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Sample General Surgery and Plastic Surgery Reports

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GENERAL SURGERY / PLASTIC SURGERY:
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.


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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.


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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 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 nd 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:
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.


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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.


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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 was cut off and removed from 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.


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FLEXIBLE SIGMOIDOSCOPY

PROCEDURE: The Olympus-60 scope was passed to 40 cm. On withdrawal, two polyps, about 3-4 mm, were noted. One was at 35 cm and the other at 20 cm. Multiple diverticula were noted in the sigmoid colon. Scope was not advanced past 60 cm, due to sharp flexures of the sigmoid colon and redundancy. Patient tolerated procedure well. Preparation was excellent. Mucosa was otherwise normal.

ASSESSMENT:
Two polyps that appear benign, at 20 and 35 cm.

PLAN
Referral for colonoscopy.


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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:
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 symphy sis pubis was then made dividing the rectus abdominis muscle bellies. The Space of Retzius 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 perfor med. 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 r econstructed 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.


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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.


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OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Right foot infection.

POSTOPERATIVE DIAGNOSIS: Right foot infection.

PROCEDURE: Right below-knee amputation.

SURGEON: Save A. Life, M.D.

ANESTHESIA: Spinal.

FLUIDS: 300 cc Ringer's lactate.

ESTIMATED BLOOD LOSS: 250 cc.

INDICATIONS FOR SURGERY: This is a 70-year-old male with a history of insulin-dependent diabetes mellitus, coronary artery disease, chronic renal failure and heart failure who was initially admitted for congestive heart failure and nonhealing bilateral foot ulcers treated for years with debridement and whirlpool. The patient was readmitted for acute diabetic right foot. Recently his foot had been worsening. He had been using dry dressings. He was admitted and taken to the operating room for incision and drainage of his right foot and first ray amputation. The patient's infection could not be eradicated from the foot; therefore, it was decided to take him for right below-knee amputation.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating room table in the right lateral decubitus position. After placement of intravenous lines and electrocardiogram leads, spinal anesthesia was induced. The patient was placed supine and the patient's right lower limb was sterilely scrubbed with Betadine and prepared with Betadine paint in a sterile fashion. The patient's right lower limb was draped in a sterile fashion after the application of a tourniquet to th right upper thigh. The tourniquet was not inflated during the case.

We first turned our attention to the foot and made a transmetatarsal incision with a 10-blade scalpel around the foot. We performed a transmetatarsal amputation at first. There did not seem to be bleeding or viable tissue at this amputation site, especially posteriorly on the foot. Therefore it was decided to carry the amputation up to a below-knee amputation. A fish-mouth incision was made at the midtibia, leaving more posterior tissue to form a lip for closure. Using the 10-blade scalpel, we cut circumferentially the soft tissue around the tibia and fibula, being careful to clamp bleeding vessels which appeared along the way. We cut through all the soft tissue muscle tendons and were careful to identify the peroneal nerve and the tibial nerve, and to stretch these as far down as possible and cut them as far proximally as possible so they would retract and not form neuromas. We tied off the major vessels, the tibial and peroneal arteries. After the soft tissue was removed, the tibia was cut with the oscillating hand saw approximately 3 cm proximal to the skin incision. The end was rasped away so there would be smooth edges. The fibula was cut with the hand saw 2 cm above this, and the end was rasped off as well to a smooth dry point. Hemostasis was obtained with the cautery, and also with Vicryl suture used to tie off some bleeding vessels.

The fascial tissue layer was closed with 0-Vicryl figure-of-eight sutures. After this, 0-Vicryl was used to bring the skin together by bringing the subcutaneous tissue above the fascia. The last layer of skin was closed with 4-0 nylon interrupted sutures. A sterile dressing and Ace wrap were placed over the wound. We also inserted a small drain into the wound. The patient tolerated the procedure well and was returned to the recovery room in stable condition.


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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 previous‘ 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.


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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.


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.


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