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RADIOLOGY AND OPERATIVE REPORTS ONLY ON THIS PAGE

DIAGNOSIS: STAGE IV, T4, N1, M0 SQUAMOUS CELL CARCINOMA OF THE OROPHARNYX. RADIATION TREATMENT WAS COMPLETED 10/2/99

Dear Dr. X:

INTERVAL HISTORY: Mr. John Doe returned yesterday. It has been a month since he was last seen here. He is status post osteonecrosis of his right mandible. He has seen Dr. X. He has had some of the exposed bone removed. He has been feeling a lot better since then. Very little pain remains. Last night when he was eating popcorn, he developed some swelling and discomfort over his right cheek. I told him that his salivary gland probably was swollen. He is having no difficulties swallowing. He is eating garnishes, breakfast with protein enhancers, and some soft foods. His weight has dropped about 2-1/2 pounds since last month. No other complaints or problems were offered; no suggestion of a new primary.

PHYSICAL EXAMINATION: Weight 244-1/2 lbs. Mr. Doe appears about the same as the last time I saw him. He is in no apparent distress. Neck was supple without lymph node. Lungs were clear to auscultation bilaterally. Inspection of oral cavity and oropharnyx shows he has some small area of exposed bone in the right posterior mandible. There are two separate areas of some bridging of the gingiva covering partially over those areas. It is smooth to feel. I do not feel any rough edges or jagged edges. View of the thyroid scope, supraglottic and glottic structures are readily visualized. They appeared to be normal. The oropharnyx is also visible and palpably normal.

IMPRESSION:
1. No evidence of disease recurrence.
2. Osteonecrosis of the right mandible.

PLAN: I will ask Mr. Doe to return to see me in one month. If he continues to heal, that would be great. If there is some delay in his healing, our concern for progression is osteonecrosis. I think he should have hyperbaric oxygen. Once again, thank you very much for allowing us to participate in Mr. Doe's oncology care.


EYE SURGERY

Description of Procedure: The patient was taken to the operating room, anesthetized with a peribulbar anesthetic, 5 cc, and prepped and draped in the prescribed manner. A wire lid speculum was then placed beneath the lid of the left eye and a 4-0 silk suture was placed beneath the belly of the superior rectus muscle. A peritomy was made at the limbus at 12 o'clock. Superficial episcleral bleeders were cauterized with wet-field cautery. With a Beaver #69 blade, a groove was made 1.5 mm posterior to the limbus. A crescent knife was used to dissect the scleral tunnel to clear cornea.

The chamber was entered with a sharp keratome. Healon was used to deepen the chamber. A capsulotomy was performed with the can-opener technique and the lens nucleus rocked loose. A phacoemulsification tip was introduced and a large bowl sculpted. The remaining nucleus was brought into the anterior chamber, and with the pulse mode and phacoemulsification with high vacuum, the remaining nucleus was removed without complication. With the irrigation and aspiration, the cortical material was removed. The posterior capsule was polished. The chamber was deepened with viscoelastic and a posterior chamber lens implant of the appropriate power was placed in the capsular bag. The lens was centered with a Sinskey hook. The Healon was removed and Miochol injected. The pupil was noted to be round and small. A single 10-0 nylon suture was used to close the wound. The wound was checked for leakage and found to be secure. The conjunctiva was closed with wet-field cautery and antibiotic and steroid combination injected sub-Tenon. The superior rectus suture was removed and the lid speculum was removed. A patch and shield were placed over the eye and the patient returned to the recovery room in good condition.


TITLE OF OPERATION:
Radical retropubic prostatectomy.
Bilateral pelvic lymph node dissection.

INDICATIONS FOR SURGERY:
This 64-year-old gentleman was recently found to have a PSA elevation to 4.1 which prompted a biopsy of the prostate, which then showed prostate cancer. A metastatic workup was negative for disease spread. He was counseled regarding treatment options and desired to undergo a radical prostatectomy. He was well informed regarding all risks, alternatives, and expectations, and provided his adequate informed consent prior to surgery.

PREOPERATIVE DIAGNOSIS:
Prostate cancer, stage T1c.

POSTOPERATIVE DIAGNOSIS:
Prostate cancer, stage T1c.

ANESTHESIA:
Regional.

SPECIMEN:
Prostate with seminal vesicles and bilateral pelvic lymph nodes.

DESCRIPTION: The patient was brought to the operating room and regional anesthesia was achieved. He was placed supine on the operating table. His lower abdomen and genitalia were prepped and draped in a sterile manner. The operating room table was flexed. Routine antibiotic prophylaxis was provided. A 20-French Foley catheter was inserted per urethra at the beginning of the case and connected to straight drainage. A lower midline abdominal incision between the umbilicus and the 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.


TITLE OF OPERATION:
Right stereotactic percutaneous trigeminal glycerin rhizotomy under fluoroscopic control.

PREOPERATIVE DIAGNOSIS:
Recurrent resistant right-sided trigeminal neuralgia.

POSTOPERATIVE DIAGNOSIS:
Recurrent resistant right-sided trigeminal neuralgia.

ANESTHESIA:
Light general intravenous sedation.

DESCRIPTION: The patient was brought to the general operating room, placed on the table in the supine position, and light general intravenous sedation was established by anesthesia. A lateral fluoroscopic image of the skull was established, and then the right cheek was prepared and draped in the usual sterile fashion for glycerin rhizotomy. The cheek was infiltrated with 1% Xylocaine, and then utilizing external stereotactic landmarks and an internal finger in the lateral pterygoid wing, a long 20-gauge spinal needle was passed to the level of the foramen ovale. This was done with some degree of difficulty, but eventually it was possible to guide the tip of the needle to the level of the clivus under fluoroscopic control.

The stylette was withdrawn with no initial return of cerebrospinal fluid, and then advanced until there was some cerebrospinal fluid. The head of the bed was then elevated to 60 degrees, and 0.4 cc of anhydrous glycerin slowly injected. There was no bradycardia. The needle was withdrawn and the patient was left in the 60-degree head-up position and taken to the recovery room in satisfactory condition.


CIRCUMCISION:

DESCRIPTION: With the patient in the supine position and under general anesthesia, the lower abdomen and genitalia were prepped and draped appropriately. A hemostat was used to bluntly take down adhesions between the foreskin and glans. A circumferential incision was made on the outer prepuce at the level of the corona. A second incision was made on the inner prepuce 4 mm beneath the corona and carried straight across the frenulum. A plane of dissection was established dorsally and the dorsal foreskin was divided. Attachments between the foreskin and penis were then taken down sharply. Bovie electrocautery was used for hemostasis. Then 5-0 chromic interrupted sutures were used to complete the procedure. A sterile Tegaderm dressing was applied. The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.


TITLE OF OPERATION:
Extracapsular cataract extraction, right eye, by phacoemulsification with implantation of posterior chamber intraocular lens.

INDICATIONS FOR SURGERY:
Slow, painless decreased vision, right eye, secondary to cataract formation, interfering with the patient's ability to perform daily activities.

PREOPERATIVE DIAGNOSIS:
Cataract, right eye, with impaired function.

POSTOPERATIVE DIAGNOSIS:
Cataract, right eye, with impaired function.

ANESTHESIA:
Local with intravenous sedation.

DESCRIPTION: Following instillation of dilating and antibiotic eye drops, the patient was brought to the operating room where anesthesia was induced through neuroleptic along with peribulbar injection. Following onset of anesthesia and akin esia, the patient was prepared and draped for ophthalmic surgery. A wire lid speculum was placed in the right eye and a 5-0 black silk stay suture was placed beneath the superior rectus muscle. A fornix-based conjunctival flap was formed with Westcott s cissors and hemostasis was achieved with electrocautery. Clear-cornea paracentesis wound was made with a Supersharp blade. A #7 blade was used to make a superior scleral incision 2 mm posterior to the surgical limbus. From this point, the crescent blade was used to fashion a scleral tunnel through which the anterior chamber was entered with a 3.2-mm keratome. Viscoelastic was injected into the anterior chamber to deepen it, and an anterior capsulotomy performed with a capsulorrhexis technique. The nu cleus was hydrodissected with balanced salt solution and emulsified with the phacoemulsification device. The remaining cortex was removed using irrigation and aspiration. Additional viscoelastic was reintroduced into the anterior chamber to deepen it. The scleral tunnel was enlarged with a 5.2-mm keratome. The posterior chamber intraocular lens was inspected and irrigated with balanced salt solution. Using a smooth lens forceps, we introduced the lens into the eye and placed it in the appropriate pos ition. Following rotation, it was noted to be well centered and well positioned with the loop in the horizontal position. The viscoelastic was removed using irrigation and aspiration, and Miochol was injected into the anterior chamber, producing a small round pupil. The scleral wound was closed with an interrupted 10-0 nylon suture. The wound was found to be watertight, as was the paracentesis wound. The anterior chamber was deep and well formed with a well-centered intraocular lens. The conjunctiva was closed with electrocautery. The wire lid speculum and stay suture were removed from the eye which was then dressed with topical antibiotic and steroid drops followed by a patch and shield. The patient tolerated the procedure well and was taken to the recovery room in alert and stable condition.


TITLE OF OPERATION:
Right breast needle-localization biopsy.

PREOPERATIVE DIAGNOSIS:
Right breast mammographic abnormality.

POSTOPERATIVE DIAGNOSIS:
Right breast mammographic abnormality.

ANESTHESIA:
Local with sedation.

DESCRIPTION: The patient was first taken to the mammography suite where the right breast mammographic abnormalities were needle localized in a routine fashion. She was then brought to the operating room and placed on the operating room table in the supine position. The patient's right breast was then prepared and draped in the usual sterile fashion. Local anesthesia was then infiltrated in the proposed incision site. A small circumareolar incision was then made over the area in question. The incision was carried down to the subcutaneous tissue to the breast tissue proper. The area in question was then grasped with an Allis clamp and dissected free using Bovie electrocautery. The specimen was then removed and sent to mammography which confirmed removal of the mammographic abnormality.

Attention was now turned back to the breast tissue proper. Hemostasis was obtained with Bovie electrocautery. The wound was irrigated with bibiotic solution. At this point, there was good hemostasis and sponge and needle counts were correct. The subcutaneous tissue was then reapproximated with several interrupted 3-0 Vicryl sutures. The skin was then closed with a running subcuticular 4-0 Prolene suture. At the end of this portion of the case, there was good hemostasis and the sponge and needle counts were correct. The incision was then cleaned with a wet and a dry, and then benzoin and Steri-Strips were applied. A dry sterile dressing was applied. The patient tolerated the procedure well. Estimated blood loss was approximately 10 cc.


TITLE OF OPERATION:
Right orchidopexy.

PREOPERATIVE DIAGNOSIS:
Undescended right testis.

POSTOPERATIVE DIAGNOSIS:
Undescended right testis.

ANESTHESIA:
General mask anesthesia.

DESCRIPTION: With the patient in the supine position after a suitable level of general mask anesthesia had been obtained, the penis and genitalia were prepared and draped in the usual manner. A transverse incision was made in the suprapubic skin fold on the right with a #15 blade. Bleeding was controlled with electrocautery. The subcutaneous tissues were incised and the testis was noted just emerging from the external inguinal ring. The external oblique fascia was opened with a #15 blade and Metzenbaum scissors. The testis was grasped and freed up from the surrounding fibers. This was freed up to the level of the internal inguinal ring. The hernia sac was then opened and the hernia sac dissected up to the level of the internal ring wh ere it was twisted and transfixed with 4-0 Vicryl. With this maneuver, quite adequate testis length was obtained.

Dr. X then returned to the operating room, rescrubbed and regowned and joined the operation. The testis was brought down to the subcutaneous dartos pouch created in the manner of Latimer in the scrotum. The testis was brought into the pouch and 3-0 silk suture was placed in the connective tissue of the testis, brought out through the scrotal wall and tied over a cotton pledget. The scrotal incision which had been made with a #15 blade was then closed with a 5-0 Vicryl. Careful search for bleeding was undertaken. None was seen in the scrotum or in the groin. The external oblique fascia was then closed with running 4-0 Vicryl. The subcutaneous tissue was closed with 4-0 Vicryl. The skin was closed with running subcuticular 3-0 Prolene suture. There were no intraoperative complications. The child was discharged from the operating room in satisfactory condition.


TITLE OF OPERATION:
Cystourethroscopy, left retrograde ureteropyelogram and left dismembered pyeloplasty.

PREOPERATIVE DIAGNOSIS:
Left ureteropelvic junction obstruction.

POSTOPERATIVE DIAGNOSIS:
Left ureteropelvic junction obstruction.

ANESTHESIA:
General endotracheal anesthesia.

DESCRIPTION: The patient was brought to the operating room and underwent general anesthesia. He was placed in the dorsal lithotomy position. He was prepared and draped in the usual manner. The 9.5 pediatric cystoscope was placed in the bladder and a #3 ureteral catheter was placed through the torquing channel. A left retrograde ureteropyelogram was obtained. This showed a clear obstruction at the junction of the left ureteropelvic junction. The cystoscope and stent were then removed.

The patient was then placed in the left-flank-up position. An incision was made off the tip of the 12th rib with a #15 blade. Bleeding was controlled utilizing electrocautery. The muscle fibers were all incised in the flank with electrocautery. Two Richardson retractors were placed. Gerota's fascia was opened in a vertical fashion and the kidney was delivered. The ureter was found in the retroperitoneal space and dissected out to the level of the renal pelvis. There was clear obstruction and kinking at the level of the ureteropelvic junction. Markings sutures were placed in the ureter and the renal pelvis with 6-0 Vicryl. The obstructive segment was excised and the tenth renal pelvis was then decompressed. An oblique anastomosis was then effected between the upper ureter which had been spatulated and the renal pelvis. This was accomplished with two sutures of 6-0 Vicryl at the apices and then running sutures on the anterior and posterior wall with 6-0 Vicryl. Prior to completing the anterior anastomosis, a 10-French Malecot catheter was used as a nephrostomy tube and brought with the nephrostomy needle through the substance of the kidney and was brought out through the flank, and it was sewn to the flank with 4-0 Prolene. The anterior aspect of the anastomosis was then completed after a #3 pediatric feeding tube was placed through the anastomosis and� to be watertight. The kidney was returned to the renal space. Gerota's fascia was left open in the caudad portion. A Penrose drain was placed through a stab wound and brought down to the inferior portion below the anastomosis. This was sewn to the skin with 4-0 nylon. The muscle layers were then closed with running 3-0 Vicryl. The subcutaneous layer was closed with 4-0 Vicryl and the skin was closed with a running subcuticular 3-0 Prolene suture. There were no intraoperative complication. The patient was discharged to the recovery room in satisfactory condition.


EYE SURGERY: MEDIAL RECTUS RECESSION

PREPARATION: Both eyes were prepared with Ioprep and draped in the usual sterile manner.

DESCRIPTION: After appropriate draping, a lid speculum was placed between the lids of the right eye. An incision was made supertemporally to expose the right medial rectus muscle. This was hooked with a muscle hook and secured with 6-0 Vicryl sutures and disinserted from the globe. It was reattached to the globe in hang-back, adjustable suture fashion, recessing it 6 mm from the original insertion. A 5-0 Mersilene suture was placed for traction purposes during the adjustment process.

The right superior rectus muscle was then approached through the same supranasal incision, hooked to the muscle hook and cleared of surrounding tissue far backwards over the top surface of the muscle, and was disinserted from the globe after being secured with a double-armed 6-0 Vicryl suture. It was reattached to the globe in hang-back adjustable suture fashion, recessing it 4 mm from the insertion site, and 5-0 mersilene traction suture was placed.

The left medial rectus muscle was then recessed in a similar manner, 5.5 mm on an adjustable suture. Both eyes were dressed with Pred-G ointment. The patient was returned to her room in good condition, having tolerated the procedure well.


EYE SURGERY: TRABECULECTOMY WITH BIOPSY:

The patient was brought to the operating room and placed in the supine position. Local anesthesia was induced with a retrobulbar injection of 2% Xylocaine mixed 1:1 with 0.75% Marcaine with Wydase. The eye was prepared and draped in the usual sterile fashion. A lid speculum was placed between the lids. Conjunctival incisions were made nasally and temporally, and a 4-mm infusion cannula was sutured into the inferotemporal quadrant 4 mm posterior to the limbus using a 4-0 Vicryl suture. After cannula tip placement in the vitreous cavity had been verified, infusion was begun. Supranasal and superotemporal sclerotomies were performed, and the trocar and cannula system was introduced. The vitrectomy was performed. The posterior vitreous was not detached. It was elevated from the posterior pole and trimmed back into the far periphery.

We then selected a biopsy site inferiorly and cut out a 2 x 2-mm piece of retina at 6 o'clock at the border of infected and noninfected retina. There was no significant bleeding. We then performed a fluid-gas exchange, flatting the retina through the biopsy site. Laser was placed around the biopsy for 360 degrees to demarcate the peripheral retinitis. We then filled the eye with silicone oil. The sclerotomies were sutured shut with 7-0 Vicryl, and the conjunctiva was closed with 6-0 plain. Sub-Tenon's Ancef and Decadron were injected. The patient tolerated the procedure well and was returned to the recovery room in stable condition.


CATARACT SURGERY:

Description of Procedure: The patient was brought to the operating room where the anesthesiologist established I.V. lines and cardiac monitoring leads. Mild intravenous sedation was administered. Using a solution containing 0.75% Marcaine and 2% lidocaine with Wydase, a peribulbar block was administered to the right eye. Gentle digital pressure was applied to the eye for approximately 2 minutes to help diffuse the anesthetic. The patient was then prepared with a 5% solution of povidone-iodine to the conjunctivalf ornix and lashes, and a 10% solution of povidone-iodine to the lids and periorbital skin. The patient was then draped in the usual sterile fashion. A lid speculum and 4-0 silk superior rectus bridle suture were then placed in the operative eye. A keratome blade was then used to create a biplanar incision into the anterior chamber. Healon was then instilled into the anterior chamber.

A capsulorrhexis was then fashioned with a cystotome blade. BSS and a cannula were then used to hydrodissect and hydrodelineate the lens. Aparacentesis incision was made at 3 o'clock with a Supersharp blade. The phacoemulsification unit, after being properly tuned and tested, was then used to emulsify the nucleus. Residual cortical material was aspirated from the capsular bag with the irrigation and aspiration unit. Healon was then instilled into the anterior chamber, severing the anterior and posterior sections of the capsular bag. The corneal wound was then enlarged to the size of the optic with the keratome blade. The intraocular lens was then inspected and thought to be satisfactory. Then the lens was gently placed in the capsular bag. Positioning within the capsular bag was confirmed by direct visualization. Optic centration was accomplished with a Sinskey hook. Residual Healon was removed from the anterior chamber using the irrigation and aspiration unit. Miostat was then instilled into the anterior chamber, producing myosis without optic capture. The corneal wound was then tested for leaks and none were found. The conjunctiva was closed using bipolar cautery. Subconjunctival injections of Ancef and dexamethasone were then given inferiorly with the needle tip visible at all times. The bridle suture and lid speculum were then removed. Betoptic-S and Pred-G ointment was then placed in the conjunctival fornix. Sponge and needle counts were correct. An eye patch and shield were placed over the operative eye. The patient was taken to the recovery room in stable condition. There were no complications. The patient tolerated the procedure well. Dr. X performed the entire procedure.


TITLE OF OPERATION:
Extracapsular cataract extraction.
Lens implantation, right eye.

PREOPERATIVE DIAGNOSIS:
Cataract, right eye.

POSTOPERATIVE DIAGNOSIS:
Cataract, right eye.

ANESTHESIA:
Local with sedation.

PREPARATION: Soap and Ioprep.

DESCRIPTION: The patient was placed on the operating room table in the supine position. After adequate local anesthesia was achieved, the right face was prepared and draped in the usual fashion. A lid speculum was placed between the right lids. A stay suture of 4-0 black silk was placed beneath the insertion of the superior rectus muscle and the eye retracted downward. A peritomy was then performed from the 9 o'clock to the 3 o'clock position at the limbus. Hemostasis was achieved using biopolar cautery. A groove was then made from the 10 o'clock to the 2 o'clock position using a Beaver blade. A suture of 8-0 black silk was then preplaced in a mattress fashion at 10 o'clock and 2 o'clock. The sutures were removed from the groove. The anterior chamber was entered at the 12 o'clock position using a Supersharp blade. The anterior chamber was reformed using Healon.

An anterior capsulotomy was then performed using a bent 30-gauge needle. The wound was then opened to its entire extent using straight corneoscleral scissors. Lens nucleus was expressed without complication. Previously placed 8-0 black silk sutures were temporarily tightened and tied. Irrigation and aspiration tip was entered into the anterior chamber and the cortical remnants were removed. The lens was then inserted without complication. The previously placed 8-0 black silk sutures were permanently tightened, tied and cut. Miochol was introduced into the anterior chamber in such a fashion that the Healon was irrigated free. The pupil came down nicely and was round. The wound was secured using multiple simple placed 10-0 nylon stitches at 11 o'clock, 1 o'clock. These sutures were tightened, tied and cut. The patient received subconjunctival injection of Decadron and Ancef. The stay suture and the lid speculum was removed. The eye was dressed and patched. The patient was returned to the recovery room, having tolerated the procedure well without complication.


TITLE OF OPERATION:
Direct laryngoscopy, bilateral modified neck dissection and total laryngectomy.

INDICATIONS FOR SURGERY:
This is a 37-year-old white male who has a bulky supraglottic cancer with bilateral nodal metastases. He is to undergo surgical treatment with curative intent.

PREOPERATIVE DIAGNOSIS:
T3, N2c squamous cell carcinoma of the supraglottic larynx.

POSTOPERATIVE DIAGNOSIS:
T3, N2c squamous cell carcinoma of the supraglottic larynx.

ANESTHESIA:
General endotracheal anesthesia.

FINDINGS: There were large, greater-than-2-cm nodes in both the jugular sheaths in level 2 and 3. There were small nodes in the left level 5. The tumor in the larynx extended along the entire length of the left false cord and eroded the arytenoid and the thyroid cartilage with extension into the base of tongue and the base of the left piriform. Frozen section was taken from the left base of tongue and left piriform and were negative for tumor.

DESCRIPTION: In the supine position, general anesthesia was induced and the patient was intubated without difficulty. The Dedo laryngoscope was introduced and the larynx, hypopharynx were inspected, noting the extent of the tumor. The 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:
Phacoemulsification with intraocular lens, right eye.

PREOPERATIVE DIAGNOSIS:
Cataract, right eye.

POSTOPERATIVE DIAGNOSIS:
Cataract, right eye.

ANESTHESIA:
Local with standby.

DESCRIPTION: After the patient was given a peribulbar block consisting of 0.75% Marcaine with 2% Xylocaine and Wydase, she was routinely prepared and draped for right cataract surgery. A lid speculum was placed in the eye and a superior rectus suture on the superior rectus muscle. A fornix-based flap was raised and any bleeding vessels were cauterized. A sharp knife was used to make a side port and partial-scleral-thickness incision which was dissected anteriorly. A 3-Mm keratome was used to enter the anterior cha mber. Under Provisc, an anterior capsulotomy was performed and hydrodissection occurred.

Phacoemulsification was performed, and irrigation and aspiration of any remaining cortical material. The wound was enlarged under Provisc to 5.5 mm so that a #8191 IOLab lens could be placed in the bag and switched to the 3 and 9 o'clock position with a Sinskey hook. The remaining Healon was removed. Miochol was placed in the eye. The wound was found to be watertight. The fornix-based flap was closed with cautery. Ancef and Decadron solution was injected subconjunctivally. Pred-G ointment was place in the eye. The eye was patched and shielded, and the patient was taken to the recovery room in excellent condition.


TITLE OF OPERATION:
Extracapsular cataract extraction.
Placement of posterior chamber intraocular lens implant, right eye.

PREOPERATIVE DIAGNOSIS:
Visually significant immature cataract, right eye.

POSTOPERATIVE DIAGNOSIS:
Visually significant immature cataract, right eye.

ANESTHESIA:
Neuroleptic with I.V. sedation combined with local consisting of 2% Xylocaine mixed half-and-half with 0.75% Marcaine by retrobulbar and Nadbath.

PROSTHETIC DEVICE/IMPLANT:
Posterior chamber intraocular lens.

DESCRIPTION: After satisfactory local and neuroleptic anesthesia, the right eyelids and face were prepped and draped in the usual fashion for sterile ophthalmic surgery. A lid speculum was placed between the lids of the right eye and traction suture of 4-0 black silk was placed superiorly and attached to the drape. A coelastic material, a capsulotomy of 360 degrees was performed using the can-opener technique. The capsular material was then removed from the center and the lens was gently freed. The corneoscleral wound was then extended to 10 mm and the lens nucleus was expressed intact without difficulty. The cortical material was then removed with aspiration. Following this, additional viscoelastic material was placed and a posterior chamber intraocular lens implant, 15 diopters, #MC60, was inserted. This was centered. Each of the haptics was checked for positioning and appeared to be tight.

The wound was closed with multiple interrupted 10-0 nylon sutures. Each of the sutures was buried. The viscoelastic material was removed with aspiration. Following this, the traction suture was removed and the conjunctiva was closed with subconjunctival gentamicin and Decadron. Maxitrol ointment and Betoptic drops were placed and a pad and shield were placed. The patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.


EYE SURGERY: After preoperative evaluation, Mr. X was transported to the operating room. After administration of intravenous sedation by anesthesiology, a left retrobulbar block was then performed using a 1.21 mixture of 4% lidocaine and 0.75% bupivacaine with Wydase without complication. The fellow unoperated right eye was covered with a Fox shield for the duration of the surgery. On satisfactory akinesia and anesthesia were demonstrated, the left eye was then prepped and draped in the usual sterile fashion. A Maumenee lid speculum was then placed between the lids of the left eye to expose the left globe. A limited fornix-based conjunctival peritomy was then performed to expose the superior, inferotemporal, and superonasal sclera. A caliper was used to measure 3 mm inferior to the limbus in the inferotemporal quadrant, and the globe was penetrated with a 19-blade MVR blade. An infusion was placed. After visualizing deep in the vitreous cavity, it was turned on. Sclerotomies were then made superonasally and superotemporally 3 mm posterior from the limbus. The MVR blade was then used to penetrate the equator of the lens. Fragmentation of the lens was performed, keeping the anterior capsule of the lens intact. Following this, the trocar and cannula system was introduced and the vitrectomy was performed, letting the previous silicone oil out of the eye. The posterior pole was visualized using the flat lens followed by the quartz prism lens followed by the AVI lens. Because of extensive anterior Postvoiding residual, membrane peeling was performed anteriorly followed by retinotomy for 360 degrees. Perfluorocarbon was used to flatten the retina which flattened nicely. The endolaser was applied in 360 degrees around the retinotomy. Following this, a fluid-air exchange was performed and 5000 centistokes of silicone oil was injected. It should be noted that during the procedure there was leakage of fluid from the superonasal sclerotomy which was lacerated. It was then sutured with 8-0 nylon sutures and an additional sclerotomy was performed more superiorly. Further sclerotomies in these areas should be avoided.

Following the silicone oil injection, the sclerotomies were closed with 7-0 Vicryl sutures. The conjunctiva was closed with 6-0 plain gut. Subconjunctival dexamethasone and Ancef were injected. The eye was patched and shielded and the patient was returned to the floor in good condition.


TITLE OF OPERATION:
Phacoemulsification of cataract with intraocular lens implantation, OS, clear-cornea approach.

PREOPERATIVE DIAGNOSIS:
Cataract, OS.

POSTOPERATIVE DIAGNOSIS:
Cataract, OS.

ANESTHESIA:
Local/MAC. PROSTHETIC DEVICE:
Intraocular lens, Alcon model #MA60BA, 22 diopters, serial #427252.090.

DESCRIPTION: After informed consent was obtained and all questions were answered, the patient was brought to the operating room and placed in the supine position. After adequate I.V. sedation, a retrobulbar block of 5 cc of a 50:50 mixture of 2% lidocaine with Wydase and 0.75% Marcaine was given. The Honan balloon was then applied to the left eye at 40 mmHg for 5 minutes. The left eye was prepped and draped in the usual sterile fashion. A lid speculum was placed between the lids of the left eye. A clear-corneal incision was made at the temporal limbus. Healon was used to reform the anterior chamber. A continuous-tear capsulorrhexis was performed. Hydrodissection of the lens nucleus was performed. The lens nucleus was then removed using the phacoemulsification handpiece. The I/A handpiece was used to remove the residual cortex. The capsular bag was reinflated with Healon. The intraocular lens was folded and placed into the capsular bag under direct inspection. The I/A hand piece was used to remove residual Healon. Miochol was injected. The wound was closed with a single 10-0 Vicryl suture. Ancef and Decadron were injected beneath the conjunctiva. The lid speculum was removed and Pred-G ointment applied. A patch and shield were applied. The patient left the operating room in stable condition and there were no complications. Dr. X was present and assisted for the entire procedure.


DESCRIPTION: After obtaining adequate witnessed informed consent from Ms. X regarding the indications, current methods, potential risks including complete loss of the eye, as well as the possible significant limitations of cataract surgery, she was brought to the operating room area. She was administered several drops of topical proparacaine 0.5% in the left eye as well as tetracycline 0.5%. She was administered some intravenous sedation. The left face and eyelid regions were then thoroughly prepared with povidone-iodine 10% solution. A few drops of dilute povidone-iodine 5% solution were placed directly into her left eye. She was then draped in the usual sterile fashion for ocular surgery. A wire lid speculum was placed between the left eyelids. There were no superior or inferior rectus sutures utilized. The distance of 3 mm was marked along the superonasal limbal zone. Using a diamond blade, an initial perpendicular groove of approximately 500-micron depth was created. The diamond blade was then used to create a corneal tunnel perpendicular to the initial groove, extending approximately 1.5 mm into clear cornea. The diamond keratome was then directed perpendicular to the plane of the iris in order to enter the anterior chamber and create a self-sealing corneal-valve incision. The anterior chamber was then reformed with Healon GV. The operating microscope was brought in; the light was initially on low power and then gradually intensified. A 27-gauge needle was entered through the corneal valve incision and a nick created in the anterior capsule. A continuous 360-degree curvilinear capsulorrhexis was then carried out without difficulty. Balanced salt solution was injected beneath the capsule to achieve both hydrodissection and hydrodelineation. The lens nucleus was then emulsified without difficulty using the Alcon Masters Series 10,000 unit. Any remaining cortical debris was removed with the automated irrigation/aspiration unit. The posterior capsule was then vacuum polished clean. The anterior chamber and capsular bag were reinflated with Healon GV. The AcrySof +19.5-diopter PC IOL was then carefully folded using the folding forceps and grasped with the direct-action forceps. The PC IOL was then introduced through the corneal-valve incision and delivered into the anterior chamber and capsular bag. The lens was centered into position within the capsular bag using the Sinskey hook. Any remaining Healon GV was then removed with the automated irrigation/aspiration unit.

Miochol was instilled to achieve pupillary myosis. The corneal valve incision was then closed with a single interrupted 10-0 Vicryl suture. The suture was cut and the knot buried in the wound. The wound was tested and found to be free of any leaks. Subconjunctival cefazolin, gentamicin, and dexamethasone were then injected superonasally. The left eye was then dressed with Pred-G ophthalmic ointment and Pilopin gel. A sterile eye patch and fox metallic shield were placed over her left eye. Ms. X tolerated the procedure extremely well and the operation went without difficulty. She was transported to her room in stable condition.


TITLE OF OPERATION:
Exploratory laparotomy.
Omental biopsy.
Cholecystectomy.
Gastrojejunostomy.
Alcohol splanchnicectomy.

INDICATIONS FOR SURGERY:
The patient is an 86-year-old lady who began having pain six months ago and developed jaundice four months ago. She had a percutaneous transhepatic stent placed, and subsequently had a metallic endoprosthesis placed. Afterwards she developed acute cholecystectomy and required percutaneous cholecystostomy. She has had considerable pain from the gallbladder tube, but attempts to sclerose the gallbladder have not been successful. A CT scan recently showed extensive tumor encasing blood vessels without occlusion, and no obvious metastatic disease. The spread of the tumor was somewhat reminiscent of a lymphoma. Therefore a biopsy was recommended, but a tissue diagnosis could not be established. In addition, the patient has recently begun to have problems with vomiting. Therefore exploration was undertaken to establish a diagnosis, remove the gallbladder, consider doing a gastrojejunostomy and probably an alcohol splanchnicectomy.

PREOPERATIVE DIAGNOSIS:
Pancreatic tumor.

POSTOPERATIVE DIAGNOSIS:
Metastatic adenocarcinoma of the pancreas.

ANESTHESIA:
General endotracheal anesthesia.

SPECIMEN:
From omentum, gallbladder, and ascitic fluid for culture and cell count.

DESCRIPTION: The patient was brought to the operating room where general endotracheal anesthesia was induced. The abdomen was prepared with Betadine and draped in the usual sterile fashion. A midline incision was made from the xiphoid to the umbilicus. Hemostasis was achieved with cautery. The falciform ligament was divided and tied with 2-0 silk. Chylous ascites was present and totalled about 750 cc. Fluid was sent for aerobic and anaerobic cultures as well as cell count. Exploration of the abdomen revealed adhesions around the gallbladder and around the liver on the right. Tumor was present on the diaphragmatic peritoneum. The liver was relatively normal in size, shape and consistency. It had some tiny nodules but no definite metastases.

The spleen was slightly enlarged. The stomach, small intestine, colon, bladder and kidneys were grossly normal. The gallbladder was shrunken and surrounded by inflammatory tissue. The pancreas was enlarged and consistent with a primary. Tumor nodules were present in the omentum around the gallbladder, and some of these were excised and sent for frozen section, and found to be metastatic adenocarcinoma. Tumor was also present on a small uterus as well as in the pouch of Douglas and along the right paracolic gutter. Adhesions around the gallbladder were taken down, and the percutaneous catheter 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.


TITLE OF OPERATION:
Transurethral resection of the bladder tumor.

PREOPERATIVE DIAGNOSIS:
Bladder carcinoma.

POSTOPERATIVE DIAGNOSIS:
Bladder carcinoma.

ANESTHESIA:
Spinal.

DESCRIPTION: The patient was taken to the operating room and after induction of anesthesia and the administration of intravenous antibiotics, he was prepared and draped in the usual relaxed dorsal lithotomy position.

The anterior urethra was sounded to 30-French, and then the Iglesias resectoscope was placed and cystopanendoscopy was performed with the results noted below. The urethra was within normal limits. The outlet nonocclusive bladder capacity was adequate.

The orifices were normal in position and morphology, and the left orifice was adjacent to a large fungating bladder carcinoma which was obviously necrotic. The tumor extended to the entire surface of the left lateral wall and was sequy resected into deep muscle using the Iglesias resectoscope. No other lesions were identified. A separate biopsy of the prostatic urethra was obtained. Electrocautery was used to achieve hemostasis. The chips were removed and the bladder was once again inspected and found to be free of evidence of injury, and the ureteral orifices were intact at the conclusion of the procedure. No evidence of perforation was identified. The scope was withdrawn and a 24-French 30-cc bag, three-way Foley catheter was placed to continuous bladder irrigation with clear efflux of urine noted. The patient was taken to the recovery room in stable condition, having tolerated the procedure well.


TITLE OF OPERATION:
Exploration of radial artery with embolectomy.

PREOPERATIVE DIAGNOSIS:
Embolus, left radial artery.

POSTOPERATIVE DIAGNOSIS:
Embolus, left radial artery.

ANESTHESIA:
Local with intravenous sedation.

DESCRIPTION: The patient was brought to the operating room and given intravenous sedation. The left arm was prepared with an iodine-containing solution and draped in a sterile fashion. Local anesthesia was provided. An incision was made in the proximal third of the forearm over the course of the radial artery. The pulse became nonpalpable. Dissection was carried down until the artery was identified. It was freed of surrounding tissues and controlled with vessel loops. It was open in a transverse direction for approximately one-half its circumference. There was good inflow with very poor backbleeding. A size #2 embolectomy catheter was passed distally multiple times, retrieving several clot fragments. At the end of the procedure, there was good backbleeding. The catheter was passed for a total distance of approximately 40-50 cm, which would have extended well into the palm of the hand. The artery was flushed with heparinized saline. It was allowed to flush at the inflow site and was flushed with heparinized saline. The arteriotomy was then closed with interrupted 7-0 Prolene sutures. Hemostasis was assured. The wound was irrigated and closed in layers using Vicryl suture. Sterile dressings were applied. At the end of the procedure, there was a dopplerable pulse at the wrist, and the hand was warm. The patient was sent from the operating room in satisfactory condition. Estimated blood loss was minimal.


TITLE OF OPERATION:
Orthotopic liver transplant including total hepatectomy, cholecystectomy, venovenous bypass, open liver biopsy and cholangiogram.
Cadaveric renal transplant into the right iliac fossa.

PREOPERATIVE DIAGNOSIS:
Liver failure secondary to recurrent hepatitis B and kidney failure presumed secondary to FK-506 toxicity.

POSTOPERATIVE DIAGNOSIS:
Liver failure secondary to recurrent hepatitis B and kidney failure presumed secondary to FK-506 toxicity.

ANESTHESIA:
General endotracheal anesthesia.

DESCRIPTION: The patient was brought to the operating room and induced with general endotracheal anesthesia. She was prepared with an iodine-containing solution and draped in a standard fashion. A standard transplant incision was made and dissection was carried down until the peritoneal cavity was identified. There were dense adhesions of the intestine to the liver, and also the liver to the diaphragm. Dissection was carried out to mobilize the liver fully. Vascular structures were identified. The artery and bile duct were divided between ties. The portal vein was mobilized adequately until the suprahepatic and infrahepatic cavae were dissected free.

Next the donor liver was prepared on the back table. Venovenous bypass was instituted by cannulating the left femoral vein with a percutaneous 19-French cannula. This was then brought to bypass pump and returned to a Cordis in the jugular vein. It was determined after dissection of the recipient hepatic artery that this would be too small for anastomosis; therefore, an arterial graft was fashioned from the cadaveric iliac artery. This was anastomosed to the aorta using supraciliac position. The recipient's aorta was very friable and buttressing of the anastomosis with Teflon pledgets was required. It should be noted that on the dome of the liver there was a 3-cm firm nodule. There was no evidence of any adenopathy or spread of the lesion outside the confines of the liver. The donor liver was brought to the operative field. It was kept cold during the period of anastomosis. Suprahepatic caval anastomosis was performed in standard fashion using a running 3-0 Prolene suture. Infrahepatic caval anastomosis was then performed in standard fashion using a running 4-0 Prolene suture. Next a portal venous anastomosis was performed using a running 6-0 Prolene suture finished with a growth knot. The suprahepatic caval clamp was removed and the portal venous clamp. During the period of anastomosis, the liver was flushed with cold lactated Ringer's solution through the portal vein. Hemostasis was assured. The patient tolerated the procedure well. The liver was well perfused and the infrahepatic caval clamp was removed. Next an end-to-end anastomosis of the donor hepatic artery to the arterial bypass graft was performed using a running Prolene suture. Vascular control was released. There was an excellent thrill through the arterial anemia. The liver was well perfused. The liver biopsy was obtained and hemostasis was assured. The bile duct anastomosis was then performed in end-to-end fashion using interrupted PDS sutures over a 8-French T-tube. Cholangiogram was obtained and there was no leak. Hemostasis was again assured. The wound was irrigated copiously. Three closed suction drains were placed through separate stab incisions. The fascia was then closed using a running Prolene stitch. Subcutaneous tissues were irrigated. Hemostasis was assured. The skin was closed with staples.

Next a standard right iliac fossa incision was made. Dissection was carried down through the retroperitoneal space until the iliac vessels were identified. These were mobilized. Overlying lymphatics were ligated between individual silk ties. Vascular clamps were applied to the vessels. The kidney which had been prepared previously on the back table was brought to the operative field. A venotomy was made and an end-to-side venous anastomosis was performed using a running Prolene suture. Arteriotomy was then made and a running anastomosis was performed for an end-to-side arterial anastomosis. Vascular control was released and the kidney was well perfused. The patient began making some urine. The bladder was exposed with the mucosa over an appropriate length. A ureteroneocystostomy was made after the ureter had been trimmed to the appropriate length. The musculature was then reapproximated over this anastomosis for a distance of approximately 3 cm using PDS sutures. The wound was irrigated. The fascia was closed with a running Prolene suture and the skin was closed with staples. The venovenous bypass catheter was removed. All drains were secured at their exit sites as well as the T-tube. The patient was sent to the operating room in satisfactory condition. All needle, instrument and sponge counts were correct.


TITLE OF OPERATION:
Direct laryngoscopy with excision of vallecular cyst.

INDICATIONS FOR SURGERY:
This is a 73-year-old white female with a history of dysphagia and lump-in-throat sensation. The patient was evaluated by Dr. X who noted a left-sided vallevular cyst. The patient was counseled and agreed to undergo the above procedure. The risks, alternatives and potential complications were discussed. Witnessed informed consent was signed.

PREOPERATIVE DIAGNOSIS:
Left-sided vallecular cyst and dysphagia.

POSTOPERATIVE DIAGNOSIS:
Left-sided vallecular cyst and dysphagia.

ANESTHESIA:
General endotracheal anesthesia.

FLUIDS: 600 cc crystalloid.

FINDINGS: 4-mm, left-sided vallecular cyst.

description: The patient was taken to the operating room where she was placed on the table in the supine position. General endotracheal anesthesia was administered. The patient was then prepared and draped in the usual sterile fashion using the Holinger laryngoscope, the oral cavity, oropharynx, piriform sinuses, vallecula, epiglottis, true vocal cords, false vocal cords were all examined. She was noted to have a left-sided vallecular cyst. The Holinger scope was then removed and the Dedo laryngoscope inserted to visualize the cyst. Using the upbiting cup forceps and straight scissors, the cyst was excised. There was some bleeding which was controlled with direct pressure. Exploration of the vallecula was carried out to make sure she did not have any others. The patient was then awakened and taken to the recovery room in satisfactory condition, having tolerated the procedure well. Dr. X was present for the entire procedure.


TITLE OF OPERATION:
Adenotonsillectomy.

INDICATIONS FOR SURGERY:
The patient is a 10-year-old white female child with a history of chronic tonsillitis refractory to medical therapy. She was taken to the operating room for adenotonsillectomy. Witnessed informed consent was obtained prior to the procedure.

PREOPERATIVE DIAGNOSIS:
Chronic tonsillitis.

POSTOPERATIVE DIAGNOSIS:
Chronic tonsillitis.

ANESTHESIA:
General endotracheal anesthesia.

SPECIMEN:
Tonsils and adenoids.

FLUIDS: Crystalloid.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Less than 20 cc.

FINDINGS: Large cryptic tonsils and moderate adenoids. Palate normal.

DESCRIPTION: The patient was brought to the operating room and general anesthesia was established via endotracheal tube. Intravenous ampicillin and Decadron were administered. She was placed in the rose position. A Crowe-Davis mouth gag was inserted. The adenoids were removed with the adenoid curet. The nasopharynx was packed. The tonsils were removed using electrocautery to dissect between the superior constrictor muscle and the tonsillar capsule. Hemostasis was achieved with suction cautery. With adequate hemostasis, the pharynx was irrigated and suctioned free of secretions. The stomach was emptied free of secretions. She was awakened from anesthesia without difficulty.


TITLE OF OPERATION:
Adenotonsillectomy.

INDICATIONS FOR SURGERY:

The patient is a 5-1/2-year-old white female child with a history of chronic tonsillitis and tonsillar adenoidal hypertrophy with nocturnal breathing disturbance which was very mild. She was brought to the operating room for adenotonsillectomy. Witnessed informed consent was obtained prior to the procedure.

PREOPERATIVE DIAGNOSIS:
Tonsillar and adenoidal hypertrophy.

POSTOPERATIVE DIAGNOSIS:
Tonsillar and adenoidal hypertrophy.

ANESTHESIA:
General endotracheal anesthesia.

SPECIMEN: Tonsils and adenoids.

FLUIDS: Crystalloid.

FINDINGS: Large tonsils and adenoids and a normal palate.

ESTIMATED BLOOD LOSS: Less than 20 cc.

DESCRIPTION: The patient was brought to the operating room and general anesthesia was established via endotracheal tube. Intravenous ampicillin and Decadron were administered. She was placed in the rose position. A Crowe-Davis mouth gag was inserted. The adenoids were removed with the adenoid curet. The nasopharynx was packed. The tonsils were removed using electrocautery to dissect between the superior constrictor muscle and the tonsillar capsule. Hemostasis was achieved with suction cautery. With adequate hemostasis, the pharynx was irrigated and suctioned free of secretions. She was awakened from anesthesia without difficulty.


TITLE OF OPERATION:
Reduction osteoplasty of craniofacial bones with contouring bur.
Revision of scar, 17 cm of scalp, unusual, extended.

PREOPERATIVE DIAGNOSIS:
Cranial deformity secondary to previous reconstruction and cranial growth abnormality.

POSTOPERATIVE DIAGNOSIS:
Cranial deformity secondary to previous reconstruction and cranial growth abnormality.

ANESTHESIA:
General endotracheal anesthesia.

DESCRIPTION: The patient was placed on the operating table in the supine position. After adequate induction of general anesthesia, the patient was prepared and draped in the usual sterile fashion. This was accomplished after an appropriate removal of hair and prescrubbing. Dr. X then reopened the vertical portion of the incision and repaired the defect with a piece of titanium mesh. Once this was complete, the secondary procedure was begun.

Attention was directed to the segments. We extended the vertical incision transversely to the left side in order to allow exposure of the prominent right frontal or right parietal thickened bone. This was contoured with a pineapple bur. This was reduced in sized down to the minimal amount in view of the thickness of the bone. This gave a smoother overall contour. Other areas were difficult to reach to correct any more extensive irregularity. I discussed the case with Dr. X regarding the extension of the temporal region. He agreed that since there was extensive tension on the wound repair that extending down into the frontal region with the associated swelling could compromise the skin closure which was extraordinarily difficult, and would not have otherwise allowed for the scar revision. Therefore we elected to proceed with the scar revision. This was discussed with the family.

The old scar was removed down to the area where there appeared to be hair growth. This was trimmed appropriately and hemostasis was achieved with electrocautery. Closure was then accomplished with 2-0 Vicryl interrupted sutures followed by 3-0 Vicryl on the periphery, followed by a running 3-0 nylon. A sterile dressing was applied. The patient tolerated the procedure well, anesthesia was reversed and the patient was transferred to the recovery room in good condition.


TITLE OF OPERATION:
Removal of varied irritating plates and screws.
Reduction osteoplasty of craniofacial bones.
Scar revision (bicoronal).

INDICATIONS FOR SURGERY:
This patient underwent a craniofacial reconstruction in the past. This resulted in a good overall extension of the skull. He had a smooth forehead but with some irregularity in the temporal parietal region. He had some irregularities of the overlying bone with a slight temporal hollow. Iliotibial was elected to proceed with revision of the scar, removal of the prominent hardware and contouring of the bone, possibly reconstructing a temporal fossa.

PREOPERATIVE DIAGNOSIS:
Loosening of plate and screws following craniofacial reconstruction.
Prominent hypertrophic scar.
Prominent reconstructive craniofacial bones.

POSTOPERATIVE DIAGNOSIS:
Loosening of plate and screws following craniofacial reconstruction.
Prominent hypertrophic scar.
Prominent reconstructive craniofacial bones.

ANESTHESIA:
General endotracheal anesthesia.

DESCRIPTION: The patient was placed in the supine position. After adequate induction of general anesthesia, a small episode. We then proceeded with preparation and draping in the usual sterile fashion. The old incision was excised. Old scar was excised and the incision opened. Subperiosteal dissection with some supraperiosteal dissection proceeded without difficulty. We then extended all the way down to the forehead where the plates, screws and wires were all removed.

Attention was directed to the frontotemporal orbital region where some of the excess bone was contoured down. This was also accomplished in the upper sagittal and parietal region. This appeared decrease the prominence of this area and diminished the temporal hollow. This allowed for a good overall shape, and therefore the area was copiously irrigated with saline. Closure was accomplished with 3-0 Vicryl and a running 4-0 nylon. The patient tolerated the procedure well and was reversed from anesthesia and transferred to the recovery room in good condition.


TITLE OF OPERATION:
Right groin exploration; neurolysis.

INDICATIONS FOR SURGERY:
Right groin pain in the ilioinguinal nerve distribution, status post open right inguinal herniorrhaphy with Marlex mesh. The patient is a 28-year-old male who underwent a right incisional herniorrhaphy with Marlex mesh in the past at an outside institution. He developed pain postoperatively in the right groin in the distribution of the ilioinguinal nerve. His pain failed to improve with multiple therapies, and he was referred to X Hospital and seen by Dr. X and his pain group for appropriate intervention. I also had the opportunity to examine him preoperatively and felt that his pain was most likely related to an ilioinguinal nerve injury. Appropriate operative consent was obtained.

PREOPERATIVE DIAGNOSIS:
Right ilioinguinal nerve entrapment secondary to past inguinal herniorrhaphy.

POSTOPERATIVE DIAGNOSIS:
Right ilioinguinal nerve entrapment secondary to past inguinal herniorrhaphy.

ANESTHESIA:
General endotracheal anesthesia.

SPECIMEN: Portion of ilioinguinal nerve with attached Marlex mesh and scar.

DESCRIPTION: The patient was brought to the operating room and placed on the operating room table in the supine position. After the successful induction of general endotracheal anesthesia, the right groin was prescrubbed, shaved, prepared and draped in the routine fashion using Prepodyne. We reopened the previous right inguinal hernia incision superficially and extended it up laterally and cephalad up around toward the anterosuperior iliac spine. We divided the subcutaneous tissue using the electrocautery, and identified the external oblique muscle lateral to the 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.


TITLE OF OPERATION:
Exploratory laparotomy.
Cholecystectomy and en bloc resection of the extrahepatic biliary tree.
Drainage of noninfected peripancreatic necrosis.
Roux-en-Y hepaticojejunostomy.
Placement of two 16-French Silastic stents.

INDICATIONS FOR SURGERY:
The patient is a 55-year-old white male who became ill several weeks ago after eating crabs. He developed obstructive jaundice and eventually his imaging studies revealed dilated intrahepatic ducts and a decompressed gallbladder. Cholangiography showed a stricture of the common hepatic duct and proximal common bile duct consistent with either cholangiocarcinoma, gallbladder cancer or unlikely sclerosing cholangitis. Percutaneous transhepatic stenting was performed on both the right and left sides. Angiography showed no evidence of arterial or venous encasement or occlusion. A routine bowel preparation was performed and preoperative consent obtained.

PREOPERATIVE DIAGNOSIS:
Adenocarcinoma of the extrahepatic biliary tree involving the gallbladder infundibulum as well as the common hepatic duct and common bile duct.

POSTOPERATIVE DIAGNOSIS:
Adenocarcinoma of the extrahepatic biliary tree involving the gallbladder infundibulum as well as the common hepatic duct and common bile duct.

ANESTHESIA:
General endotracheal anesthesia.

SPECIMEN:
En bloc resection specimen including gallbladder and extrahepatic biliary tree; portion of necrotic pancreas.

PROSTHETIC DEVICE/IMPLANT:
Two 16-French Silastic stents and four 3/16-inch drains.

DESCRIPTION: The patient was brought to the operationg room and placed on the operating room table in the supine position. After the successful induction of general endotracheal anesthesia, the abdomen was prescrubbed and shaved. A Foley catheter was placed and the abdomen was prepared and draped in routine fashion using Prepodyne. The previous Ring catheter which exited the right flank and the epigastrium were prepared into the wound. The abdomen was open ed using a skin knife from the xiphoid to below the umbilicus, and carried down using electrocautery. On entry into the abdomen, there was no evidence of carcinomatosis or omental implants. The gallbladder was shrunken and had a mass palpable near the i nfundibulum. There was thickening and scar formation in the porta hepatis. There was also evidence of recent acute pancreatitis with some necrotic material and inflammation around the head of the pancreas which was debrided. The mesentery of the small bowel was markedly foreshortened. There was no ascites and only a small amount of blood up around the right Ring catheter.

Attention was turned first to performing a Kocher maneuver and debriding a bit of the head of the pancreas. The remainder of the pancreas, the body and tail felt firm, but there was no evidence of any pancreatic neoplasm. We took the gallbladder down ou t of the gallbladder fossa using electrocautery. This was accomplished without incident. We left the gallbladder in place, however, and then at the level of the superduodenal portion of the common bile duct, we encircled it with a vessel loop. There wa s a significant amount of scar and inflammation here, and this was quite a difficult dissection. We were eventually able to completely encircle the common bile duct at this level and elevate it with a vessel loop. We then divided the common bile duct wi th electrocautery. We removed the previously placed endoprosthesis which had been occluded and the left the Ring catheters exiting out from the proximal common bile duct. We performed a biopsy of the distal common bile duct at this level, and this retur ned negative for tumor. The distal common bile duct was then oversewn using 3-0 Prolene sutures in a running fashion. We then elevated the specimen up off the portal vein up towards the hilum, taking care to avoid any injury to major vascular structures. In particular, we avoid injury to the common hepatic artery and proper hepatic artery into the portal vein. We eventually dissected up to the level of the left hepatic duct and right hepatic duct, and took these up as high as was possible which was ap proximately 1 cm above the bifurcation. The left and right hepatic ducts were divided using electrocautery. The specimen was removed, including the right hepatic duct, left hepatic duct, hepatic duct bifurcation and the entire extrahepatic biliary tree with the gallbladder attached down to the level of the intrapancreatic portion of the common bile duct. Hemostasis was assured at this point. The Ring catheters were exiting from both the right and left hepatic ducts.

At one point, we thought there was perhaps a posterior segment branch of the biliary tree, but this did not materialize. It was tied with 2-0 silk. During the cholecystectomy, we did note a small branch of the right posterior segment draining into the bile duct. Attention was next turned to the reconstruction. We used the Ring catheters to pull Silastic stents through the liver, first using a guide wire followed by a 12-French coude catheter, a 14-French coude catheter and subsequently a 16-French Silastic stent. We positioned the Silastic stent exiting the hepatic duct sites with no side holes within the liver to tamponade any bleeding. We then went down below the ligament of Treitz and felt it would be very difficult to create a Roux-en-Y limb, but we made this effort.

Approximately 25 cm below the ligament of Treitz, which is a bit further than I usually go, I divided the mesentery of the small bowel and pedicled the blood supply of the Roux-en-Y limb on a more distal jejunal arcade. This was accomplis hed with some difficulty as the mesentery was quite foreshortened. Numerous clamps and ties were placed along the mesentery and we made every effort to preserve the arterial circulation to the Roux-en-Y limb. We then divided the jejunum with a GIA stapl er and oversewed its distal end using 3-0 silk sutures. The Roux-en-Y limb would not come up in the antecolic position because of its foreshortened mesentery and short length. We therefore were obliged to put the Roux-en-Y limb in the retrocolic position which brought it very close to the necrotic area of pancreatitis. We debrided the pancreatitis, and there was absolutely no way to bring the limb antecolic, and therefore we had to bring it up retrocolic up to the porta hepatis. It was with some diffi culty and a bit of tension that we actually got the Roux-en-Y limb up to the porta hepatis. We then made a longitudinal jejunotomy approximately 3 cm downstream from the cut end of the jejunum. We performed one hepaticojejunostomy to both of the limbs of the right and left hepatic bile ducts using interrupted 4-0 Vicryl sutures, first doing the posterior row in interrupted single-layer fashion and subsequently doing the anterior row in interrupted single-layer fashion. We placed Silastic stents into th e jejunal limb to decompress our biliary-enteric anastomosis. The anastomosis was quite difficult, and we found we were sewing well up into the liver. Nonetheless we tested the anastomosis, and apart from one small leaking area which was oversewn using three interrupted 3-0 Vicryl sutures. We appeared to have a watertight anastomosis without evidence of bile leak. Then 60 cm downstream from the hepaticojejunostomy, we then reimplanted the proximal jejunum as an end-to-side jejunojejunostomy using an outer layer of interrupted 3-0 silk and an inner layer of running 3-0 Vicryl. The mesenteric trap was closed using interrupted 3-0 silk. We irrigated the abdomen copiously using 3 L of warm bibiotic solution. We brought the Silastic stents out the anter ior abdomen and sewed them in place with 4-0 steel wire. We pulled the side holes back to allow at least one side hole to be up into the liver to drain bile.

Four 3/16-inch drains were placed through separate stab incisions, two on the left, two on the right side and sewn in place using 4-0 steel wire. We then brought one of the drains on each side up to the hepatotomy site and the second drain was placed to the hepaticojejunostomy. We again irrigated with bibiotic solution and closed using skin clips. All counts were reported as correct. I was present for the critical portion of this operation defined as from the opening to the closing, and I was immediately present for the entire surgery. All counts were reported as correc t. The patient tolerated the procedure well and came from the operating room to the anesthesia care unit in satisfactory condition.


TITLE OF OPERATION:
Hysteroscopy and dilatation and curettage.

PREOPERATIVE DIAGNOSIS:
Dysfunctional uterine bleeding.

POSTOPERATIVE DIAGNOSIS:
Dysfunction uterine bleeding.

ANESTHESIA:
Local sedation.

DESCRIPTION: The patient was brought to the operating room and placed in the supine position and given intravenous sedation. She was placed in the dorsal lithotomy position and examined. Examination revealed an enlarged uterus with a suspected posterior wall leiomyomata in the cul-de-sac. There was no evidence of adnexal masses. The rectovaginal examination was confirmatory.

The patient was then prepared and draped in the usual manner for hysteroscopy and possible dilatation and curettage. A Wolf carbon dioxide hysteroscope was utilized. The cervix was inspected and found to be normal. A paracervical block was placed with a total of 18 cc of 1% Xylocaine plain, 9 cc in each lateral paracervical area. The endocervical canal was normal. The uterine cavity: The right and left uterotubal ostia and cornua were identified. They appeared normal. The anterior, posterior and lateral walls were smooth, although the posterior wall was somewhat extrinsically compressed. No lesions were noted. The hysteroscope was reinserted to verify sampling of the cavity. All instruments were then removed. Tissue specimen was submitted to pathology.


TITLE OF OPERATION:
Operative hysteroscopy with lysis of adhesions, tubal cannulation, intrauterine device insertion and diagnostic laparoscopy.

PREOPERATIVE DIAGNOSIS:
Severe Asherman's syndrome.

POSTOPERATIVE DIAGNOSIS:
Severe Asherman's syndrome.

ANESTHESIA:
General endotracheal anesthesia.

PROSTHETIC DEVICE:
Paragard T380 intrauterine device inserted.

DESCRIPTION: The patient was brought to the operating room and placed in the supine position, and given general anesthesia and intubated. She was placed in the dorsal lithotomy position and examination under anesthesia revealed a normal-sized anteverted uterus, no evidence of adnexal masses. She was then prepared and draped in the usual manner for simultaneous operative hysteroscopy and laparoscopy. These procedures were performed simultaneously after the bladder was catheterized and drained of about 200 cc of urine. A stab incision was made within the umbilicus through which a Veress needle was placed and 2 liters of carbon dioxide gas infused. Laparoscopic trocar and sleeve were inserted. Eventually a secondary puncture was created above the symphysis pubis. Vaginally a speculum was inserted into the vagina uterine cavity was explored. The scope was inserted a few centimeters into the endocervical canal into the lower uterine segment and was met with a wall of dense adhesions. Using blunt probes and flexible and rigid scissors, a cavity was eventually created and the limits of the uterotubal ostium or the cornua were determined by the use of a blunt probe, visualizing the movement of the probe in the cornual region of the uterus through the laparoscope, passed through the umbilicus. The left fallopian tube was actually cannulated with a Miles Novy cannula. Dye spill from the left tube was observed. Following the creation of the uterine cavity. Adhesions were dense and the procedure was involved. A Paragard T380 IUD was inserted and the position within the cavity verified by reinsertion of the hysteroscope.

Laparoscopically the uterus appeared to be normal in size. An old perforation site near the right cornua was identified. The left ovary was normal in size, oval in shape, white in coloration. Smooth surface was apparent. No adhesions or lesions were noted. The right ovary was normal in size, oval in shape, white in coloration. No adhesions or lesions noted. The left tube was normal in length, normal surface appearance, normal in size. The fimbria were delicate. As previously mentioned, this tube was cannulated and dye spill was seen. No adhesions or lesions noted. The right tube was normal in length. Normal surface appearance. Normal in size. This tube was not cannulated. The fimbria were delicate. No dye spill was seen. No adhesions were noted.

Following the procedure, the pelvis was irrigated. Hemostasis was found to be complete. Instruments were removed. Carbon dioxide gas was expelled. Incisions were closed with 4-0 Vicryl. The patient was reversed from anesthesia, extubated and transferred to the recovery room in satisfactory condition. She will receive Premarin therapy for the next morning prior to removing the IUD.


TITLE OF OPERATION:
Wide local excision of malignant melanoma and left axillary sentinel lymph node biopsy.

PREOPERATIVE DIAGNOSIS:
Malignant melanoma, intermediate depth, left posterior shoulder.

POSTOPERATIVE DIAGNOSIS:
Malignant melanoma, intermediate depth, left posterior shoulder.

ANESTHESIA:
General endotracheal anesthesia.

SPECIMEN:
Wide local excision of melanoma after shave biopsy, and left axillary lymph nodes.

DESCRIPTION: Under general anesthesia, the axilla was prepared and draped in the usual sterile fashion. Using a gamma probe, the axillary lymph node was noted. A 3- to 4-cm incision was made sharply. The skin and subcutaneous tissues were dissected down sharply through the clavipectoral fascia. The probe then located a small lymph node along the thoracodorsal vessels. This was excised with sharp and blunt dissection, taking care to tie off the lymphatics with 3-0 Vicryl suture. In addition, two other small specimens were also taken. The wound was irrigated copiously with normal saline. Bleeding vessels were cauterized and the wound was closed with interrupted 3-0 Vicryl suture and a running 4-0 Vicryl subcuticular suture. Benzoin, Steri-Strips and a dry sterile dressing were applied.

New gowns, instruments and gloves were used to perform the wide local excision on the left posterior shoulder. An elliptical incision was made to allow a 2-cm margin around the lesion in question. The skin and subcutaneous tissues were dissected down sharply to the level of the fascia. The fascia and tissue were then removed with electrocautery. The wound was irrigated copiously with normal saline. Bleeding vessels were cauterized. The wound was closed with interrupted 3-0 Vicryl suture and interrupted 3-0 nylon vertical mattress sutures. The patient tolerated the procedure well and was sent to the recovery room in stable condition.

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