OPERATIVE REPORT FILES SET_A

OPNT_1A

PREOPERATIVE DIAGNOSIS:  Acute appendicitis. 

POSTOPERATIVE DIAGNOSIS:  Acute appendicitis. 

ANESTHESIA:  General. 

FINDINGS:  Acute appendicitis. 

PROCEDURE:  The patient was brought to the operating room and placed in the supine position.  After receiving general anesthesia and endotracheal intubation, the abdomen was prepped and draped in the usual fashion.  A supraumbilical incision was made through which a Visiport and 10-mm scope were placed under direct vision.  Pneumpperitoneum was established at 10 mmHg to 15 mmHg of pressure.  A suprapubic 5-mm port in left lower quadrant and 12-mm port were then placed under direct vision.  Examination of the right lower quadrant revealed an acutely inflamed appendix.  The appendix was dilated and thickened.  The base of the appendix had a slight phlegmon on it.  The base of the appendix was then transected with one firing of EndoGIA 2.5 stapler and the mesoappendix with one firing of the EndoGIA 2.0 vascular stapler.  The appendix was placed in the Endobag and brought out through the left lower quadrant port site.  Copious irrigation was performed.  A dry field was noted, and attention was then brought to closure.  The CO2 was evacuated, the ports removed, and the wounds were closed with zero Vicryl for the fascia and 4-0 Vicryl for the skin Steri-Strips, telfa, and Tegaderm were applied.

The patient tolerated the procedure well, was extubated in the operating room, brought to the recovery room in stable condition.

OPNT_2A

PREOPERATIVE DAIGNOSIS:  Chronic and recurrent tonsillitis.

POSTOPERATIVE DAIGNOSIS:  Chronic and recurrent tonsillitis.

PROCEDURE:  Tonsillectomy.

ANESTHESIA:  General with oral endotracheal intubation.

COMPLICATIONS:  None.

DISPOSITION:  Recovery room.

CONDITION:  Stable.

ESTIMATED BLOOD LOSS:  Less than 5 cc.

INSTRUMENT AND SPONGE COUNTS:  Correct.

INDICATIONS:  The patient is a 6-year-old with a history as described above.  After discussion with the patient’s mother including discussion of risks, benefits, and alternatives, she decided he should undergo the above operation and a written informed consent was obtained.

PROCEDURE:  The patient was brought to the operating room, positioned in the usual supine manner and adequate general anesthesia with oral endotracheal intubation was obtained.  He was draped using sterile towels, head frappe, and split sheet.  Using a headlamp for visualization, a McIvor mouth gag was inserted and suspended.  Attention was first directed to the left tonsil, which was grasped with an Allis clamp, retracted medially, and excised using cautery technique.  The tonsil was moderately large and cryptic, and contained copious exudates.  A few small areas of oozing were easily controlled with suction cautery.

Attention was then directed to the opposite tonsil, which was removed in an identical manner and findings were the same.  Now the anesthesiologist performed several Valsalva maneuvers where the tonsillar fossae were gently agitated with a tonsil sponge.  No further bleeding ensued.  The McIvor mouth gag was removed from suspension and removed from the patient’s mouth.  The patient was then awakened and extubated with plans to send him back to recovery room in good condition.

OPNT_3A

Right skin-sparing mastectomy.

Second part of the procedure was done by, which is a tissue expander with the use of AlloDerm.

PREOPERATIVE DIAGNOSIS:  History of left breast cancer.

POSTOPERATIVE DIAGNOSIS:  Pending pathology.

PREPERATION:  Betadine.

PROCEDURE:  The patient was placed in supine position.  Both breasts were prepped using Betadine and draped in the sterile fashion.  A skin incision had been designed by Dr. encompassing the right nipple-areolar complex.  After executing the skin incision, skin hemostasis was achieved with electrocautery.  Skin flaps were then raised carefully superiorly to the clavicle, medially to the sternum, inferiorly below the inframammary fold and laterally to the edge of latissimus dorsi muscle.  Care was taken superiorly to dissect out the axillary tail.  As I proceeded, hemostasis was mainly achieved with electrocautery.  The breast was reflected from medial-to-lateral direction off of the anterior chest wall, multiple small vessels were controlled with either 3-0 Vicryl ties or electrocautery.  On further dissection laterally and inferiorly released the specimen, we did not formally enter the axilla, but no enlarged nodes were palpable at this level.  The axillary tail was marked with a suture.  The skin was reinspected.  In some areas, some additional subcutaneous fat was removes.  When we were assured that all evidence of breast tissue had been removed, the wound was irrigated with bacitracin solution.  The case was then turned over to Dr. for immediate reconstruction.

OPNT_4A

PROCEDURE:  A caudal epidural steroid injection with threading of radiopaque catheter under fluoroscopic guidance.  This is the patient’s second procedure of this particular series.

Her last procedure was on January 2, 2008.

The patient is a 74-year-old woman with a long-standing history of low back pain and severe rheumatoid arthritis.  Currently, at best her pain is at 2/10 on a verbal analog scale, at worst it is 10/10.

She was escorted by ambulation to the fluoroscopy suite.  The above discussion occurred.  Consent was obtained.  She was positioned prone and all pressure points were padded.  Standard monitors were applied.  Scout films of the lumbosacral spine were done.  The sacral hiatus was identified upon palpation and confirmed with fluoroscopic guidance on lateral view and was appropriately marked.  The sacral and coccygeal region was prepped with Betadine and a sterile drape was applied.  Then, 5 cc of 1% lidocaine without epinephrine was injected for local anesthetic initially using a 25-guage 1-1/2-inch needle.  A 17-guage 3-1/2-inch Tuohy needle was inserted to and through the sacral hiatus under fluoroscopic guidance.  There was no cerebrospinal fluid, blood, or complaints of paresthesia.  A radiopaque catheter was inserted through the Tuohy needle and advanced to the L5-S1 level.  There was negative aspiration of blood or clear fluid form the catheter.  Then, 3 cc Omnipaque 180 was injected and appropriate flow within the epidural space was noted on both anterior-posterior and lateral views.  Then, 1.5 cc of 0.25% Marcaine without epinephrine followed by 80 mg of Kenalog complete with an addition of 1.5 cc of 0.25% Marcaine without epinephrine was injected.  The catheter and the epidural needle were removed simultaneously and the tip of the catheter was intact.  The coccyx and sacral regions were cleaned with alcohol and a Band-Aid was applied.  The patient was able to sit up and stand without complaints of lightheadedness, headache, or weakness.  She was escorted by ambulation with the use of her cane to the medical ambulatory unit in stable condition.

PLAN:

1.  She is to schedule on an as-needed basis the third caudal epidural steroid injection of this particular series.

2.  Again we will consider her for a trial of Biowave percutaneous neuromodulation stimulation.

OPNT_5A

The third session of her percutaneous neuromodulation stimulation trial using the Biowave systems.

An 81-year-old woman with left low back pain radiating to her left buttock and into her anterolateral thigh.  She felt some relief from her last percutaneous neuromodulation stimulation session on April 16, 2008.  Currently, her pain is 9/10 on a verbal analog scale, at best is 0/10, at worst is 10/10.  She states that she felt a little better for few hours, but she still cannot walk.  Her pain is worse at the left buttock and that it radiates to her anterolateral thigh into her lateral upper calf with throbbing sensation.

Her blood pressure was 143/80 with a pulse of 60 and regular.  Room air oxygen is 97%.  Respiratory rate is 18 and unlabored.  Again the “U pads” were used.  The circular stimulation pad was placed at the left lumboscaral region with a large feeding pad to the upper left lateral hip and thigh.  Thirty minutes of stimulation was provided with a maximum stimulation of 38.5%.  Upon completion of stimulation, the pads were removed and her skin was intact.  The patient stated that she was able to stand better and stated that she would like to learn more about the home wave system.

She was discharged to home in stable condition.

PLAN:

1.  She is to call in a few days after she has better opinion on response today’s treatment, and if helpful, she will be provided more information in regards to possible home therapy system.

2.  She was referred to physical since she wishes to continue treatment.

OPNT_6A

Preoperative diagnosis is complex right upper forehead laceration with tissue loss and foreign body contamination.

Operative procedure is reconstruction of large and complex right upper forehead skin and soft tissue defect with fasiocutaneous flap.

Postoperative diagnosis is complex right upper forehead laceration with tissue loss and foreign body contamination.

Anesthesia is local.

Position of the patient is supine.

The indication for the operation for the operation is as follows:  The patient is a 72-year-old white female who sustained a large and complex degloving injury of the right upper forehead lesion after she tripped and fell on some flagstone steps outside her house earlier in the day on Friday, April 11, 2008.  The patient had a significant amount of bleeding from the area of injury, which was difficult to control despite applying direct pressure to the area of injury.  However, the patient had no loss of consciousness.  After the injury, she remained alert and oriented thereafter.  Of note, the patient does have a history of having fallen in the past.  The etiology of this is unclear, but the patient does have a history of a transient ischemic attack in the past as well as multiple falling episodes according to her husband.  The patient did not complain of any headache or visual acuity changes and there was no nausea or vomiting after the event.  There were no other associated injuries except for a small abrasion over the nasal bridge.  The patient was brought by her husband to Hospital emergency room where a plastic surgery consultation was requested and obtained.

The operative procedure was as follows.  The patient was seen in the separate suture area.  She was noted to have a 4 cm long x 2-3 wide deep jagged avulsion flap laceration of the right upper forehead region, which was down to the bone with a significant amount of foreign body contamination and tissue loss.  The patient reported that she tripped on the ledge of a flagstone step and landed squarely on her forehead in a mulch bed, which had been recently filled by her gardener.  The patient had a large and substantial amount of embedded mulch material within her forehead along the bone periosteum and embedded within the skin and soft tissues of the surrounding skin.  This required sharp debridement of a large amount of skin and soft tissue.  The area of the injury was prepped and draped in the usual sterile fashion and a local block was administered into the surrounding soft tissue with a total of 7 cc of 1% lidocaine with 1:100,000 epinephrine solution.  The wound was then thoroughly irrigated and debrided sharply.  All hematoma and debris were removed.  The jagged edges of laceration were trimmed conservatively.  All nonviable tissue was removed sharply and all foreign body contamination was removed as well.

The wound was thoroughly irrigated and the resultant defect was repaired with a fasciocutaneous flap from the surrounding forehead and scalp regions.  The flap was designed created, elevated, rotated, into the defect and repaired in an anatomic manner.  The flap was sutured in place with 5-0 fast absorbing gut sutures for the periosteum, muscle fascia, and subcutaneous layers, and 6-0 Prolene sutures for a precise skin repair.  The wound was then cleaned with wet and dry saline sponges.  A sterile dressing of bacitracin ointment was applied over the suture line as well as over the surrounding abrasion.  A small amount of bacitracin ointment was applied over the abrasion over the nasal bridge area.  The patient tolerated the procedure well.  She was discharged to home same day of the surgery on Friday, April 11, 2008, at approximately 9 p.m. accompanied by her husband were told keep the suture line and all abrasions moist with bacitracin ointment in a postoperative period.   In addition, the patient was discharged with prescription for Keflex 500 mg 3 times a day for 1-week time.  She was told to take Tylenol postoperatively for pain and was instructed to call my office for any other questions or problems and to make a followup appointment to be seen in 1 week’s time for a wound check.  The patient was discharged with instructions and followup as noted above.

INTRAVENOUS FLUID:  None.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:  None.

DRAINS:  None.

CULTURES:  None.

COMPLICATIONS:  None.

OPNT_7A

ADMISSION DIAGNOSES:  Term pregnancy with A1 diabetes.  At term for induction.

OTHER DIAGNOSES:  Clinical hypothyroidism, Group B strep positive, and Beta cell trait.

DISCHARGE DIAGNOSES:  Clinical hypothyroidism, Group B strep positive, and Beta cell trait.  Live born male 7 pounds 1 ounce, Apgars 8 and 9.

PRINCIPAL PROCEDURE:  Normal spontaneous vaginal delivery.

ADMISSION H AND P:  The patient is a 37-year-old gravid 4, para 2, who presents at 39 weeks via 22-week sonogram and she is for induction due to gestational diabetes for which she takes glyburide.  Her antepartum course is significant for being beta cell positive and having had GBS bacteriuria.  She is Rh positive, antibody negative, rebulla immune.  Her Pap is normal.

On general exam, everything is fine.  Her admission fingerstick is in the 120s and routine diabetic orders are started with diabetic liquid diet and she was given penicillin IV for prophylaxis of her group B strep.  Her exam in the office yesterday or the day before was 2 cm, so I did not initially examine her.  Pitocin was begun and fetal heart rate was 140 and reactive.  Several hours later, she was contracting and uncomfortable.  I examined her she was 3 and 75%.  Baby was 120 and reactive and within a couple of hours she progressed to full dilation.  Her membranes were ruptured at 1430.  She was fully dilated at 1535, she delivered a little boy in the LOA position at 1542 over an intact perineum.  There was a nuchal cord x1, which was easily reduced.  Shoulders delivered easily.  Cord was clamped and I cut it and the baby was vigorous.  The placenta delivered spontaneous and intact with 3 vessels.  There was some mild atony by Pitocin especially in the lower segment.  Massage was done and one dose of Methergine was given IM.

Estimated blood loss is 400 cc.  The patient tolerated the procedure well.  Once again the perineum was intact.

OPNT_8A

PREOPERATIVE DIAGNOSIS:  Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:  Acute appendicitis.

OPERATIVE PROCEDURE:  Laparoscopic appendectomy.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMEN:  Appendix.

PROCEDURE:   The   patient   was   brought  to  the  operating  room  and  placed  on  the  OR  table  in  the  supine  position.  After  smooth  induction  of  general  endotracheal  anesthesia,  a  Foley  catheter  was  placed.  The  patient's  abdomen  was  then  prepped  and  draped  in  the  usual  sterile  fashion.  Using  a  #15-blade,  an  infraumbilical  incision  was  made.  The  skin  and  subcutaneous  tissues  were  dissected  down  to  the  fascia.  The  fascia  was  opened  along  the  midline.  The  posterior  fascia  was  opened  sharply  and  the  abdomen  was  entered.  A  12-mm  blunt  port  was  placed  through  the  infraumbilical  incision  and  a  pneumoperitoneum  of  15  mmHg  was  then  achieved  with  carbon  dioxide  insufflation.

Under  direct  visualization  with  laparoscopic  camera,  a  5-mm  port  was  placed  in  the  suprapubic  position.  In  a  similar  fashion,  a  second  5-mm  port  was  placed  in  the  left  lower  quadrant.  The  appendix  was  visualized.  It  was  acutely  inflamed,  but  not  perforated.  There  was  no  abscess  formation.  A  window  was  created  between  the  base  of  the  appendix  and  the  mesoappendix  using  blunt  dissection.  Next,  the  mesoappendix  was  divided  with  a  single  firing  of  the  EndoGIA  2.5-mm  stapler.  The  appendix  was  then  amputated  from  the  cecum  using  a  single  firing  of  the  EndoGIA 3.5-mm  stapler.  The  appendix  was  placed  in  an  Endopouch,  which  was  removed  through  the  infraumbilical  incision  and  sent  to  Pathology  for  further  evaluation.  The  right  lower  quadrant  was  irrigated.  Hemostasis  was  noted  to  be  complete.  All  the  irrigation  fluid  was  removed  and  the  laparoscopic  ports  were  removed.  There  was  no  bleeding  from  the  abdominal  wall.  The  infraumbilical  incision  was  closed  with  interrupted.