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She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.

Surgery

Delivery Note - 9

DELIVERY NOTE:, This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation at 1900 At this time, a bulging bag was noted, which ruptured and thick meconium was present. At 1937 hours, she delivered a viable male infant, left occiput, anterior. Mouth and nares suctioned well with a DeLee on the perineum. No nuchal cord present. Shoulders and body followed easily. Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance. Apgars 9 and 9. Pitocin 15 units infused via pump protocol. Placenta followed complete and intact with fundal massage and general traction on the cord. Three vessels are noted. She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area. Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL. The remainder of the lacerations was not at all bleeding and no other lacerations present. Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly. EBL was about 500 mL. Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically. Mom and baby currently doing very well.

surgery, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Dental restorations and extractions. Dental caries. He has had multiple severe carious lesions that warrant multiple extractions at this time.

Surgery

Dental Restorations & Extractions

PREOPERATIVE DIAGNOSIS:, Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled. He has had multiple severe carious lesions that warrant multiple extractions at this time. It is also unclear to me as to how his prior or existing restorations were accomplished. In any case, he has been cleared for the procedure today. He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position. Dr. X administered the general anesthetic, after which a throat pack was placed. Available full mouth x-rays were reviewed. These x-rays were taken at another location. Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies. All of these aforementioned teeth were extracted using combinations of forceps and elevators. Hemostasis in all of these sites was accomplished with direct pressure using gauze packs. ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal. These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces. ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite. ,Tooth 7 had caries involving the distal surface. ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area. These carious lesions were excavated, and both of these teeth were restored with composite. ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite. ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam. ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly. The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours. There was negligible blood loss.

surgery, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries

An 83-year-old diabetic female presents today stating that she would like diabetic foot care.

Surgery

Diabetic Foot Care

S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1. Onychocryptosis.,

surgery, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,

Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.

Surgery

Diagnostic Laparoscopy - 1

PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:, Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:, None.,CULTURES:, Intra-abdominally are done.,HISTORY: ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room. The pain has started in the umbilical area and radiated to McBurney's point. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix. The patient was seen by Dr. Y at my request in the ER with me in attendance. We went over the case. He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed. The patient on ultrasound had a 0.9 cm ovarian cyst on the right side. The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality. The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection. The patient has had hospitalization for this. The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery. All questions were answered. ,PROCEDURE: ,The patient was seen in the Emergency Room. In the Emergency Room, there is really no apparent vaginal discharge. No odor or cervical motion tenderness. Negative bladder sweep. Adnexa were without abnormalities. In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size. The patient had no adnexal fullness. The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope. We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus. The both fallopian tubes were seen. There did not appear to be hydrosalpinx. The ovaries were seen. The left showed some adhesions into the ovarian fossa. The cul-de-sac had a banded adhesions. The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged. The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap. The patient's bowel was otherwise unremarkable. The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID. The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right. The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left. The patient's case was turned over to him. Dr. Y was performed an appendectomy following which cultures and copious irrigation. Dr. Y was then closed the case. The patient was placed on antibiotics. We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1. Periappendicitis.,2. Pelvic inflammatory disease.,3. Chronic adhesive disease.

surgery, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,

The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.

Surgery

Diagnostic Laparoscopy

TITLE OF OPERATION:, Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:, 900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid. No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:, After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. No active bleeding was noted. No evidence of ectopic pregnancy was noted. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The sponge on a sponge stick was removed from the vagina. The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.

surgery, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,

Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.

Surgery

Dental Restoration

PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:, Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY: ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting. He was referred to me for that reason to be treated under general anesthesia for his dental work. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. There are no contraindications to this procedure. He is healthy. His history and physical is in the chart.,PROCEDURE: ,The patient was brought to the operating room at 10:15 and placed in the supine position. Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined. A throat pack was then placed. Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite. Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite. Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite. Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary. This was done using ferric sulfate and zinc oxide eugenol. For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly. The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30. There was no blood loss.

surgery, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries,

Dental prophylaxis under general anesthesia.

Surgery

Dental Prophylaxis

OPERATION PERFORMED: ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1. Impacted wisdom teeth.,2. Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1. Impacted wisdom teeth.,2. Moderate gingivitis.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,Minimal.,DURATION OF SURGERY: ,One hour 17 minutes.,BRIEF HISTORY: ,The patient was referred to me by Dr. X. He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him. I agreed. I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination. This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION: ,The patient was brought to Hospital Day Surgery accompanied by her mother. I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with a nasal endotracheal tube and the tube was stabilized. The head was wrapped and the eyes were taped shut for protection. An Angiocath was previously placed in preop. The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath. A moist continuous throat pack was placed beyond tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative digital intraoral photographs were taken. No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office. A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done. She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars. She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were taken. The continuous gauze throat pack was removed with continuous suction and visualization. Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition. Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander. Oral hygiene was fair. There was generalized plaque and calculus throughout. She did not have any caries, did not require any restorative dentistry.,CONCLUSION:, Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates. There were no postop pain requirements. I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.

surgery, dental prophylaxis, impacted wisdom teeth, gingivitis, wisdom teeth, moderate gingivitis, dental rehabilitation, throat pack, digital radiographs, restorative dentistry, impacted, anesthesia, restorative, wisdom, oral, prophylaxis, teeth, dental,

Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.

Surgery

Diagnostic Arthroscopy

PREOPERATIVE DIAGNOSIS:, Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Torn rotator cuff, right shoulder.,2. Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with subacromial decompression.,2. Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity. There is moderate amount of synovitis noted throughout the glenohumeral joint. There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repair. All risks and benefits of the surgery were discussed with her at length. She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital. She was placed supine on the operating table. General anesthesia was applied by the Anesthesiology Department. She was placed in the modified beachchair position. Her upper extremity was sterilely prepped and draped in usual fashion. A stab incision was made in the posterior aspect of the glenohumeral joint. A camera was placed in the joint and was insufflated with saline solution. Intraoperative pictures were obtained and the above findings were noted. A second port site was initiated anteriorly. Through this a probe was placed and the intraarticular structures were palpated and found to be intact. A tear of the inner surface of the rotator cuff was identified. The camera was then taken to the subacromial space. A straight lateral portal was also used and a shaver was placed into the subacromial space. Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed. The edges of the rotator cuff were then debrided. The camera was then removed and the shoulder was suction and dried. A lateral incision was made over the anterolateral border of the acromion. Subcuticular tissues were carefully dissected. Hemostasis was controlled with electrocautery. The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur. A trough was then made in the greater tuberosity using the rongeur. Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff. The ends of the suture were tied down from the fixating the rotator cuff within the trough. The rotator cuff was then further oversewed using the Panalok suture. The wound was then copiously irrigated and it was then suction dried. The deltoid muscle was reapproximated using #1 Vicryl. A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control. The subcutaneous tissues were reapproximated with #2-0 Vicryl. The skin was closed with #4-0 PDS running subcuticular stitch. Sterile dressing was applied to the upper extremity. She was then placed in a shoulder immobilizer. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient was guarded. She will begin pendulum exercises postoperative day #3. She will follow back in the office in 10 to 14 days for reevaluation. Physical therapy initiated approximately six weeks postoperatively.

surgery, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial,

Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started.

Surgery

Delivery Note - 8

DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital. The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital. Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started. The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started. The patient did have labor epidural, which worked well. It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep. The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth. The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid. DeLee suctioning was performed at the perineum. A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl. The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.

surgery, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.

Surgery

Delivery Note - 6

DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09. The patient is a patient of Dr. X's. Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She also has a history of tobacco abuse with asthma. She was admitted here and labor was confirmed with rupture of membranes. She was initially 5, 70%, -1. Her bag was ruptured, IUPC was placed. She received an epidural for pain control and Pitocin augmentation was performed. She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation. Delivery of the head was manual assisted. The shoulders and the rest of body then followed without difficulty. Baby was bulb suctioned, had a vigorous cry. Cord was clamped twice and cut and the infant was handed to the awaiting nursing team. Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord. The inspection of the perineum revealed it to be intact. There was a hymenal remnant/skin tag that was protruding from the vaginal introitus. I discussed this with the patient. She opted to have it removed. This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis. Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair. Overall EBL is 300 mL. Mom and baby are currently doing well. Cord gases are being sent due to prematurity.,

surgery, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Pitocin was started quickly to allow for delivery as quickly as possible. Baby was delivered with a single maternal pushing effort with retraction by the forceps.

Surgery

Delivery Note - 2

Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck. These were variable decelerations occurring late in the contraction phase. The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps. The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes. The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet. Cord gases were sent and the placenta was sent to Pathology. The cervix, the placenta, and the rectum all seemed to be intact. The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl. Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place. She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter. The baby's father was present for the delivery, as was one of the patient's sisters. All are relieved and pleased with the good outcome.

surgery, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.

Surgery

Delivery Note - 5

DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. Apgars were 8 at 1 minute and 9 at 5 minutes. Placenta was delivered intact with three-vessel cord. The cervix was visualized. No lacerations were noted. Perineum remained intact. Estimated blood loss is 300 mL. Complications were none. Mother and baby remained in the birthing room in good condition.

surgery, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.

Surgery

Delivery Note - 10

DELIVERY NOTE: ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor. The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum. Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes. No meconium was noted. Infant was delivered on 12/25/08 at 2154 hours. Two doses of ampicillin was given prior to rupture of membranes. GBS status unknown. Intrapartum events, no prenatal care. The patient had epidural for anesthesia. No observed abnormalities were noted on initial newborn exam. Apgar scores were 9 and 9 at one and five minutes respectively. There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child. Placenta was delivered spontaneously and was normal and intact. There was a three-vessel cord. Baby was bulb suctioned and then sent to newborn nursery. Mother and baby were in stable condition. EBL was approximately 500 mL, NSVD with postpartum hemorrhage. No active bleeding was noted upon deliverance of the placenta. Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone. Pitocin was started following deliverance of the placenta. Baby delivered vertex from OA position. Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.

surgery, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.

Surgery

Delivery Note - 7

DELIVERY NOTE:, The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009. The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting. She was Group B Streptococcus positive, however, was 5 cm dilated. The patient was started on Group B Streptococcus prophylaxis with ampicillin. She received a total of three doses throughout her labor. Her pregnancy was complicated by scanty prenatal care. She would frequently miss visits. At 37 weeks, she claims that she had a suspicious bump on her left labia. There was apparently no fluid or blistering of the lesion. Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2. I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery. The patient requested an epidural anesthetic, which she received with very good relief. She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions. She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum. The baby delivered in the occiput anterior position. The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated. The umbilical cord was doubly clamped and then cut. The baby's Apgars were 8 and 9. The placenta was delivered spontaneously intact. There was a three-vessel cord with normal insertion. The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol. The perineum was inspected and was found to be fully intact. Estimated blood loss was approximately 400 mL. The patient's blood type is A+. She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.

surgery, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum.

Surgery

Delivery Note - 3

DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. Cord clamped and cut and infant handed to the awaiting nurse in attendance. Cord blood sent for analysis, intact. Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours. A 15 units of Pitocin was started after delivery of the placenta. Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion. Estimated blood loss was approximately 400 mL. The patient was taken to the recovery room in stable condition. Infant was taken to Newborn Nursery in stable condition. The patient tolerated the procedure well. The only intrapartum event that occurred was thick meconium. Otherwise, there were no other complications. The patient tolerated the procedure well.

surgery, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Spontaneous controlled sterile vaginal delivery performed without episiotomy.

Surgery

Delivery Note - 1

The patient presented in the early morning hours of February 12, 2007, with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilation, but 80% effacement by nurse examination. The patient was admitted. Expected management was utilized initially. Stadol was used for analgesia. Examination did not reveal vulvar lesions. Epidural was administered. Membranes ruptured spontaneously. Cervical dilation progressed. Acceleration-deceleration complexes were seen. Overall, fetal heart tones remained reassuring during the progress of labor. The patient was allowed to "labor down" during second stage. Early decelerations were seen as well as acceleration-deceleration complexes. Overall, fetal heart tones were reassuring. Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty. Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck. There was no loop or coil of cord. Infant was vigorous female sex. Oropharynx was aggressively aspirated. Cord blood was obtained. Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue. Examination of the cervix did not reveal lacerations. Upper vaginal lacerations were not seen. Multiple first-degree lacerations were present. Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule. All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried. Post-approximation examination of the rectum showed smooth, intact mucosa. Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders. Nursing personnel will be notified of Gilbert's syndrome.

surgery, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder.

Surgery

Debridement - Shoulder

TITLE OF OPERATION: ,1. Incision and drainage with extensive debridement, left shoulder.,2. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3. Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections. Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES: ,1. Deep extensive infection, left total shoulder arthroplasty.,2. Biceps tenosynovitis.,3. Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE: ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder. He was then placed Beach chair position and all bony prominences were well padded. Pillows were placed around his knees to protect his sciatic nerve. He was brought to the side of the table and secured with towels and tape. The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch. Left upper extremity was then prepped and draped in usual sterile fashion. Unfortunately, preoperative antibiotics were given prior to the procedure. This occurred due to lack of communication between the surgical staff and the anesthesia staff. The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped. Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made. The patient's had a cephalic vein, it was identified and protected throughout the case. It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible. The patient did have significant scar from this point on and did bleed from many surfaces throughout the case. As a result, he was transfused 1 unit postoperatively. He did not have any problems during the case except for one small drop of blood pressure. However this was due primarily because of the extensive scarring of his proximal humerus. He had scar between the anterior capsular structures and the conjoint tendon. Also there was significant scar between the deltoid and the proximal humerus. The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve. Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3. This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid. As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material. There was some suggestion of a synovitis type reaction also inside this cystic area. This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment. This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm. All of the mucinous material and fibrinous material was removed from the proximal humerus. This was fairly extensive debridement. All of this was sent to pathology and also sent for culture and sensitivity. It should be noted that Gram stain became as multiple white blood cells but no organism seen. The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it. There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous. This was also removed. Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever. It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever. As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion. The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps. It was tracked proximally and transverse ligament released. The biceps tendon was flat and somewhat erythematous. As a result, it released and tagged with an 0 Vicryl suture. It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures. The joint was then entered and noted significant synovitis throughout the entire glenoid. This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set. Unfortunately, this device would not hold the proximal humerus and we could not get the component to release. As a result, bone contact of the metal proximally was released using a straight osteotome. Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it. There was no cement. There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate. This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection. It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid. The glenoid component was very carefully dissected free and found to be very loose. It was essentially removed with digital dissection. There was no remaining cement in the cavity itself. The patient's glenoid was very carefully debrided. The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself. This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation. Rather than place a spacer, it was elected to use antiobiotic beads. This was with antibiotic impregnated cement with one package with 3 gram of vancomycin. These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region. These three did not have a Prolene attached to them. The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon. There was essentially no capsule left purely to close over the proximal humerus. It was electively the proximal humerus. A portion of bone intact because it did have some bleeding surfaces. Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and shoulder immobilizer. The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case. This was a significantly scarred patient which required extra dissection and attention. Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case. Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis. The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case. This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.

surgery, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision,

Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.

Surgery

Delayed ORIF

PREOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE: ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour. He was on a curve and lost control. He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding. There were no other injuries. He was treated in Kentucky. A close reduction was performed and splint applied. Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan. The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight. The patient showed up in the emergency department where a CT scan was asked to be performed. This was performed and reviewed. The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days. At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches. The patient was x-rayed in the office. He had lost some of his reduction. Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally. It appeared as an abduction type injury with minimal rotation. This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type. The syndesmosis appeared to be intact. This appeared as an AO type B fracture. However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted. CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner. A posterior Tillaux fragment appeared to be separate. However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient. He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness. We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan. We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery. We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness. Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly. We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions. We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally. He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula. We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction. He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space. With this, the patient understood that the hardware may necessitate removal as well in the future. We discussed hardware irritation. We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly. With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:, The patient was brought to operating theater and given successful general anesthetic. His right leg was prepped and draped in the usual fashion. Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction. It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up. However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue. The superficial peroneal nerve was seen and this was avoided. The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally. The fracture was seen. The fracture was elevated and medialized and de-rotated. The anterior portion of the distal fibula was significantly comminuted with defect. The posterior aspect was still intact. However, there were multiple fracture lines demonstrating a crush-type injury. This was reduced manually. At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon. No sharp dissection was performed. The posterior malleolar fragment was palpated with the distal fibula reduced. The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus. This was taken only through subcutaneous tissue. The saphenous vein was found, dissected out. Its branches were cauterized. Penrose drain was placed around this.,Dissection was undertaken. The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides. Next, the towel clip was used. Ends were freshened up using irrigation. The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws. Anatomic reduction was gained. X-rays were taken showing excellent anatomic reduction. Next, attention was drawn towards the fibula. Standard 6-hole one-third tubular plate was applied to this. Again, this was more of a transverse impacted fracture. Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction. Screws were placed. It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled. They were double-checked. Screws had excellent purchase and were tightened up. At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond. This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used. Finger was placed on this fragment and the pin was advanced even before the finger. X-ray views could show the posterior cortex and location of the pin. This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed. This was double checked to ensure good positioning and this was so. On the lateral view, we could see this was not in the joint. AP views and mortise views showed this was not in the joint. One could palpate this as well. The screw was placed slightly proximal to distal in the anteroposterior plane. At the distal tip of it, it was just in the subchondral bone but not in the joint. There was slight to excellent purchase of this posterior lateral fragment. Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin. Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage. Posterior splint was placed on the patient. The patient's leg was placed in neutral position. Significant amount of cast padding were used and large bulky trauma ABD type dressings. The heel was padded and leg was padded with approximately 2 inches of padding. Tourniquet was deflated. The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications. Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied. Positioning of the leg was accomplished by the physician assistant. As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue. The patient is expected to do well overall. He does have an area of comminution shown on the CT scan. However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment. Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.

She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.

Surgery

Delivery Note - 4

DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated. Membranes ruptured this morning by me with some meconium. An IUPC was placed. Some Pitocin was started because the contractions were very weak. She progressed in labor throughout the day. Finally getting the complete at around 1530 hours and began pushing. Pushed for about an hour and a half when she was starting to crown. The Foley was already removed at some point during the pushing. The epidural was turned down by the anesthesiologist because she was totally numb. She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping. She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed. With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance. Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly. The placenta separated with some bleeding seen and was assisted expressed and completely intact. Uterus firmed up well with IV pit. Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural. Once this was complete, mom and baby doing well. Baby was a female infant. Apgars 8 and 9.

surgery, iupc, meconium, pitocin, epidural, rectum, sphincter, labor, perineum, pushed, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.

Surgery

Debridement - Foot Ulcer

PREOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1. Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2. Sharp excision of left distal foot plantar fascia.,ANESTHESIA:, None required.,INDICATIONS:, The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation. She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:, The procedure was performed in the patient's room. The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound. Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided. There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure.

surgery, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot

Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.

Surgery

Delivery Note

HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X. This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:, She was admitted. She was 3 cm dilated on admission. She desired induction of labor. Therefore, Pitocin was started. Epidural was placed for labor pain. She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy. She remained febrile, approximately 100.3. She then progressed. On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated. She had reported previously some mucous discharge with no ruptured membranes. Upon my exam, no membranes were noted. Attempted artificial rupture of membranes was performed. No fluid noted and there was no fluid discharge noted all the way until the time of delivery. Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor. She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:, Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise. Placenta delivery spontaneous. Condition was intact with a three-vessel cord. Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration. These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively. Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal. Apgars were 0 and 0. Weight pending at this time.,NARRATIVE OF DELIVERY:, I was called. This patient was completely dilated. I arrived. She pushed for three contractions. She was very comfortable. She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant. There was a tight nuchal cord x1 that was reduced after delivery of the fetus. Cord was doubly clamped. The infant was transferred to a bassinet cleaned by the nursing staff en route. The placenta delivered spontaneously, was carefully examined, found to be intact. No signs of abruption. No signs of abnormal placentation or abnormal cord insertion. The cord was examined and a three-vessel cord was confirmed. At this time, IV Pitocin and bimanual massage. Fundus firm as above with minimal postpartum bleeding. The vagina and perineum were carefully inspected. A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture. At this time, the repair is intact. She is hemostatic. All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time. We have called pastor in to baptize the baby as well as calling social work. They are deciding on a burial versus cremation, have decided against autopsy at this time. She will be transferred to postpartum for her recovery. She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise. I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.

surgery, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal

Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

Surgery

Decompressive Laminectomy

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.

surgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,

Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area. Pannus and left peritoneal specimen sent to Pathology.

Surgery

Debridement Necrotic Tissue

PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:, Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:, Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,ANESTHESIA:, General.,FLUIDS:, 800 cc given.,ESTIMATED BLOOD LOSS: ,350 cc.,SPECIMEN,: Pannus and left peritoneal specimen sent to Pathology.,REASON FOR PROCEDURE:, This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin. The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control. He has had a groin abdominal wound drained for about four days. The patient states that there has been pus that has saturated his sheath. He has had a possible fever at home that he did not chart with a thermometer. He has had the same groin infection twice in the past with tunneling lesions. The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day. Bowel habits and eating were essentially normal.,Urinary habits were normal. The patient is morbidly obese and is approximately 450 lb. He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,PAST MEDICAL HISTORY:, Diabetes, morbid obesity, and nephrolithiasis.,PAST SURGICAL HISTORY:, Appendectomy and stone extraction.,PROCEDURE: , The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture. The patient had a white count of 11.4 and a hemoglobin of 13.4. Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products. The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted. In the operative suite, he was prepped and draped in the usual sterile fashion. The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen. Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized. Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis. Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated. The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards. The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis. The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia. The necrotic tissue was lifted out of the abdomen. All bleeding was cauterized using the Bovie. A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned. A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing. The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm. The tissue was incised to the muscle layer of the muscle. There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well. There was a mild amount of pus that drained from the wound. Cultures were taken from the groin wound and were sent to pathology. The specimen was excised using traction with the Allis clamps as well as Bovie set on coag. Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit. After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.,It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date. The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology. The patient tolerated the procedure well and was taken to recovery in good condition.

surgery, debridement, abdomen, peritoneal, pannus, pathology, necrotizing infection, necrotic tissue, tissue, infection, necrotizing, groin, wound,

DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,

Surgery

DDDR Permanent Pacemaker

PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name: Sigma.,Model #: SDR203.,Serial #: 123456.,ATRIAL LEAD,Model #: 4568-45 cm.,Serial #: 123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #: 4068-52 cm.,Serial #: 123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.,Again, thank you for allowing to participate in this care.

Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.

Surgery

D&C, Laparoscopy, & Salpingectomy

PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,3. Hemoperitoneum.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Right salpingectomy.,4. Lysis of adhesions.,5. Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:, Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile. No adnexal masses, however, were appreciated on the bimanual exam. Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus. There were also adhesions to the left fallopian tube and the right fallopian tube. There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood. There was some questionable gestational tissue ________ on the left sacrospinous ligament. There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:, After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. A weighted speculum was then placed in the vagina. The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology. At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed. Next, attention was then turned to the abdomen. The surgeons all are removed the dirty gloves in the previous portion of the case. Next, a 2 cm incision was made immediately inferior to umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision. Next, a syringe was used to inject normal saline into the Veress needle. The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting. The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting. The abdomen was insufflated to an adequate distension. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted. Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera. A Veress needle and a step sheath were inserted through this incision. Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization. Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion. A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization. The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes. Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen. Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port. Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy. An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy. This was then sent to the pathology. Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic. The abdomen was further irrigated. The liver was examined and appeared to be within normal limits. At this point, the two size #5 ports and a size #12 port were removed under direct visualization. The camera was then removed. The CO2 gas was disconnected and the abdomen was desufflated. The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit. All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion. They were then steri-stripped and bandaged appropriately. At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She was discharged home with a postoperative hemoglobin of 8.9. She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain. She will follow up within a week in the OB resident clinic.

surgery, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube,

Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.

Surgery

Debridements

PREOPERATIVE DIAGNOSIS:, Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:, Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field. The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin). The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. The lateral compartment appeared contractile. The anterior compartment appeared necrotic for most of the muscle in the compartments. What appeared viable was left intact. A vacuum-assisted closure system was utilized on each fasciotomy wound. Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there. This was included in the VAC seal, as well as the traumatic wound. A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded. He tolerated the procedure well, was taken to the recovery room in good condition.

surgery, left lower extremity, debridement of wound, fasciotomies, debridement of muscle, vacuum-assisted closure systems, status post motorcycle accident, vacuum assisted closure systems, vacuum assisted closure, assisted closure systems, wound fasciotomies, fasciotomies debridement, vacuum assisted, closure systems, lower extremity, lateral compartments, anterior compartment, fasciotomy wounds, traumatic wound, wound, anterior, polytrauma, motorcycle, accident, contractile, vacuum, debridements, traumatic, muscle, fasciotomy, compartment

Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.

Surgery

D&C & Tubal Pregnancy Removal

PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Right ruptured tubal pregnancy.,2. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain. She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900. Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis. It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted. There were no adnexal masses appreciated although there was some fullness in the right lower quadrant. The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary. There were some pelvic adhesions in the right abdominal wall as well. The left fallopian tube and ovary and uterus appeared normal. There was no evidence of endometriosis. There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position. The bimanual exam was performed, which revealed the above findings. A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated using Hank dilators up to a #10. A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue. The tissue was sent to pathology for evaluation. The uterine elevator was then placed in the patient's cervix. Gloves were changed. The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made. While tenting up the abdominal wall, the Veress needle was placed without difficulty. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 step trocar was then placed without difficulty in abdominal wall. The placement was confirmed with a laparoscope. It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents. The above findings were then noted. Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen. A #12 step trocar port was placed under direct visualization. Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers. This was removed with the gallbladder grasper through the right lateral port site. There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached. Partial salpingectomy was therefore performed. This was done using the LigaSure. The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected. Good hemostasis was obtained in all of the right adnexal structures. The pelvis was then copiously suction irrigated. The area again was then visualized and again found to be hemostatic. The instruments were then removed from the patient's abdomen under direct visualization. The abdomen was then desufflated and the #11 step trocar was removed. The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips. The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well. The sponge, lap, and needle count were correct x2. She will follow up postoperatively as an outpatient.

surgery, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,

Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. Carpal tunnel release and de Quervain's release. A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.

Surgery

de Quervain Release - Carpal

PREOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1. Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat. The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat. The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl. Care was taken to avoid entrapping the motor branch of the median nerve in the suture. A hemostat was placed under the repair to ensure that the median nerve was not compressed. The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip. Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches. I released the compartment in a separate subsheath for the EPB on the dorsal side. Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl. It was checked to make sure that there was significant room remaining for the tendons. This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers. Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed. The patient was sent to the recovery room in good condition, having tolerated the procedure well.

surgery, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut,

Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.

Surgery

de Quervain Release - Wrist

PREOPERATIVE DIAGNOSIS:, Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2. Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid. Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected. Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve. I then incised it under direct vision dorsal to its axis and incised it both proximally and distally. The EPB subsheath was likewise released.,I irrigated the wound thoroughly. In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position. I did this with 3-0 Vicryl. I then passed an instrument underneath to check and make sure that the sheath was not too tight. I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately. The patient was sent to the recovery room in good condition, having tolerated the procedure well.

surgery, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet,

Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.

Surgery

D&C & Laparoscopy - 2

PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Enterolysis.,4. Lysis of the pelvic adhesions.,5. Left salpingo-oophorectomy.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:, None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions. Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 12 cm. The cervix was then serially dilated with Hank dilators to a size #20 Hank. Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum and weighted speculum were removed. Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision. Small amount of normal saline was injected into Veress needle and seemed to drop freely. So, the Veress needle was connected to he CO2 gas, which was started at the lower setting. It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. The abdomen was then insufflated to an adequate distention. Next, the Veress needle was removed and a size #11 step trocar was inserted. Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas. At this point, the initial operative findings were seen. Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization. A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. These were used to see the above operative findings. Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. Care was taken at all times to avoid the bowel and the ureters. The fallopian tubes appeared massively scarred and completely obliterated from disease. After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel. At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. Next, the needle was removed and the ligature device was inserted. This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. Then, the attention was turned to the inferior aspect of the ovary. First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. This was grasped with a clamp. The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port. The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant. Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. At this point, the remaining two size #5 ports were removed under direct visualization. The camera was removed and the abdomen was desufflated. Next, an introducer was replaced on a #11 port. The #11 port was removed. Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle. Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.

D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining. 6. Grade 1+ rectocele.

Surgery

D&C & Hysteroscopy Followup

PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Enlarged fibroid uterus.,3. Hypermenorrhea.,4. Intermenstrual spotting.,5. Thickened endometrium per ultrasound of a 2 cm lining.,6. Grade 1+ rectocele.,PROCEDURE PERFORMED: ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery. She has heavy periods lasting 7 to 14 days with spotting in between her periods. The patient's uterus is 12.2 x 6.2 x 5.3 cm. Her endometrial thickness is 2 cm. Her adnexa is within normal limits. The patient and I had a long discussion. Consent was reviewed in layman's terms. The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery. Questions were answered. The patient was taken back to the operative suite. The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position. The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities. The patient's history is that she is at risk for development of condyloma. The patient's husband was found to have a laryngeal papillomatosis. She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation. Her uterus appears to be mobile by 12-week size. There is a good descend. There appears to be no adnexal abnormalities. Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis. The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens. The patient underwent hysteroscopy. The outflow valve was opened at all times. The inflow valve was opened just to achieve appropriate distension. The patient did have no evidence of trauma of the cervix. No Trendelenburg as we were in room #9. The patient also had the bag held two fingerbreadths above the level of the heart. The patient was seen. There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature. The patient also has one in the fundal area. The thickened tissue was removed via sharp curettage. Therefore, we reinserted the hysteroscope. It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed. The patient's procedure was ended with specimen being obtained and sent to Department of Pathology. We will follow her up in the office.

surgery, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus

Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.

Surgery

D&C & Hysteroscopy - 1

PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:, Less than 10 cc.,INDICATIONS: ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time. The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:, The patient was consented and seen in the preoperative suite. She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation. She was prepped and draped in the normal sterile fashion. Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine. A bimanual exam was done, was performed by Dr. X and Dr. Z. The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage. The cervix and vagina were grossly normal with no obvious masses or deformities. A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm. The cervix was sterilely dilated with Hank dilator and then Hagar dilator. At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously. The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus. Under direct visualization, the ostia were within normal limits. The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps. The hyperplastic tissue did not appear to have calcification or other abnormalities. There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature. The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance. Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting. The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation. A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac. There was a normal consistency of the cervix and the normal step-off. The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum. The cervix was found to be hemostatic. The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room. The patient will be sent home once stable from anesthesia. She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings. The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin. The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks. The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.

surgery, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,

Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.

Surgery

D&C & Hysteroscopy

PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Hypermenorrhea.,3. Secondary anemia.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm. The cervix is patulous and nulliparous without lesions. Adnexal examination was negative for masses.,PROCEDURE: ,The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum. The uterus was sounded to a depth of 11 cm. The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar. The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera. The endometrial cavity was distended with fluids and the cavity visualized. Multiple irregular areas of fibroid degeneration were noted throughout the cavity. The coronal areas were visualized bilaterally with corresponding tubal ostia. A moderate amount of proliferative appearing endometrium was noted. There were no direct intraluminal lesions seen. The patient tolerated the procedure well. Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis. The instrument was removed from the vaginal vault. The patient was sent to recovery area in satisfactory postoperative condition.

surgery, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus

Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.

Surgery

Cystourethroscopy & TURP - 1

PREOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA:, Spinal.,RESECTION TIME:, Less than one hour.,INDICATION FOR PROCEDURE: ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE: PROCEDURE: , Informed written consent was obtained. The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position. She was sterilely prepped and draped in normal fashion. A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder. The bladder was visualized in all quadrants, no bladder tumors or stones were noted. Ureteral orifices were visualized and did appear to be near the enlarged median lobe. Prostate showed trilobar prostatic enlargement. There were some cellules and tuberculations noted. The visual obturator was removed. The resectoscope was then inserted utilizing the #26 French resectoscope loop. Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers. Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum. Ureteral orifices were kept out of harm's way throughout the case. Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion. Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way. The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed. Open prostatic fossa was noted. All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated. Clear return was noted. The patient was then hooked up to better irrigation. The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN: ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.

surgery, urinary retention, transurethral resection of prostate, prostate, enlarged, obstructive voiding symptoms, benign prostate hypertrophy, ureteral orifices, prostate hypertrophy, cystourethroscopy, turp, hypertrophy, resectoscope, urinary, bladder, resection,

Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.

Surgery

D&C & Laparoscopy

PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Pelvic pain.,3. Infertility.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Infertility.,3. Pelvic pain.,4. Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy.,3. Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile. The cervix is nulliparous without lesions. Adnexal examination was negative for masses.,PROCEDURE: ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum. Uterus sounded to a depth of 10.5 cm. Endocervical canal was progressively dilated with Hanks dilators to #20-French. A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis. A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air. A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity. The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted. The laparoscope was then inserted through the trocar with visualization of the pelvic contents. In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas. The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria. The ovaries also appeared normal bilaterally. The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area. An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still. Both fallopian tubes apparently were blocked. The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum. The patient tolerated the procedure well. Instruments were removed from the vaginal vault and the abdomen. Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures. Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.

surgery, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,

Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.

Surgery

D&C & Laparoscopy - 1

PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,5. Possible adenomyosis.,6. Left hydrosalpinx.,7. Suspicion for endometriosis.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:, None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion. This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living. Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996. The cyst was not diagnosed as an endometrioma. The patient does desire future fertility; however, would like a definitive diagnosis. Conservative medical therapy was offered i.e. Lupron or repeat oral contraceptives, but declined.,FINDINGS:, Bimanual exam reveals a small retroverted uterus which is easily mobile. There were no adnexal masses. The cervix was normal on palpation. A fibrotic band was noted at the internal os during dilation. On laparoscopic exam, the uterus was found to be small with mild spongy texture. On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis. The left ovary was grossly normal. The left fallopian tube had a mild hydrosalpinx present. The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis. The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac. The liver appeared grossly normal. There were no obvious pelvic adhesions. The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE: ,The patient was seen in the preop suite. History was reviewed and all questions were answered. The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube. She was placed in a dorsal lithotomy position in Allen stirrups. She was prepped and draped in the normal sterile fashion. Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine. A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted. A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum. There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible. A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen. An infraumbilical incision was made using skin scalpel. The Veress needle was placed and CO2 was insufflated. It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed. A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure. The #12 port was placed and the laparoscope was inserted. Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position. The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette. A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation. This procedure was performed under direct laparoscopic visualization. Laparoscopic evaluation of the pelvis was performed and the above findings noted. A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization. A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization. The manipulator was then removed and the Harmonic scalpel was placed through the #5 port. The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament. The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis. There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment. The Harmonic scalpel was removed from the abdomen as was the #5 port. The incision was internally found to be hemostatic. The laparoscope was then removed from the abdomen. The abdomen was desufflated. The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen. The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic. The weighted speculum was then removed. The patient taken out of dorsal lithotomy position. She was recovered from general anesthesia and taken to the postoperative suite for complete recovery. The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology. Her family was notified of the findings. She will be instructed not to have intercourse or use tampons or douche for the next two weeks. The patient will be sent home with a prescription for Darvocet for pain.

Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP).

Surgery

Cystourethroscopy & TURP

PREOPERATIVE DIAGNOSES:,1. Benign prostatic hypertrophy.,2. Urinary retention.,POSTOPERATIVE DIAGNOSES:,1. Benign prostatic hypertrophy.,2. Urinary retention.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA: ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS: ,150 cc.,DISPOSITION: ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe. Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder. Cystoscopy performed with the above findings. Cystoscope was removed. A #27 French resectoscope with a #26 cutting loop was inserted into the bladder. Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed. ________ irrigator was used to evacuate the bladder of prostatic chips. Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop. Any obvious bleeding from the prostatic fossa was controlled with electrocautery. Resectoscope was removed. A #24 French three-way Foley catheter inserted into the urethra and into the bladder. Bladder was irrigated and connected to three-way irrigation. The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.

surgery, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp,

Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration. Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.

Surgery

Cystourethroscopy & Urethral Dilation

PREOPERATIVE DIAGNOSIS: ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1. Urinary hesitancy and weak stream.,2. Urethral narrowing.,3. Mild posterior wall erythema.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Urethral dilation.,3. Bladder biopsy and fulguration.,ANESTHESIA: ,General.,SPECIMEN: ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:, Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French. A midureteral polyp was noted. Cystoscopy revealed multiple cellules and mild trabeculation of the bladder. Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa. No obvious raised bladder tumor was noted. No foreign bodies were noted. The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope. Cystoscopy was performed in its entirety with the above findings. The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area. The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined. No evidence of active bleeding noted. The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks. She is given prescription for Levaquin and Pyridium and given discharge instructions.

surgery, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,

Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.

Surgery

Cystoscopy, Ureteropyelogram, & Ureteral Barbotage

PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.

surgery, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine,

Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.

Surgery

Cystourethroscopy & Retrograde Pyelogram - 1

PREOPERATIVE DIAGNOSES:,1. Right renal mass.,2. Hematuria.,POSTOPERATIVE DIAGNOSES:,1. Right renal mass.,2. Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Right retrograde pyelogram.,3. Right ureteral pyeloscopy.,4. Right renal biopsy.,5. Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:, The patient is a 74-year-old male who was initially seen in the office with hematuria. He was then brought to the hospital for other medical problems and found to still have hematuria. He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position. He was given IV sedation and placed in dorsal lithotomy position. He was then prepped and draped in the standard fashion. A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder. The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder. There were no masses or any other abnormalities noted other than the tuberculation. Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice. A retrograde pyelogram was performed. Upon visualization, there was no visualization of the upper collecting system on the right side. At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed. The bladder was drained and the cystoscope was removed. The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire. The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities. The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire. The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance. The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter. The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction. The wire was then again passed through the flexible scope and the flexible scope was removed. A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation. The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system. Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system. The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass. Once this was done, the wire was left in place and the ureteroscope was removed. The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis. The stent was noted to be clear within the right renal pelvis as well as in the bladder. The bladder was drained and the cystoscope was removed. The patient tolerated the procedure well. He will be transferred to the recovery room and back to his room. It has been discussed with his primary physician that the patient will likely need a nephrectomy. He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.

surgery, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogram, ureteral, cystoscope, ureteroscope, renal, bladder

Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.

Surgery

Cystourethroscopy & Retrograde Pyelogram

PREOPERATIVE DIAGNOSES:,1. Recurrent bladder tumor.,2. History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:,

surgery, recurrent bladder tumor, bladder carcinoma, bilateral retrograde pyelogram, transurethral resection of bladder tumor, lateral wall bladder tumor, transurethral resection, retrograde pyelogram, tumor, bladder, cystourethroscopy, pyelogram,

Cystoscopy & Visual urethrotomy procedure

Surgery

Cystoscopy & Visual Urethrotomy

CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:, The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia. A Storz urethrotome sheath was inserted into the urethra under direct vision. Visualization revealed a stricture in the bulbous urethra. This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder. Visualization revealed no other lesions in the bulbous or membranous urethra. Prostatic urethra was normal for age. No foreign bodies, tumors or stones were seen within the bladder. Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.

surgery, cystoscopy, foley catheter, storz urethrotome sheath, teflon-coated guidewire, urethrotomy, bladder, bulbous urethra, dorsal lithotomy position, knife, membranous urethra, cystoscopy & visual urethrotomy, visual urethrotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Cystoscopy. Transurethral resection of the prostate.

Surgery

Cystoscopy & TURP

PREOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,PROCEDURES:,1. Cystoscopy.,2. Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer. His history dates back to 2003 when he had a non-muscle invasive bladder cancer. He had multiple cystoscopies and followups since that time with no evidence of recurrence. However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ. Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities. I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites. We elected to allow his bladder to recover before starting the BCG. We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter. I repeated a cystoscopy in the office with findings of a high bladder neck and BPH. After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms. There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion. A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described. We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds. Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck. The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock. Hemostasis was achieved, and then a similar procedure performed in the right side. We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis. Chips were removed with Ellik evacuator. There was no bleeding at the conclusion of the procedure, and the resectoscope was removed. A #24 French three-way Foley catheter was placed with efflux of clear irrigant. The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.

surgery, urinary bladder, benign prostatic hypertrophy, transurethral resection of the prostate, turp, acmi panendoscope, van buren sounds, transitional cell carcinoma, foley catheter, bladder neck, bladder, carcinoma, cystoscopy

Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.

Surgery

Cystoprostatectomy

PREOPERATIVE DIAGNOSES:,1. Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2. New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1. Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2. New right hydronephrosis.,3. Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005. During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in. He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event. The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time. In that interval, he had a coronary artery bypass graft and was taken off of Plavix. Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated. I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer. We could not identify the right ureteral orifice, and he had a right ureteral stent placed. Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy. He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier. Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS: ,On exploration, there were multiple abnormalities outside the bladder as follows: There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface. There were two much smaller lesions also with a small white scar, with very little palpable mass. The larger of the two was resected and found to be a carcinoid tumor. There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes. The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined. There was a frozen section of the distal right external iliac lymph node that was negative. The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface. The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures. The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that. The rest of the large bowel appeared normal. There were no masses in the liver, and the gallbladder was surgically absent. There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion. The radiologist placed a radial arterial line and an intravenous catheter. Intravenous antibiotics were given for prophylaxis. We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline. Exploration was carried out with the findings described. The bladder was adherent and did appear immobile. Moist wound towels and a Bookwalter retractor was placed for exposure. We began by assessing the small and large bowel with the findings in the small bowel as described. We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture. We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum. The ureters were carefully dissected out and down deep in the true pelvis. The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber. I kept the ureters intact until we were moving the bladder off as described above. At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes. The common iliac lymph nodes remained stuck to the ureter. Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally. I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels. Clips were used to control the lymphatics distally. These lymph nodes were sent for frozen section, which was negative. We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it. The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those. On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down. I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate. At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally. The endopelvic fascia was incised. I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia. I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically. I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch. I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra. I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field. The bivalved prostate appeared normal. We then carefully inspected the rectal wall and noted to be intact. The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch. I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. The colon was divided proximal to the middle colic using a GIA-80 stapler. I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler. We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60. The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler. The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures. The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75. Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis. The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture. The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture. The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis. The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. We then matured our stoma through the umbilicus. We removed the plug of skin through the umbilicus and delivered the ileal segment through this. A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures. The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant. Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia. Interrupted stitches were placed as well. The subcutaneous tissue was irrigated and skin closed with surgical clips. The estimated blood loss was 2500 mL. The patient received 5 units of packed red blood cells and 4 units of FFP. The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.

Right lower pole renal stone and possibly infected stent. Cysto stent removal.

Surgery

Cysto Stent Removal

PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose. The patient was on vancomycin for the last 5 days.,BRIEF HISTORY: ,The patient is a 53-year-old female who presented with Enterococcus urosepsis. CT scan showed a lower pole stone with a stent in place. The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology. The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone. There was some pus that came out. The patient was cultured; actually it was negative at that time. The patient subsequently was found to have lower extremity DVT and then was started on Coumadin. The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE. The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact. The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers. The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated. Due to drug interaction, the patient was admitted for IV antibiotic treatment. The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed. Since the stone is not obstructing, there is no reason to replace the stent at this time. We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated. So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient. Risks, benefits, and options were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. The patient understood all the risks and benefits of removing the stent and wanted to proceed. The patient was brought to the OR. The patient was placed in dorsal lithotomy position. The patient was given some IV pain meds. The patient had received vancomycin and Levaquin preop. Cystoscopy was performed using graspers. The stent was removed without difficulty. Plan was for repeat cultures and continuation of the IV antibiotics.

surgery, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,

Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.

Surgery

Cysto & Double-J Stent Insersion

PREOPERATIVE DIAGNOSIS:, Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:, General via endotracheal tube.,BLOOD LOSS:, Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and laid supine. General anesthesia was accomplished. A 16-French Foley was placed using aseptic technique. The patient was then placed on the operating table prone. His right flank was prepped and draped in a sterile fashion. At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed. The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire. The wire would not go down the ureter. Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained. After multiple attempts, access was lost. At this point, the tubes were left out of the kidney and sterile dressings were applied. The patient was then placed on another operating table supine. His genitalia were prepped and draped after removing his Foley catheter. Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous. The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope. The wire was removed. Contrast injection with good placement in the collecting system. The wire was replaced. The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance. The wire was removed leaving the double-J stent in good position. _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated. The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.

surgery, residual stone, percutaneous, cobra catheters, amplatz, double j stent, pollack catheter, cysto, catheter, nephrolithotomy, stent, french

Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.

Surgery

Cystolithalopaxy

PREOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,OPERATION:, Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,ANESTHESIA: ,General.,INDICATIONS:, This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate. He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA: ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria. He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1. Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia. Prepped and draped in the dorsal lithotomy position. A 27-French Olympus rectoscope was passed via the urethra into the bladder. The bladder, prostate, and urethra were inspected. He had an obstructing prostate. He had marked catheter reaction in his bladder. He had a lot of villous changes, impossible to tell from frank tumor. He had a huge bladder calculus. It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone. There was still stone left at the end of the procedure. Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB. We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP. We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.

surgery, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,

Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.

Surgery

Cystoscopy & Bladder Biopsy

PREOPERATIVE DIAGNOSIS:, History of bladder tumor with abnormal cytology and areas of erythema.,POSTOPERATIVE DIAGNOSIS: , History of bladder tumor with abnormal cytology and areas of erythema.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bladder biopsy with fulguration.,ANESTHESIA: , IV sedation with local.,SPECIMEN: , Urine cytology and right lateral wall biopsies.,PROCEDURE:, After the consent was obtained, the patient was brought to the operating room and given IV sedation. He was then placed in dorsal lithotomy position and prepped and draped in standard fashion. A #21 French cystoscope was then used to visualized the entire urethra and bladder. There was noted to be a narrowing of the proximal urethra, however, the scope was able to pass through. The patient was noted to have a previously resected prostate. On visualization of the bladder, the patient did have areas of erythema on the right as well as the left lateral walls, more significant on the right side. The patient did have increased vascularity throughout the bladder. The ________ two biopsies of the right lateral wall and those were sent for pathology. The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema. Bovie was also utilized to cauterize the areas of erythema on the left lateral wall. No further bleeding was identified. The bladder was drained and the cystoscope was removed. The patient tolerated the procedure well and was transferred to the recovery room.,He will have his defibrillator restarted and will followup with Dr. X in approximately two weeks for the result. He will be discharged home with antibiotics as well as pain medications. He is to restart his Coumadin not before Sunday.

surgery, bladder biopsy with fulguration, iv sedation, bladder biopsy, bladder tumor, abnormal cytology, bladder, cystoscopy, tumor, cytology, erythema,

Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.

Surgery

Cystoscopy

PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:, Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,SPECIMENS:, Urine sent for culture.,ABNORMAL FINDINGS: ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices. Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS: ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction. He has had a STING procedure performed but continues to have reflux bilaterally. Plan is for another injection.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, IV antibiotics were given. He was then placed in a lithotomy position with adequate padding of his arms and legs. His urethra was calibrated to 12-French with a bougie a boule. A 9.5-French cystoscope was used and the offset system was then used. His urethra was normal without valves or strictures. His bladder was fairly normal with minimal trabeculations but no cystitis noted. Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone. This was similarly found on the left side where the Deflux was not close to the orifice as well. It was slightly more difficult because of the amount impacted upon our angle for injection. We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect. Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding. Similar procedure was done on the left. This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed. There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection. At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra. The patient tolerated the procedure well and was in stable condition upon transfer to Recovery. A low-dose of IV Toradol was given at the end of the procedure as well.

surgery, bilateral vesicoureteral reflux, deflux, sting procedure, hit technique, cystoscopy under anesthesia, hit/sting with deflux, vesicoureteral reflux, ureteral orifices, vesicoureteral, cystoscopy, urethra, hit/sting, ureteral,

Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.

Surgery

Cystopyelogram

PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones. The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A 0.035 glidewire was placed in the left system. Using graspers, left-sided stent was removed. A semirigid ureteroscopy was done. A stone was visualized in the mid to upper ureter. Using laser, the stone was broken into 5 to 6 small pieces. Using basket extraction, all the pieces were removed. Ureteroscopy all the way up to the UPJ was done, which was negative. There were no further stones. Using pyelograms, the rest of the system appeared normal. The entire ureter on the left side was open and patent. There were no further stones. Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. Over the 0.035 glidewire, a 26 double-J stent was placed. There was a nice curl in the kidney and one in the bladder. The patient tolerated the procedure well. Please note that the string was kept in place and the patient was to remove the stent the next day. The patient's family was instructed how to do so. The patient had antibiotics and pain medications at home. The patient was brought to recovery room in a stable condition.

surgery, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,

CT of abdomen with and without contrast. CT-guided needle placement biopsy.

Surgery

CT-Guided Needle Placement Biopsy

EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.

surgery, ct, ct-guided, ct-guided biopsy, hounsfield units, mri, abdomen, biopsy, cholecystectomy, contrast, contrast administration, decubitus position, images, needle, postcontrast, renal lesions, renal mass, renal tumor, with and without, ct guided needle placement, ct of abdomen, needle placement, lower pole, ct guided, renal

Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.

Surgery

Cystopyelogram - 1

PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS: ,Gross hematuria.,OPERATIONS: ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS: ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed. There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs. The patient had hematuria. Cystoscopy revealed atypical biopsy. The patient came in again with gross hematuria. The first biopsy was done about a month ago. The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria. The options of watchful waiting, removal of the clots and biopsies were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed. Morbidity and mortality of the procedure were discussed. Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. The patient had been off of the Coumadin for about 4 days and INR had been reversed. The patient has significant amount of clot upon entering the bladder. There was a tight bladder neck contracture. The prostate was not enlarged. Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed. It took about half an hour to just remove the clots. After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected. This was lateral to the left ureteral opening. The base was coagulated for hemostasis. Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized. The back wall and the rest of the bladder appeared normal. Using 8-French cone-tip catheter, left-sided pyelogram was normal. The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation. The patient did have CT with contrast, which showed that the kidneys were normal. At this time, a #24 three-way irrigation was started. The patient was brought to Recovery room in stable condition.

surgery, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,

Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.

Surgery

Culdoplasty & Vaginal Hysterectomy

PREOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,PROCEDURE PERFORMED:,1. Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2. McCall's culdoplasty.,3. Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS: ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia. On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated. The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY: ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities. On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis. There was also evidence of fibroid change in the right fundal aspect of the uterus. There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes. There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate. She was then prepared and draped in the normal sterile fashion. A Foley catheter was initially placed and was noted to be draining clear to yellow urine. A weighted speculum was placed in the patient's vagina. The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus sounded to 7 cm and the cervix was then progressively dilated. A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator. At this time, after the gloves were changed, attention was then turned to the patient's abdomen. A small approximately 1 cm infraumbilical incision was made with the scalpel. A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures. A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope. On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions. There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance. At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope. A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope. Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site. The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper. The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time. Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper. An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament. At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic. In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted. At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers. The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated. The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure. At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic. The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure. The weighted speculum was placed into the patient's vagina. At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb. The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure. The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps. The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position. The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly. Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly. At this time, two curved Heaney clamps were placed across the uterine artery on the right. This was then transected and suture ligated with #0 Vicryl suture. The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture. Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture. This second clamp was then advanced to capture the vasculature and the cardinal ligament complex. This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff. Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology. At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure. Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position. Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly. The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum. Two additional sutures medially were placed and these were tagged and not tied in place. A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized. This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches. At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg. The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic. The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time. The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time. The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen. The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia. The Steri-Strips were placed. The patient tolerated the procedure well and taken to recovery in stable condition. Sponge, lap, and needle counts were correct x2. The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes. The patient will have her Foley catheter maintained for approximately 7 to 10 days.

surgery, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, inflammatory, laparoscopic,

Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.

Surgery

Cystic Suprasellar Tumor Resection

TITLE OF OPERATION:, Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache. All endocrine labs were normal. Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:, Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended. The patient was then prepped and draped in the usual sterile fashion. With the assistance of fluoro and mapping the localization, the right nostril was infiltrated. Dr. X will dictate the procedure of the approach. Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling. Once the operating microscope was in the field, at this point, the drilling was completed. The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor. This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down. Once this was completed, there was no evidence of any bleeding. The endoscope was then used to remove any residual fragments __________ with the arachnoid. Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X. She was reversed, extubated, and transported to the ICU in stable condition. Blood loss, minimal. All sponge, needle counts were correct.

surgery, microsurgical transnasal resection, cystic suprasellar tumor, transnasal resection, endoscopic, transnasal, microsurgical, suprasellar, cystic, tumor,

CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.

Surgery

CT-Guided Biopsy - Kidney

REASON FOR EXAM: This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE: The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient. The patient understood. All questions were answered, and informed consent was obtained. With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney. Conscious sedation was utilized with the patient being monitored. The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach. Two biopsy specimens were obtained and placed in 10% formalin solution. CT documented needle placement. Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly. I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding. The bleeding stopped. The co-axial sheath was then removed. Bandage was applied. Hemostasis was obtained. The patient was placed in the supine position. Postbiopsy CT images were then obtained. The patient's hematoma appeared stable. The patient was without complaints of pain or discomfort. The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable. The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS: Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney. Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass. Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass. There are small droplets of air within the hematoma. No hydronephrosis is identified.,CONCLUSION:,1. Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2. Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.

surgery, embolization, ct localization, gelfoam pledgets, ct guided needle placement, ct guided biopsy, needle placement, renal mass, ct guided, inferior pole, ct, biopsy, hematoma, kidney, mass,

Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.

Surgery

Craniotomy - Frontotemporal

PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood.

surgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,

Left temporal craniotomy and removal of brain tumor.

Surgery

Craniotomy - Temporal

PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.

surgery, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,

Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.

Surgery

Craniotomy - Frontotemporal - 1

PREOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,PROCEDURE:, Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia. He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency. He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury. His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy. The images were brought up on the electronic imaging and confirmed that this was a left-sided condition. He was fixed in a three-point headrest. His scalp was shaved and prepared with Betadine, iodine and alcohol. We made a small curved incision over the temporal, parietal, frontal region. The scalp was reflected. A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created. After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain. The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up. We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline. After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline. We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates. The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment. Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this. I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.

surgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,

Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.

Surgery

Craniotomy - Frontal Zygomatic

PREOPERATIVE DIAGNOSIS:, Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:, Metopic synostosis with trigonocephaly.,PROCEDURES: ,1. Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2. Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3. Bilateral forehead reconstruction with autologous graft.,4. Advancement of the temporalis muscle bilaterally.,5. Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut. Scalp was clipped. He was prepped with ChloraPrep. Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis. Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly. These were subgaleal flaps. Bipolar and Bovie cautery were used for hemostasis. The craniectomy was outlined with methylene blue. The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture. One was just above the nasion and the other was near the bregma. Also bilateral pterional bur holes were drilled. There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut. I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately. Great care was taken when removing the bone from the midline. Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents. Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally. This was a very thick and vertically oriented orbital roof on each side. Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura. The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet. Bone wax was used for hemostasis. It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed. So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit. This was done with the Midas Rex drill using B5 bit. Also, the marked ridge just above the nasion was burred down with the Midas Rex drill. The osteotomies were also carried down through the zygoma. At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim. This created a shelf for the notched bone graft to lean against basically anteriorly. The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture. This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation. Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good. The advancement was about 1 cm and we were pleased with the results. The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin. The patient tolerated procedure well. No complications. Sponge and needle counts were correct. Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.

surgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies,

Left retrosigmoid craniotomy and excision of acoustic neuroma.

Surgery

Craniotomy - Retrosigmoid

PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL: ,Following induction of adequate general anesthetic, the patient was positioned for surgery. She was placed in a lateral position and her head was maintained with Mayfield pins. The left periauricular area was shaved, prepped, and draped in the sterile fashion. Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified. The proposed incision was injected with 1% Xylocaine with epinephrine. Next, T-shaped incision was made approximately 5 cm behind the postauricular crease. The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. Bergen retractors were used to maintain exposure. Using a cutting bur with continuous suction and irrigation of craniotomy was performed. The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. From these structures approximately 4 x 4 cm, a window of bone was removed. Bone shavings were collected during the dissection and placed in Siloxane suspension for later use. The bone flap was also left at the site for further use. Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. Bone wax was used to occlude air cells lateral to the sigmoid sinus. There was extensively aerated temporal bone. At this point, Dr. Trask entered the case in order to open the dura and expose the tumor. The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. The dura was excised from around the porous acusticus extending posteriorly along the bone. Then, using diamond burs, the internal auditory canal was dissected out. The bone was removed laterally for distance of approximately 8 mm. There was considerable aeration around the internal auditory canal as well. The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. The eighth nerve was identified and transected. Tumor debulking allowed for retraction of the tumor capsule away from the brainstem. The facial nerve was difficult to identify at the brainstem as well. It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. Attention was then redirected to the internal auditory canal where this portion of the tumor was removed. The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. At this point, plane of dissection was again indistinct. The tumor had been released from the porous and could be rotated. The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. The nerve could be stimulated, but was quite splayed over the anterior face. Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. However, the cerebellopontine angle portion of the nerve was not usually delineated. However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness. It was released from the brainstem ventrally. The tumor was then cauterized with bipolar electrocautery. The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. Overall, the remaining tumor volume would be of small percentage of the original volume. At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis. The air cells around the internal auditory canal were packed off with muscle and bone wax. A piece of fascia was then laid over the bone defect. Next, the dura was closed with DuraGen and DuraSeal. The bone flap and bone ***** were then placed in the bone defect. Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures. The skin was also closed using interrupted subdermal 3-0 Vicryl sutures. Running 4-0 nylon suture was placed at the skin levels. Sterile mastoid dressing was then placed. The patient tolerated the procedure well and was transported to the PACU in a stable condition. All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS: ,100 mL.

surgery, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor

Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.

Surgery

Craniotomy - Occipital

PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:, Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:, Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:, The patient was placed in the prone position after general endotracheal anesthesia was administered. The scalp was prepped and draped in the usual fashion. The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor. Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor. The bone flap was elevated. The ultrasound was then used. The ultrasound showed the tumors directly I believe are in the interhemispheric fissure. We noticed that the dura was quite tense despite that the patient had slight hyperventilation. We gave 4 ounce of mannitol, the brain became more pulsatile. We then used the stealth to perform a ventriculostomy. Once this was done, the brain began to pulsate nicely. We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus. After having done this we then used operating microscope and slight self-retaining retraction was used. We obtained access to the tumor. We biopsied this and submitted it. This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total. After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery. The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates. The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle. This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage. The next step was to close the wound after reapproximating the bone flap. The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures. The sterile dressings were applied to the scalp. The patient returned to the recovery room in satisfactory condition. Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy. The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.

surgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,

Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.

Surgery

Craniotomy - Biparietal

PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1. Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3. Right suboccipital craniectomy and excision of tumor.,4. Microtechniques for all the above.,5. Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. Metastatic workup does reveal multiple bone metastases, but no spinal cord compression. She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol. She was brought to the operating room with fiducial still on her scalp. General endotracheal anesthesia was obtained. She was placed on the Mayfield head holder and rolled into the prone position. She was well padded, secured, and so forth. The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint. This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system. Sterile drapes were applied and the accuracy of the system was confirmed. A biparietal incision was performed. A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system. The dura was opened and reflected back to the midline. An inner hemispheric approach was used to reach the very large metastatic tumor. This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. The tumor was wrapped around and included the choroidal vessels. At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. A linear incision was made just lateral to the greater occipital nerve. Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull. A burr hole was placed down low using a craniotome. A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa. Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator. A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers. The dura was closed with interrupted and running mattress of 4-0 Nurolon. The dura was watertight, and it was covered with blue glue. Gelfoam was placed over the dural closure. Then, the muscle and fascia were closed in individual layers using #0 Ethibond. Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound. The bone flap was brought on to the field. The dura was closed with running and interrupted 4-0 Nurolon. At the beginning of the case, dural tack-ups had been made and these were still in place. The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates. The wound was then closed in layers. The galea was closed with multiple sutures of interrupted 2-0 Vicryl. The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L. The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.

surgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions,

Cystoscopy, cryosurgical ablation of the prostate.

Surgery

Cryosurgical Ablation of Prostate

PREOPERATIVE DIAGNOSIS: ,Carcinoma of the prostate, clinical stage T1C.,POSTOPERATIVE DIAGNOSIS: , Carcinoma of the prostate, clinical stage T1C.,TITLE OF OPERATION: , Cystoscopy, cryosurgical ablation of the prostate.,FINDINGS: ,After measurement of the prostate, we decided to place 5 rows of needles--row #1 had 3 needles, row #2 at the level of the mid-prostate had 4 needles, row #3 had 2 needles in the right lateral peripheral zone, row #4 was a single needle directly the urethra, and in row #5 were 2 needles placed in the left lateral peripheral zone. Because of the length of the prostate, a pull-back was performed, pulling row #2 approximately 3 mm and rows #3, #4 and #5 approximately 1 cm back before refreezing.,OPERATION IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After adequate general endotracheal anesthesia was obtained, the patient was positioned in the dorsal lithotomy position. Full bowel prep had been obtained prior to the procedure. After performing flexible cystoscopy, a Foley catheter was placed per urethra into the bladder. Next, the ultrasound probe was placed into the stabilizer and advanced into the rectum. An excellent ultrasound image was visualized of the entire prostate, which was re-measured. Next, the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement. Then 17-gauge needles were serially placed into the prostate, from an anterior to posterior direction into the prostate. Ultrasound guidance demonstrated that these needles, numbering approximately 14 to 15 needles, were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra. Repeat cystoscopy demonstrated a single needle passing through the urethra; and due to the high anterior location of this needle, it was removed. The CMS urethral warmer was then passed per urethra into the bladder, and flow instituted. After placing these 17-gauge needles, the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior. The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself. Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature. The urethral warmer was left on after the needles were removed and the patient brought to the recovery room. The patient tolerated the procedure well and left the operating room in stable condition.

surgery, carcinoma of the prostate, ablation, cystoscopy, cryosurgical ablation, prostate, ultrasound, cryosurgical, urethra,

Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.

Surgery

Craniotomy & Neuronavigation

PROCEDURES:,1. Right frontal craniotomy with resection of right medial frontal brain tumor.,2. Stereotactic image-guided neuronavigation for resection of tumor.,3. Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE: ,The patient is a 71-year-old female with a history of left-sided weakness and headaches. She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago. An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor. After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube. She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor. We marked external landmarks. Then we shaved the head over the right medial frontal area. This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline. This was opened and hemostasis obtained using Raney clips. The skin flap was retracted medially. Two burr holes were made and were carefully connected. One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap. Hemostasis was obtained. Using the neuronavigation, we identified where the tumor was. The dura was then opened based on a horseshoe flap based on the medial sinus. We retracted this medially and carefully identified the brain. The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor. Subsequently, we entered the tumor. The tumor itself was extremely hard. Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case. We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor. Then we collapsed the tumor on itself and removed it entirely. In this fashion, microdissection and magnification resection of the tumor was carried out. We resected the entire tumor. Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam. We also lined the cavity with Surgicel. The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion. Surgicel was placed over the dural closure. The bone flap was repositioned and held in place using CranioFIX cranial fixators. The galea was re-approximated and the skin was closed with staples. The wound was dressed. The patient was returned to the intensive care unit. She was awake and moving extremities well. No apparent complications were noted. Needle and sponge counts were listed as correct at the end of the procedure. Estimated intraoperative blood loss was approximately 150 mL and none was replaced.

surgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection,

Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage. Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.

Surgery

Craniotomy

TITLE OF OPERATION: , Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.,INDICATION FOR SURGERY: , The patient is very well known to our service. In brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor. He was taken to the operating room for the orbitozygomatic approach. Intraoperatively, everything went well without any complications. The brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan, developed a second seizure. He was given Ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct. I had a long discussion immediately with Dr. X and Dr. Y. We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component. It worried me and I think that we needed to go ahead and take him to the operating room immediately. The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure. The original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component. He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma.,PREOP DIAGNOSIS:, Pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage.,POSTOP DIAGNOSIS:, Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach.,ANESTHESIA: , General.,PROCEDURE IN DETAIL: , The patient was taken to the operating room. In the supine position, his head was put in a horseshoe without any complications. The patient tolerated this very well, and the prior incision was immediately opened. The surgery had taken place a few hours prior to this, the original orbitozygomatic approach. At this point, this was a life-saving procedure. We went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place. We went ahead and opened the incision and took out the pterional bone flap without any complications. We immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out. So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue. So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever. We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection. The brain was very relaxed. We had a very good resection of the actual blood clot, and the brain was very relaxed. We irrigated thoroughly. We identified the ventricles. We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure. All this was done very well, and then we lined the cavity with Surgicel, and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good. We went ahead and closed back the actual dura back. We had done a pericranial flap. This was also put back in place and the dura was closed with 4-0 Surgilons. We reconstructed everything. The frontal sinus was reconstructed thoroughly without any complications. We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates. Once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications. In summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications. So everything was stable. Estimated blood loss was about 100 cubic centimeters. The sponges and needle counts were correct. No specimens were sent to pathology.,DISPOSITION: , The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation.

surgery, orbitozygomatic, intracranial, brain tumor, intraparenchymal hematoma, orbitozygomatic approach, frontal lobe, intracranial hemorrhage, pituitary tumor, craniotomy, hemorrhage,

Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.

Surgery

Craniotomy - Burr Hole

PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:, In preoperative identification, the patient was taken to the operating room and placed in supine position. Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. Table was turned. The right shoulder roll was placed. The head was turned to the left and rested on a doughnut. The scalp was shaved, and then prepped and draped in usual sterile fashion. Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. The parietal boss incision was opened. It was about an inch and a half in length. It was carried down to the skull. Self-retaining retractor was placed. A bur hole was now fashioned with the perforator. This was widened with a 2-mm Kerrison punch. The dura was now coagulated with bipolar electrocautery. It was opened in a cruciate-type fashion. The dural edges were coagulated back to the bony edges. There was egress of a large amount of liquid. Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. It was secured with a 3-0 nylon suture. The area was closed with interrupted inverted 2-0 Vicryl sutures. The skin was closed with staples. Sterile dressing was applied. The patient was subsequently returned back to anesthesia. He was extubated in the operating room, and transported to PACU in satisfactory condition.

surgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space

Anterior cranial vault reconstruction with fronto-orbital bar advancement.

Surgery

Cranial Vault Reconstruction

INDICATION FOR OPERATION:, Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:, Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:, After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner. Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture. Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion. Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally. The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar. We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal. The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs. On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof. The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate. It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position. The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place. Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place. The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum. The wounds were irrigated out. A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings. The patient tolerated the procedure well and did receive blood transfusions.

surgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,

Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.

Surgery

Coronary Angiography & Abdominal Aortography

NAME OF PROCEDURE,1. Selective coronary angiography.,2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3. Abdominal aortography.,INDICATIONS: ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium scan has been negative. He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE: ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg. Received additional Versed and fentanyl during the procedure. Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed. Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. This revealed a very high-grade lesion at the proximal right coronary artery. This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. A 6-French sheath and a right Judkins guide was placed. The patient was started on bivalarudin. A BMW wire was easily placed across the lesion and into the distal right coronary artery. A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres. The intermediate result was improved with TIMI-3 flow to the terminus of the vessel. Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres. This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres. Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. The guiding catheter was withdrawn over wire and a pigtail was placed. This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. The catheter was removed. The bivalarudin was stopped at the termination of procedure. A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein. This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure. Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel. This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch. It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex. The ramus intermedius is free of disease. The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment. This measures 25% to 30% at its worst point. The circumflex is a large caliber vessel. There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation. This may represent a small retrograde dissection as well. There was some dye hang up in the wall.,IMPRESSION,1. Successful stenting of subtotal stenosis of the proximal coronary artery.,2. Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3. Left to right collateral filling noted prior to coronary intervention.,4. Small area of eccentric aneurysm formation in the abdominal aorta.

surgery, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,

Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage. The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.

Surgery

Control of Parapharyngeal Hemorrhage

PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:, Postoperative hemorrhage.,SURGICAL PROCEDURE: ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA: ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty. However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY: ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage. A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized. There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated. There was no other bleeding noted. The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined. There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery. No other bleeding was noted and the patient was recovered from general anesthetic. She was extubated and left the operating room in good condition to postoperative recovery room area. Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.

surgery, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,

Lateral and plantar condylectomy, fifth left metatarsal.

Surgery

Condylectomy

TITLE OF OPERATION:, Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA: ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:, Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in a normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe. The incision was deepened through the subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized. The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved. The bony prominences were removed and passed off the operating table to be sent to pathology for identification. The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp. The area was copiously flushed with saline. Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively. The incision was reinforced with Steri-Strips. Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited. The patient's left ankle tourniquet at this time was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe. The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medications and instructions on how to control her postoperative course. She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.

surgery, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal,

Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.

Surgery

Coronary Angiography

REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1. Selective coronary angiography.,2. Left heart catheterization with hemodynamics.,3. LV gram with power injection.,4. Right femoral artery angiogram.,5. Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right groin area infiltrated with lidocaine solution. Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch. The wire was removed. Catheter was engaged into the left main. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained. Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed. Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained. The cath disengaged and exchanged over J-wire into a pigtail catheter. Pigtail catheter across the aortic valve. Hemodynamics obtained. LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma. The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS: ,The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient.,ANATOMY: ,The left main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD. The LAD gave off two early diagonal branches. The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA. The left circumflex was large and patent, 6.0 mm in diameter. All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%. No mitral regurgitation identified.,IMPRESSION:,1. Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2. Nondominant right, which is free of atheromatous plaque.,3. Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4. Normal left ventricular function.,5. Evaluation for noncardiac chest pain would be recommended.

Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.

Surgery

Condyloma Cauterization

PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:, Cauterization of peri and intra-anal condylomas.,ANESTHESIA: ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week.

surgery, intra-anal, perianal, acuminata, cauterization, condyloma, anal,

Cervical cone biopsy, dilatation & curettage

Surgery

Cone Biopsy

PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:, Cervical cone biopsy, dilatation & curettage.,SPECIMENS: ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ. The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable. The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place. Anesthetic was administered and she was placed in the lithotomy position. The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction. Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices. The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os. The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm. A Kevorkian curette was used to obtain endocervical curettings. The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture. Upon completion of the suture placement, the endocervical canal was sounded to assure patency. A prophylactic application of Monsel's solution completed the procedure. ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition. Final sponge, needle, and instrument counts were.

surgery, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy,

Colonoscopy with random biopsies and culture.

Surgery

Colonoscopy with Biopsy - 4

PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea. ,POSTOPERATIVE DIAGNOSIS: ,Antibiotic-associated diarrhea. ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago. She has been having difficulty since that time with intermittent diarrhea and abdominal pain. She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes. She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE: , The risks and benefits of colonoscopy were explained to the patient in detail. She provided her consent. The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite. She was placed in the left lateral decubitus position. In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl. A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure. This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided. In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure. While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse. In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk. For this reason, the procedure was aborted at the level of the hepatic flexure. She was noted to have some pools of stool. This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes. Additionally, random biopsies were performed of the colon itself. It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum. However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome. The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:, She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures. She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum. She may also benefit from an antispasmodic and/or anxiolytic. Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.

surgery, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy

Colpocleisis and rectocele repair.

Surgery

Colpocleisis

PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:, Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass. On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy. The patient had good anterior support at the bladder. Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed. The patient understood all the risks and benefits and wanted to proceed with the procedure. Risk of retention and incontinence were discussed. Consent was obtained through the family members.,DETAILS OF THE OR:, The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient had a Foley catheter placed. The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support. A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part. Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring. Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive. Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis. Oral consent was obtained from the family and her surgery was preceded. The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors. Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus. The vaginal mucosa was pretty much completely closed off all the way up to the introitus. Indigo carmine was given. Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings. There was no injury to the bladder or kinking of the ureteral openings. The bladder was normal. Rectal exam was normal at the end of the colpocleisis repair. There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.

surgery, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,

Completion thyroidectomy with limited right paratracheal node dissection.

Surgery

Completion Thyroidectomy

TITLE OF OPERATION:, Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:, A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus. Consideration given to completion thyroidectomy. Risks, benefits, and alternatives of this procedure was discussed with the patient in great detail. Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management. The patient understood all of this and then wished to proceed.,PREOP DIAGNOSIS:, Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,POSTOP DIAGNOSIS: , Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,PROCEDURE DETAIL:, After identifying the patient, the patient was placed supine in the operating room table. After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm. Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured. The previous skin incision for a thyroidectomy was then planned, then incorporated into an ellipse. The patient was prepped and draped in a sterile fashion. Subsequently, the ellipse around the previous incision was deformed. The scar was then excised. Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively. Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side. There was some dense fibrosis and inflammation surrounding the right thyroid lobe. Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel. The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly, then preserved. Of note is that there were multiple lymph nodes in the paratracheal region on the right side. These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes. The wound was copiously irrigated. Valsalva maneuver was given. Surgicel was placed in the wound bed. Strap muscles were reapproximated in the midline with 3-0 Vicryl and incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin. The patient was extubated in the operating room table, sent to the postanesthesia care unit in good condition.

surgery, multifocal thyroid carcinoma, thyroid lobectomy, thyroid, papillary, thyroid lobe, isthmus, completion thyroidectomy, thyroidectomy, paratracheal, lobectomy,

Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.

Surgery

Colonoscopy With Photos

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Diverticulosis coli.,2. Internal hemorrhoids.,3. Poor prep.,PROCEDURE PERFORMED:, Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:, None.,HISTORY:, The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.,PROCEDURE:, After proper informed consent was obtained, the patient was brought to the Endoscopy Suite. She was placed in the left lateral position and was given sedation by the Anesthesia Department. A digital rectal exam was performed and there was no evidence of mass. The colonoscope was then inserted into the rectum. There was some solid stool encountered. The scope was maneuvered around this. There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon. The scope was then passed through the transverse colon and ascending colon to the cecum. No masses or polyps were noted. Visualization of the portions of the colon was however somewhat limited. There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls. Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted. The scope was then completely withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.

surgery, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope

A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.

Surgery

Complex Cyanotic Congenital Heart Disease

HISTORY:, The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation. These procedures were performed at Medical College Hospital. Family states that they moved to the United States. Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery. He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg. The QP:QS ratio of 0.6:1. A large decompressing venous collateral was also appreciated. The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta. A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful. Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein. Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire. This catheter then also advanced into the bridging innominate vein. The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava. A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery. There was no vascular continuity to the stump of the right Glenn. The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava. The Bernstein catheter was then reintroduced using a Terumo guidewire. Probing of the superior vena cava facilitated access into the right lower pulmonary artery. The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis. The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length. The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist. This facilitated advancement of a flexor sheath into the proximal portion of the stenosis. A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe. A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist. Angiogram demonstrated a good stent apposition to the caval wall. Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist. Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery. The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery. Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery. Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery. Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist. Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery. The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist. Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter. Repeat angiograms were then performed. Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein. A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter. An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein. Once stable device was confirmed, the device was released from the delivery catheter. The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein. A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION:, Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%. The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen. Remaining saturations reflected complete admixture. There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow. Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending, descending pressures were similar and normal. Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg. The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1. The pulmonary vascular resistance was elevated at 4.4 Woods units. Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg. Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation. There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg. There was an increase in arterial pressure. The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared. Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava. There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient. There was absence of contrast filling of the right middle and right upper pulmonary artery. Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow. Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES: ,1. Asplenia syndrome.,2. Dextrocardia bilateral superior vena cava.,3. Atrioventricular septal defect.,4. Total anomalous pulmonary venous return to the right-sided atrium.,5. Double outlet right ventricle with malposed great vessels.,6. Severe pulmonary stenosis.,7. Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Bilateral bidirectional Glenn shunt.,3. Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES: ,1. Obstructed right caval pulmonary anastomosis.,2. Obstructed right proximal pulmonary artery.,3. Venovenous collateral vessel.,CURRENT INTERVENTION: ,1. Balloon dilation of the right superior vena cava and stent implantation.,2. Balloon dilation of the proximal right pulmonary artery, stent implantation.,3. Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference. A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion. The patient will be maintained on anticoagulant medications of aspirin and Plavix. Further cardiology care will be directed by Dr. X.

A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.

Surgery

Colonoscopy with Biopsy

INDICATIONS FOR PROCEDURE: , A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.,DESCRIPTION OF PROCEDURE: , The patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding. Informed consent was signed by the patient.,With the patient in left decubitus position, had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol, using Olympus video colonoscope under direct visualization was advanced to the cecum. Photodocumentation of appendiceal orifice and the ileocecal valve obtained. Cecum was slightly obscured with stool but the colon itself was adequately prepped. There was no evidence of overt colitis, telangiectasia, or overt neoplasia. There was moderately severe diverticular change, which was present throughout the colon and photodocumented. The rectal mucosa was normal and retroflexed with mild internal hemorrhoids. The patient tolerated the procedure well without any complications.,IMPRESSION:,1. Colonoscopy to the cecum with adequate preparation.,2. Long tortuous spastic colon.,3. Moderately severe diverticular changes present throughout.,4. Mild internal hemorrhoids.,RECOMMENDATIONS:,1. Clear liquid diet today.,2. Follow up with primary care physician as scheduled from time to time.,3. Increase fiber in diet, strongly consider fiber supplementation.

surgery, olympus video colonoscope, advanced to the cecum, heme-positive stools, diverticular change, colitis, colonoscopy to the cecum, spastic colon, colonoscopy with biopsy, liver disease, biopsy, hepatitis, chronic, liver, disease, mucosa, polyp, rectal, colonoscopy,

Small internal hemorrhoids and Ileal colonic anastomosis.

Surgery

Colonoscopy with Biopsy - 2

PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:, The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy. Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day. She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon. The distal ileum was examined, which was normal in appearance. Random biopsies were obtained from the ileum and placed in jar #1. Random biopsies were obtained from the normal-appearing colon and placed in jar #2. Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1. Small internal hemorrhoids.,2. Ileal colonic anastomosis seen in the proximal transverse colon.,3. Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies. If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains.

surgery, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy

The patient with a recent change in bowel function and hematochezia.

Surgery

Colonoscopy with Biopsy - 1

PREPROCEDURE DIAGNOSIS:, Change in bowel function.,POSTPROCEDURE DIAGNOSIS:, Proctosigmoiditis.,PROCEDURE PERFORMED:, Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable. ,INDICATIONS:, The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is here for colonoscopy. He understands the risks and wishes to proceed. ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation. Digital rectal examination was performed, which showed no masses, and a boggy prostate. The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum. In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.

surgery, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,

Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.

Surgery

Colonoscopy with Biopsy - 3

PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.

surgery, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope,

Total colonoscopy with biopsy and snare polypectomy.

Surgery

Colonoscopy & Polypectomy - 3

PREOPERATIVE DIAGNOSIS:, Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:, 4/4.,DIFFICULTY:, 1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:, A 64-year-old male who has developed alternating hard and soft stools. He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding. There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided. Preoperative physical examination was performed. Informed consent was obtained. The patient was placed in the left lateral decubitus position. Premedications were given slowly by intravenous push. Rectal examination was performed, which was normal. The scope was introduced and passed with minimal difficulty to the cecum. This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice. The scope was slowly withdrawn, the mucosa carefully visualized. It was normal in its entirety until reaching the sigmoid colon. Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding. In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp. A snare was placed on the stalk of the polyp and divided with electrocautery. The polyp was recovered and sent for pathologic examination. Examination of the stalk showed good hemostasis. The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease. A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended. In addition, 2 polyps, one of which is assuredly an adenoma. Patient needs a repeat colonoscopy in 3 years.

surgery, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,

Common description of colonoscopy

Surgery

Colonoscopy Template - 1

surgery, decubitus position, cecum, colonic mucosa, ileocecal, rectum, colonoscopy, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Common description of colonoscopy

Surgery

Colonoscopy Template - 3

surgery, left lateral sims position, cecum, mass, lesions, mucosal abnormalities, friability, polyps, endoscopy suite, endoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Common description of colonoscopy

Surgery

Colonoscopy Template - 5

surgery, cecum, colonoscope, digital rectal examination, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Common description of colonoscopy

Surgery

Colonoscopy Template - 4

A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve. This was done without difficulty and the bowel preparation was good. The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal. The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,COMPLICATIONS: , None.

surgery, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Common description of colonoscopy

Surgery

Colonoscopy Template - 2

surgery, cecum, retroflexion, colon, tumor, polyp, mass, ulceration, tip, endoscope, inserted, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Colonoscopy, conscious sedation, and snare polypectomy.

Surgery

Colonoscopy & Polypectomy - 2

PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS: ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy. ,INDICATIONS: ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy. He has had previous colonoscopy. There is no family history of bleeding, no current problems with his bowels. On examination, he has internal hemorrhoids. His prostate is enlarged and increased somewhat in firmness. He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm. These were removed with snare polypectomy technique. I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation. Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%. A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve. The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port. The scope was withdrawn into the left transverse colon, where the second polyp was identified. It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well. The scope was then gradually withdrawn the remaining distance and removed. The patient tolerated the procedure well.

surgery, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy,

Patient with history of adenomas and irregular bowel habits.

Surgery

Colonoscopy - 7

PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1. Two colon polyps, removed.,2. Small internal hemorrhoids.,3. Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with a history of adenomas. She does have irregular bowel habits.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered. The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch. The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum. There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one. There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2. There were small internal hemorrhoids. The remainder of the examination was normal to the cecum. The patient tolerated the procedure well without complication.,IMPRESSION:,1. Two colon polyps, removed.,2. Small internal hemorrhoids.,3. Otherwise normal examination to cecum.,PLAN: , I will await the results of the colon polyp histology. The patient was told the importance of daily fiber.

surgery, colon polyps, internal hemorrhoids, rectum, irregular bowel habits, colon polyps removed, irregular bowel, bowel habits, polyps removed, bowel, habits, colonoscope, hemorrhoids, cecum, forceps, polyps, colonoscopy, adenomas,

Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.

Surgery

Colonoscopy & Esophagogastroduodenoscopy

PREOPERATIVE DIAGNOSES:,1. Hematochezia.,2. Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Colonic polyps at 35 cm and 15 cm.,2. Diverticulosis coli.,2. Acute and chronic gastritis.,PROCEDURE PERFORMED:,1. Colonoscopy to cecum with snare polypectomy.,2. Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURES: ,This is a 43-year-old white male who presents as an outpatient to the General Surgery Service with hematochezia with no explainable source at the anal verge. He also had refractory dyspepsia despite b.i.d., Nexium therapy. The patient does use alcohol and tobacco. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of colonoscopy, the entire length of colon was visualized. The patient was found to have a sigmoid diverticulosis. He also was found to have some colonic polyps at 35 cm and 15 cm. The polyps were large enough to be treated with snare cautery technique. The polyps were achieved and submitted to pathology. EGD did confirm acute and chronic gastritis. The biopsies were performed for H&E and CLO testing. The patient had no evidence of distal esophagitis or ulcers. No mass lesions were seen.,PROCEDURE: ,The patient was taken to the Endoscopy Suite with the heart and lungs examination unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient was placed in the left lateral position where intravenous Demerol and Versed were given in a titrated fashion.,The video Olympus colonoscope was advanced per anus and without difficulty to the level of cecum. Photographic documentation of the diverticulosis and polyps were obtained. The patient's polyps were removed in a similar fashion, each removed with snare cautery. The polyps were encircled at their stalk. Increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized. Good blanching was seen. The polyp was retrieved with the suction port of the scope. The patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site. Diverticulosis coli was also noted. With colonoscopy completed, the patient was then turned for EGD. The oropharynx was previously anesthetized with Cetacaine spray and a biteblock was placed. Video Olympus GIF gastroscope model was inserted per os and advanced without difficulty through the hypopharynx. The esophagus revealed a GE junction at 39 cm. The GE junction was grossly within normal limits. The stomach was entered and distended with air. Acute and chronic gastritis features as stated were appreciated. The pylorus was traversed with normal duodenum. The stomach was again reentered. Retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia. There were no ulcers or mass lesions seen. The patient had biopsy performed of the antrum for H&E and CLO testing. There was no evidence of untoward bleeding at biopsy sites. Insufflated air was removed with withdrawal of the scope. The patient will be placed on a reflux diet, given instruction and information on Nexium usage. Additional recommendations will follow pending biopsy results. He is to also abstain from alcohol and tobacco. He will require follow-up colonoscopy again in three years for polyp disease.

surgery, endoscopy, olympus colonoscope, snare polypectomy, ge junction, refractory dyspepsia, colonic polyps, diverticulosis coli, chronic gastritis, esophagogastroduodenoscopy, snare, biopsies, dyspepsia, gastritis, diverticulosis, polypectomy, colonoscopy, hematochezia, polyps

Colonoscopy to screen for colon cancer

Surgery

Colonoscopy - 6

INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED: ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:, The tip of the endoscope was introduced into the rectum. Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions. The rest of the colon through to the cecum was well visualized. The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified. There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation. Adverse reactions none.,IMPRESSION:, Normal colonic mucosa through to the cecum. There was no evidence of tumor or polyp.

surgery, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy,

Patient with history of polyps.

Surgery

Colonoscopy - 9

PREOPERATIVE DIAGNOSIS:, Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:, Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:, The rectal chamber revealed no external lesions. Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum. The position of the scope within the cecum was verified by identification of the ileocecal valve. Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen. There was not even a scar representing the prior polyp. I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all. The scope was then slowly withdrawn. In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma. It was freely mobile and very small with normal overlying mucosa. There was a similar lesion in the descending colon. Both of these appeared to be lipomatous, so no attempt was made to remove them. There were diverticula present in the sigmoid colon. In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery. There was no bleeding. The scope was then withdrawn. The rectum was normal. When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare. There was no specimen and there was no bleeding. The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1. Small polyps, sigmoid colon, resected them.,2. Diverticulosis, sigmoid colon.,3. Small rectal polyps, obliterated them.,4. Submucosal lesions, consistent with lipomata as described.,5. No evidence of residual or recurrent neoplasm in the cecum.

surgery, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,

Total colonoscopy and polypectomy

Surgery

Colonoscopy & Polypectomy - 1

PREOPERATIVE DIAGNOSIS:, History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:, IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding. He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE: ,The patient was prepped and draped in a left lateral decubitus position. The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum. He had an excellent prep. He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps. He tolerated the procedure well. There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon. His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since. Representative pictures were taken throughout the entire exam. There was no other evidence any problems. On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding.

surgery, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent,

Colonoscopy due to hematochezia and personal history of colonic polyps.

Surgery

Colonoscopy - 5

PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:, Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:, A History and Physical has been performed, and patient medication allergies have been reviewed. The patient's tolerance of previous anesthesia has been reviewed. The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered and informed consent was obtained. Mental Status Examination: alert and oriented. Airway Examination: normal oropharyngeal airway and neck mobility. Respiratory Examination: clear to auscultation. CV Examination: RRR, no murmurs, no S3 or S4. ASA Grade Assessment: P1 A normal healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. The anesthesia plan was to use conscious sedation. Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives. The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure. The physical status of the patient was re-assessed after the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously. The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve. The quality of the prep was good. The patient tolerated the procedure well.,FINDINGS:,1. A sessile, non-bleeding polyp was found in the rectum. The polyp was 5 mm in size. Polypectomy was performed with a saline injection-lift technique using the snare. Resection and retrieval were complete. Estimated blood loss was minimal.,2. One pedunculated, non-bleeding polyp was found in the sigmoid colon. The polyp was 7 mm in size. Polypectomy was performed with a hot forceps. Resection and retrieval were complete. Estimated blood loss was minimal.,3. Multiple large-mouthed diverticula were found in the descending colon.,4. Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1. One 5 mm benign appearing polyp in the rectum. Resected and retrieved.,2. One 7 mm polyp in the sigmoid colon. Resected and retrieved.,3. Diverticulosis.,4. Internal hemorrhoids were found.,RECOMMENDATION:,1. High fiber diet.,2. Await pathology results.,3. Repeat colonoscopy for surveillance in 3 years.,4. The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.

Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.

Surgery

Colonoscopy - 8

PROCEDURES PERFORMED:, Colonoscopy.,INDICATIONS:, Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. Vital signs were monitored by blood pressure, heart rate, and oxygen saturation. Supplemental O2 given. Specifics discussed. Preprocedure physical exam performed. Stable vital signs. Lungs clear. Cardiac exam showed regular rhythm. Abdomen soft. Her past history, her past workup, her past visitation with me for Inflammatory Bowel Disease, well responsive to sulfasalazine reviewed. She currently has a flare and is not responding, therefore, likely may require steroid taper. At the same token, her symptoms are mild. She has rectal bleeding, essentially only some rusty stools. There is not significant diarrhea, just some lower stools. No significant pain. Therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed. Past history reviewed. Specifics of workup, need for followup, and similar discussed. All questions answered.,A normal digital rectal examination was performed. The PCF-160 AL was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice. All mucosal aspects thoroughly inspected, including a retroflexed examination. Withdrawal time was greater than six minutes. Unfortunately, the terminal ileum could not be intubated despite multiple attempts.,Findings were those of a normal cecum, right colon, transverse colon, descending colon. A small cecal polyp was noted, this was biopsy-removed, placed in bottle #1. Random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3. There was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4. There was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with Crohn disease, given the relative sparing of the sigmoid colon and junk lesion. Retroflexed showed hemorrhoidal disease. Scope was then withdrawn, patient left in good condition. ,IMPRESSION:, Active flare of Inflammatory Bowel Disease, question of Crohn disease.,PLAN: , I will have the patient follow up with me, will follow up on histology, follow up on the polyps. She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job. If not, she may be started on immune suppressive medication, such as azathioprine, or similar. All of this has been reviewed with the patient. All questions answered.

surgery, sulfasalazine cortisone local therapy, inflammatory bowel disease, cortisone local, local therapy, crohn disease, sigmoid colon, bowel disease, colonoscopy, inflammatory, rectal, sulfasalazine, cecum, sigmoid, bowel, disease

Colonoscopy - Diarrhea, suspected irritable bowel

Surgery

Colonoscopy - 4

PREOPERATIVE DIAGNOSIS:, Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:, Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:, The rectal exam revealed no external lesions. The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease. The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal. The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:, Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm. These findings are certainly consistent with irritable bowel syndrome.

surgery, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel,

Colonoscopy to evaluate prior history of neoplastic polyps.

Surgery

Colonoscopy - 3

PREOPERATIVE DIAGNOSIS:, Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:, Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:, Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill. I asked the nurse to give her 25 mg of Demerol IV.,Following the IV Demerol, she had a nausea reaction. She was then given 25 mg of Phenergan IV. Following this, her headache and nausea completely resolved. She was then given a total of 7.5 mg of Versed with adequate sedation. Rectal exam revealed no external lesions. Digital exam revealed no mass.,REPORTED PROCEDURE:, The P160 colonoscope was used. The scope was placed in the rectal ampulla and advanced to the cecum. Navigation through the sigmoid colon was difficult. Beginning at 30 cm was a very tight bend. With gentle maneuvering, the scope passed through and then entered the cecum. The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal. The sigmoid colon was likewise normal. There were five very small (punctate) polyps in the rectum. One was resected using the electrocautery snare and the other four were ablated using the snare and cautery. There was no specimen because the polyps were so small. The scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1. Five small polyps as described, all fulgurated.,2. Otherwise unremarkable colonoscopy.

surgery, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope

Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps.

Surgery

Colonoscopy - 21

OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1. Colon cancer screening.,2. Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Multiple colon polyps (5).,2. Diverticulosis, sigmoid colon.,3. Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES: ,Biopsies taken from all polyps. Hot biopsy got applied to one. Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses. Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE: ,The patient was placed in left lateral decubitus after appropriate sedation. Digital rectal examination was done, which was normal. Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen. It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine. Pedunculated polyp next to it was hard to see and there was a lot of peristalsis. The scope then was advanced through rest of the transverse colon to ascending colon and cecum. Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out. Ascending colon was unremarkable. At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen. In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy. Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy. Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy. The rest of the splenic flexure and descending colon were unremarkable. Diverticulosis was again seen with almost constant spasm despite of glucagon. Sigmoid colon did somewhat hinder the inspection of that area. Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large. Excess of air insufflated was removed. The endoscope was withdrawn.,PLAN: , Await biopsy report. Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.

surgery, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy,

Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.

Surgery

Colonoscopy - 18

PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED: ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease. Upon endoscopy, the colon prep was good. We were able to reach the cecum without difficulty. There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions. There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm. This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE: ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position. IV sedation was given by Anesthesia Department. The Olympus videoscope was inserted into anus. Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted. The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel. When the polyp again was visualized, the snare was passed around the polyp. It required at least two to three passes of the snare to remove the polyp in its totality. There was a large stalk on the polyp. ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present. No bleeding was identified. The colonoscope was then removed and patient was sent to recovery room in stable condition.

surgery, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel,