was pushed laterally and an intramedullary guide was used on the femur with a 6 degree valgus cut. An extramedullary guide was used on the tibia and after the tibial cuts were completed the femoral cuts were completed and then the insert patella button was done with inset reamer.  The knee was copiously irrigated, dried, and components cemented in place in the standard manner using Polycose G cement.  A tourniquet was deflated, bleeders coagulated as needed, and then the tourniquet reinflated after 10 minutes for an additional 15 minutes as stated above.  Hemovac was brought out proximally and laterally. The parapatellar incision and retinaculum was closed with 1 Vicryl.  The subcutaneous with 0 Vicryl and the skin with staples. The incision was covered with Xeroform, Kerlix, and an anterior splint applied with the knee in extension.  The splint was held on with Ace wrap.   

 The patient tolerated the procedure well.  No complications were

sustained.  Blood loss was approximately 250 mL.

Operative NotePROCEDURE:    Meniscus repair.

SUMMARY:  The patient was brought to the operating room and placed supine on the operating table and given a spinal anesthetic and a tourniquet about the thigh.  The extremity was prepped and draped in the usual manner. The limb was elevated, exsanguinated, and tourniquet was inflated to 300 mm/Hg for approximately 35 minutes.  The scope was introduced anterolaterally, outflow superolaterally, and operating portal anteromedially.  The findings were that the anterior cruciate ligament was intact, having been reconstructed with hamstring tendon.  There was a displaced medial meniscal tear and this was resected with a portion excised and submitted to pathology.  The remainder was arthroscopically removed with the rotary meniscotome, which was initially a 5 mm resector and then a 3.5 mm resector.  Photos were taken intraoperatively.   

 Once the medial meniscus was complete, attention was paid to lateral meniscus where a complex tear, posterolateral meniscus was present, anterior to the popliteal tendon.  This was arthroscopically smoothed out and the tear resected using an up-biter vascular forceps and the 3.5 mm meniscal resector.  The knee was inspected.  The articular surface of the femoral condyle was healthy. There were no loose bodies present in the knee.  The knee was copiously irrigated at the conclusion.  The portal site was closed with interrupted 4-0 nylon and the knee injected with 20 cc 0.25% Marcaine and 0.5% Marcaine plain wrapped with Kerlix and Ace wrap. The patient tolerated the procedure well.  No complications were sustained.  He was in good condition at the conclusion of the procedure.

Operative NotePROCEDURE:      Right shoulder decompression. 

SUMMARY:  The patient was brought to the operating room and placed supine on the operating table.  He was given a general anesthetic and a gram of Ancef IV. He was then placed in the beachchair position and the right shoulder and arm were prepped and draped in the usual manner.  A 6 sonometer incision was made over the right shoulder superiorly and anteriorly, centered over the acromioclavicular joint with the distal end of the incision lateral to the coracoid.  Incision was made with the knife and medial and lateral flaps were created. The periosteum over the distal clavicle was incised and distal sonometer of the clavicle was osteotomized and removed.  The deltoid was reflected off the anterior 3 mm of the acromion and removed, and the inferior acromioplasty was performed with the saw. Os acromiale was present,

which is a congenital nonunion or failure to fuse of the acromion. There was a large fragment, so the base acromion was not removed.  The rotator cuff was noted to be intact, so after drill holes were placed in the acromion, the deltoid was sutured back to the acromion in a horizontal pants-over-vest manner.  Over the clavicular defect, the anterior deltoid was repaired to the posterior deltoid to cover the clavicular defect.  The subcutaneous was closed with interrupted 0 Vicryl and the skin was closed with 3-0 nylon staples.  The deltoid was repaired back to the acromion in a standard manner with 2-0 Ethibond. The incision was covered with Xeroform, 4X4s and tape.  A right shoulder immobilizer was applied.  Blood loss was less than 100 mL.

Operative NotePROCEDURE:     Bilateral vasectomy. 

SUMMARY:   Under adequate IV sedation, the patient was put in supine position and genitalia prepped and draped in the usual sterile manner. First, the right vas deferens was separated from surrounding cord structures by palpation and then held firmly against the stretched scrotal skin over it. About 3 cc of 1% lidocaine was injected and then skin tissue incision was made about 2 cm long and the vas deferens was grasped with hemostat and brought out of the incision.  Following that, surrounding tissue from the vas was dissected off sharply.  Hemostasis was achieved with broad cauterization.  About a 2 cm long segment of vas deferens was excised.  The cord ends were cauterized, tied with 3-0 chromic ties, and then suture ligated and folded over with suture ligature of 3-0 chromic material.  Hemostasis was confirmed.  The vas deferens was dropped back into the scrotum, scrotal incision closed with interrupted mattress suture of 3-0 chromic.  Similar procedure was carried out on the left vas deferens.  Following the procedure, sterile dressings are applied.  The patient was transferred to recovery in satisfactory condition.

Operative NotePROCEDURE:      Transurethral resection of the prostate.

SUMMARY:   Under adequate spinal anesthesia the patient was put in lithotomy position and the genitalia was prepped and draped in the usual sterile manner. A cystoscope was introduced into the urethra and advanced under direct vision into the bladder.  Following examination of the bladder, the bladder was left full.  Cystoscope was removed.

A 24-French Olympus continuous flow resectoscope was introduced in the urethra and advanced under direct vision into the bladder.  Following emptying of the bladder, the bladder was re-examined and urethral orifices were well visualized.  Following complete examination of the

bladder the obstructing prostatic tissue was resected from the bladder neck to the verumontanum and down to the prostatic capsule.  First the median lobe was resected, then the left lobe, and then the right lobe. After completing the resection the bladder was emptied of all the prostatic chips using an Ellik evacuator and bulb syringe.  The bladder was once again examined for any retained prostatic chips, none were found. Hemostasis was achieved with spot cauterization followed by roller ball electrode.  The bladder was once again examined for any retained chips, none were found.  Hemostasis was confirmed.  Bladder was left full.  The resectoscope was removed and replaced with a 24-French 3-way Foley catheter balloon of which was inflated with 45 cc of water.  The patient had a bimanual exam performed at the end of the procedure, which revealed soft abdomen and bladder was not distended. It was not fixed. Prostate felt firm and benign.  The patient had continuous bladder irrigation started in the operating room and was transferred to the recovery room in satisfactory condition.

Operative NotePROCEDURE:     Modular repair of abdominal aortic aneurysm with Gore endograft device and planning aortogram through bilateral femoral cut downs.  

SUMMARY:   With the patient supine on the operating table under adequate sedation and spinal anesthesia, the abdomen and groin were prepared with DuraPrep solution, draped with sterile sheets and towels and Ioban drape.  Oblique incisions were made over the femoral arteries and carried down to where they entered under the inguinal ligament.  We placed vessel loops around the vessels and gave the patient 5000 units of heparin.  We placed an 18 French sheath on the left, a 12 French sheath on the right, and through the 18 French sheath we placed a pigtail catheter, did a planning aortogram documenting the level of the renal artery, which was on the left.  The patient had obvious right renal artery stenosis in a middle renal artery, which was the biggest. A superior pole artery was above that.  There was a very low small inferior pole artery on the right, which we did cover.  On the left side, the renal artery appeared to be single and was mildly diseased, which we later stented, which will be described. 

 After we placed the 18 French sheath, we placed a 28 by 14 by 16 Gore endograft from the level of the left renal artery down into the left common iliac.  The graft appeared to deploy a little bit high and I was a little bit worried about the renal artery having a piece of fabric in front of it; although, the blood flow to the renal artery was brisk and unremarkable.  We watched it for a while.  The kidney made contrast and appeared to function normally.  We cannulated the gate from the right side to the 12 French sheath and placed a 14 by 12 limb down into the right common iliac.  Both of the common iliac limbs landed above the hypogastric.  We placed the Reliant balloon and sealed all the sites, shot an aortogram and found no leaks present with a good seal.  Because

of my concern about the left renal artery, I placed a .035 guidewire into it, and through that placed a renal double curve, and through that placed a 6 mm by 17 mm balloon-mounted stent with proximal end of the stent sticking out slightly into the aorta.  Upon ballooning it, it opened up nicely, and a confirmatory angiogram showed evidence of good flow to the left kidney.  After we did that, we removed the sheath and repaired the femoral artery with interrupted 5-0 Prolene sutures on the right side, being cautious in approximating the anterior wall as there was a big calcific atherosclerotic cholesterol plaque in the common femoral posteriorly.  After we finished the closures bilaterally, there was reasonable pulse on both sides at the femoral.  We then closed the wound in layers with 2-0 Vicryl in the deep tissue, 3-0 Vicryl in subcutaneous and the skin was closed with a skin stapling device.  The patient tolerated the procedure well and was taken to the recovery room in good condition with diminished pulses in the right foot, which had been present preoperatively.

Operative NotePROCEDURE:   Above-the-knee amputation.

SUMMARY:  After satisfactory prepping and draping of the area the sterile tourniquet was placed at the higher end of the thigh.  It was inflated to 300 mmHg.  The skin flaps were then raised in a fishmouth fashion with proposed bone transection at upper 1/3rd of the thigh and the skin incision extending up to the middle 1/3rd of the thigh.  The skin, subcutaneous tissue, and fascia were then incised along the line of incision.  All the muscles were individually transected and visible bleeders were cauterized.  The femoral artery, femoral vein, and sciatic nerve were also identified and they were all doubly ligated and transected.  The bone was cut with a Gigli power saw and then the rest of the muscles in the posterior compartment were also transected.  The tourniquet was released and all the minor bleeding that came from the muscular vessels were also tied.  The patient did have open femoral artery and a good blood supply to all the muscles.  So there was quite a bit of muscular blood vessels that we had to tie, but it was systematically done and satisfactory hemostasis was secured.  The fascia was closed with 2-0 Dexon.  The skin was approximated with skin staples.  Pressure dressing was applied.  The patient was sent to recovery room in good condition.

Operative NotePROCEDURE:    Left carpal tunnel release.

SUMMARY:   The patient was brought to the operating room and placed supine on the operating table and given a left upper extremity IV bier block and a gram of Ancef IV.  Once anesthetized, the left upper extremity was prepped and draped in the usual manner.  Incision was made in the palm of the left hand 2 sonometers long in line with the ring finger metacarpal and distal to the volar distal wrist crease. The incision was made with the knife through the skin and then through the

palmar aponeurosis and the transverse carpal ligament. Antebrachial fascia was released with scissor.  The incision was irrigated, closed with interrupted 4-0 nylon.  Incision was covered with Kerlix, and a volar wrist splint applied with the wrist in mild dorsiflexion and the splint held on with Ace wrap. The patient tolerated the procedure well.  No complications were sustained.  He was in good condition in the recovery room at the conclusion of the procedure.    

Operative NotePROCEDURE:   Small finger ray resection.

SUMMARY:  The patient was brought to the operating room and placed supine on the operating table and given a general anesthetic.  A tourniquet was placed about the arm, and the extremity was prepped and draped in the usual manner.  The limb was elevated and exsanguinated with an Ace wrap, and the tourniquet was inflated to 250 mm/Hg for 45 minutes.  A ratchet incision was made about the base of the proximal phalanx, and incision dorsally made over the course of the fifth metacarpal.  The incision was initially made on the ulnar aspect of an ulcer, which was eventually cut out.  The dissection was carried down to the metacarpal and then out the ratchet incision as stated for the proximal phalanx. The finger was disarticulated at the metacarpophalangeal joint prior to removing the fifth metacarpal from its bed.  The neurovascular bundles were seen and protected, especially to the ring finger.  The entire small finger metacarpal was removed.  A culture of the base was obtained and submitted to microbiology as stated above.  The ulcer on the residual dorsum of the right hand was excised and the volar flap brought dorsally for closure with 4-0 nylon.  Once closed, the incision was covered with Xeroform, Kerlix, and a volar wrist splint with the wrist in mild dorsiflexion.  The splint was held on with Ace wrap.   

Operative NotePROCEDURE:     Bilateral decompressive cervical laminectomy, C4, C5, and C6.

SUMMARY:   After satisfactory general anesthesia, the patient was fixed in the Mayfield headrest, then turned prone over the Wilson frame and prepared for surgery.  The skin over the suboccipital neck and upper shoulders were shaven, scrubbed with Betadine scrub, painted with Betadine paint, and draped for a sterile procedure.  A midline 8 cm incision was made over the posterior spinous process of C3, C4, C5, and C6.  Dissection was carried down the deep cervical fascia, bleeding encountered, controlled with bipolar forceps. Bleeding was encountered and coagulated with bipolar cautery. The deep cervical fascia was incised on either side of the posterior spines of C4, C5, and C6 and the paraspinous muscles were dissected away from the spine and lamina retracted laterally.  A metallic clip was placed in the posterior spine

of C4 and the lateral x-rays taken confirm the exact anatomical location.  Rongeurs were used to remove the spine at C5 and the lamina at C5 out to the facet joints.  Attention was then directed to the C6 lamina and the spine.  The spine was removed and the lamina was removed out to the facet joints and again attention was then directed to C4 and the same performed.  Once the laminectomy was complete, the ligamentum flavum was excised from the spinal dura. The dura remained intact.  He did not have evidence of a radiculopathy, therefore foraminotomies were not done. Neural foramina was inspected and seemed to be patent. Pledgets of gel foam were then cut and placed over the exposed dura. The paraspinous muscles were allowed to fall back into place.  Zero stay sutures were passed through the deep cervical fascia and muscle layer to be tied later.  Deep cervical fascia was then approximated in the midline with interrupted 2-0 Vicryl sutures.  Then the subcutaneous fat was approximated with interrupted 2-0 and 3-0 Vicryl sutures and half inch Steri-Strips were used for the skin closure.  Sterile postoperative dressings applied.  The patient was then turned supine. The Mayfield headrest was removed and the procedure was then terminated.  The patient was awakened and transferred to the recovery room, having tolerated the procedure quite well.  At this point he is awake, talking, and moving all his extremities.  Estimated blood loss for the entire procedure was 125 cc.  It was unnecessary to transfuse him.  Sponge count, cottonoid count, instrument counts were all correct.

Operative NotePROCEDURE:     Insertion of a dual chamber DDDR pacemaker under fluoroscopic guidance.  

SUMMARY:  With the patient supine on the operating table under adequate sedation, 20 cc of 1% local was infiltrated in the left infraclavicular region. This was done after prepping with DuraPrep solution, sterile sheets, towels, and Ioban drape.  A transverse incision was made under the left clavicular area.  We gained access to the subclavian vein with a needle, and placed a wire into the superior vena cava.  After we did that, we placed a lead into the right ventricle and screwed the lead out.  We placed a lead into the right atrium and screwed the lead out.   In the right atrium, we had a P wave of 1.6 millivolts, 560 ohms impedance. We were able to pace the atrium to 0.8 volts.  The R wave was 8.8 volts with impedance of 1392 ohms and a threshold of 1.2 volts. These 2 leads were attached to the device and tightened down properly.  This was placed into the subcutaneous pocket which we have made.  After ensuring proper hemostasis, we closed the wound in layers with 2-0 Vicryl in the deep tissue, 3-0 Vicryl in the subcutaneous. The skin was closed with running 4-0 Monocryl subcuticular stitch.  The fluoroscopic unit was used for a total of 3 minutes for the placement of the leads.  The patient tolerated the procedure well with less than 25 cc in blood loss and was taken to the recovery room and awakened in good condition with the device sensing the patient properly with lower rate limits of 60, upper rate 120. 

Operative NotePROCEDURE:     Thyroidectomy. 

SUMMARY:   The patient was brought to the operating room and prepped and draped in the usual sterile fashion.  A low collar incision was made in the standard fashion and was carried down through the platysma muscles.  The strap muscles were divided in the midline until the thyroid was identified.  Next dissection first proceeded with dissection of the left lobe of the thyroid.  This was done from inferior pole to superior pole fashion using blunt dissection and hemoclip to protect the inferior thyroid arteries, thyroid glands, thyroid arteries and all branching structures in this region with care taken to hug the capsule at all times.   The thyroid was then reflected up until it was attached to the trachea and ligament of Berry was identified at this point.  A Ray-Tec was placed behind the thyroid and attention was turned to the right lobe of the thyroid.  Upon further dissection, nodule was easily identified in the right lobe of the thyroid medially.  Dissection continued the same way as the left lobe proceeding from inferior to superior pole fashion using blunt dissection and hemoclip.  Once taken, the vascular structure of the right thyroid lobe was reflected up into the field.  Dissection continued medially until reaching the trachea and taking ligament of Berry.  At no time were the laryngeal nerves visualized as the capsule was hugged at all times.  Once the right lobe of the thyroid was freed, it was passed from the field as specimen number 1.  Surgicel was placed in the wound and attention was returned to the left lobe of the thyroid. The left lobe was dissected free from the trachea and ligament of Berry was divided using careful dissection without identifying the recurrent laryngeal nerve as the capsule of the thyroid was once again hugged on this side as well.  After this was done, the left lobe was passed off as specimen number 2.  Surgicel was placed in the wound as well.  After approximately 5 minutes of observation the wounds were checked and revealed no clotting in either wound bed.  Surgicel was left in place and the strap muscles were reapproximated loosely with interrupted Vicryl sutures.  The platysma was reapproximated as well with several interrupted Vicryl and the skin was reapproximated with running subcuticular Vicryl.  10 cc of 0.25% Marcaine were used for postoperative analgesia.  Sterile dressing was applied to the wound. At this point and time, the patient was awakened, extubated, and taken to post-anesthesia care unit in stable condition.  Lap and needle counts were correct X 2 as reported to me.  

  Of note, the patient was checked in post-anesthesia care unit postoperatively and found to have adequate vocal function and was able to annunciate vowels appropriately. 

Operative NotePROCEDURE:     Left ureteroscopy and laser lithotripsy stage stenting with insertion of 4.7 French by 24 cm double J stent. 

SUMMARY:   This is a patient with a left ureteropelvic junction calculus who underwent previous stent placement and is undergoing ureteroscopy and laser lithotripsy.  Following adequate general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion.  A 22 French rigid cystoscope was then placed into the ureter and advanced into the urinary bladder without difficulty.  The previously placed left urinary stent was identified and was grasped with biopsy forceps and this was removed from the meatus.  At the meatus, the stent was grasped and guidewire was placed up into the left renal pelvis.  Next, the stent was removed.  A dual lumen catheter was placed over the guidewire and a second guidewire was placed also within the renal pelvis.  Next, the ureteral access sheath was placed over the guidewire and advance up into the proximal ureter. One of the wires and the obturator to the ureteral access sheath was then removed and the flexible ureteroscope was then advanced up the left ureter up into the renal pelvis.  The previous proximal ureteropelvic junction stone was identified. This was an upper pole calix.  200 micron laser fiber was then used to fragment the stone into basketful sized fragments. Next, the stone basket was used to grasp the fragments and removed via ureteral access sheath. Next, the following removal of the large stone fragments there was only a small amount of debris.  Contrast was then placed within the left renal pelvis. The upper, middle, and lower pole calices were examined and no significant stone burn was identified.  Next, the ureteroscope was brought to the level of the ureteral access sheath, and the scope and access sheath were brought out in combination to examine the remainder of the ureter.  It was free of stone.  Next, a 4.7 French by 24 cm double J stent was placed over the preexisting guidewire with initial good curl within the renal pelvis.  The patient began to awaken and now it appears that the proximal end of the stent was within the lower pole calix with adequate curl.  The distal end had good curl within the urinary bladder. The bladder was then drained, scope removed.  The patient was extubated and taken to recovery in stable condition.  The patient will follow up in approximately 1 week for stent removal.  The patient was given a prescription for narcotic pain medication, Vicodin, as well as an antibiotic.