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Abdominal-Perineal Resection

OPERATIVE NOTE:  The patient was taken to the operative suite.  Following the induction of adequate general endotracheal anesthesia, he was placed supine position and his abdomen was prepped and draped in a sterile fashion.  A midline incision was made and taken down to the pubic bone.  The peritoneal cavity was entered. The sigmoid loop was mobilized by incising the lateral peritoneal reflection.  The left ureter was identified and protected throughout the case.  The incision was carried down to the floor of the pelvis and then anteriorly across the rectosigmoid colon.  Likewise, an incision was made over the right aspect of the sigmoid mesocolon.  This joined the incision in the peritoneum over the anterior surface of the rectosigmoid colon.  The inferior mesenteric artery was identified, as was the left colic artery.  The vascular pedicle was ligated distal to the take off of the left colic artery.  The sigmoid mesocolon was sequentially divided between clamps and ligated with 2-0 silk ties.  Hemoclips were also utilized down to the area of the sacral promontory. Using blunt dissection, the rectum was elevated from the hollow of the sacrum laterally on both sides.  The lateral ligaments and middle hemorrhoidal vessels were identified.  These were hemoclipped anteriorly.  A plane was developed between the rectum and the bladder.  Dissection of this segment of colon was taken down to the tip of the coccyx.  It was felt this was adequate to complete the procedure from below.  The rectosigmoid colon was divided using the TA staple instrument.  The distal stump was placed down into the pelvis.  This was irrigated and packed.  The proximal colon was inspected. There were several lymph nodes of the mesentery and a further segment of the sigmoid colon measuring approximately 6-7 cm was resected so that the mesentery could include these lymph nodes.  This left the sigmoid colon with an adequate length for the colostomy.  The pelvis was inspected and there was really no evidence of active bleeding.  The perineum was approximated to recreate the pelvic floor using a running #1 Vicryl suture.  A defect was made in the left lower quadrant through the rectus muscle, not far above the inguinal ligament.  A button of skin was excised and the fascia was incised.  The muscle was separated.  The posterior rectus sheath was opened.  The opening allowed two fingers.  The sigmoid colon was then pulled through the abdominal wall defect.  The fascia was approximated in the midline using interrupted #1 Vicryl suture.  The skin was approximated using skin staples. The colostomy was matured with interrupted 3-0 Vicryl sutures.  The patient was then placed back in the dorsal lithotomy position, exposing the anus and perineal area, which were then prepped and draped.  The anus was closed with a running #1 Vicryl suture.  An elliptical incision was made oriented in a vertical fashion, extending to 2.5 cm outside the anal verge.  This was taken through the soft tissue laterally.  The levator ani muscles were identified laterally and posteriorly.  These were divided using the electrocautery device.  The perineal dissection met with the pelvic dissection.  The stump of the rectosigmoid colon was flipped out.  Remaining attachments were divided laterally.  Dissection was undertaken anteriorly and a plane was developed between the bladder and rectum.  All remaining attachments were divided and the specimen was removed.  The wound was packed and irrigated. Hemostasis appeared adequate.  A 10-mm Jackson-Pratt drain was brought through a separate stab wound posteriorly and placed down into the pelvic space.  Likewise, a 1-inch Penrose drain was placed in the pelvic space and brought out through a separate stab wound on the other side.  The levator muscles were approximated in the midline using interrupted #1 Vicryl suture in two layers.  Subcutaneous tissue was approximated using interrupted 0 Vicryl suture.  The skin was approximated with staples.

 

Appendectomy

TECHNIQUE:  Under spinal anesthesia, the patient was prepped and draped in a sterile technique for exploratory laparotomy.  A Rocky-Davis incision was made in the right lower quadrant of the abdomen. Skin and subcutaneous tissues were divided.  Bleeding points were clamped and electrocoagulated, or ligated with 3-0 plain catgut. The anterior rectus muscle fascia was opened and the muscle retracted medially.  The posterior fascia and peritoneum were opened, exposing the abdominal cavity.  The appendix was grasped with a Babcock clamp and the mesoappendix was divided and ligated with 2-0 chromic catgut.  The base of the appendix was ligated with 2-0 chromic catgut and the appendix was removed.  The stump of the appendix was treated with phenol and alcohol, and inverted with a pursestring of 2-0 chromic catgut. Cultures were taken from the area.  After the cavity was irrigated with irrigation solution, the cavity was closed using 0 Vicryl running suture in the posterior fascia and peritoneum, 2-0 Vicryl in the anterior fascia, 2-0 chromic catgut in the subcutaneous tissue, and 4-0 nylon mattress sutures in the skin.  A dressing was applied.  No drains were left.  The patient tolerated the procedure well and left the operating room in good condition.  Estimated blood loss was minimal.

 

Bone marrow aspiration and biopsy

The procedure and complications were explained and consent was signed. The patient was placed in the right lateral position and the left posterior iliac crest area was cleaned with Betadine and draped with sterile gauze.  Using 1% lidocaine, the skin and periosteum were anesthetized.  A small stab wound was made.  Using a bone marrow aspiration needle, bone marrow aspiration was done with a good specimen obtained.  The aspirate was sent for immunophenotyping for lymphoma and leukemia panel.  Using a bone marrow biopsy needle, bone marrow biopsy was done with a good specimen obtained.  The procedure was done with aseptic technique and accomplished without complications.  A dressing was applied.  The patient was placed on his back to keep pressure for 15 minutes.

 

Breast Biopsy

OPERATIVE TECHNIQUE:  With the patient in supine position and under monitored anesthesia care, the right breast area was prepped and draped in routine sterile fashion.  Using 1% Xylocaine for local infiltration anesthesia, a curved incision was made between the point of entry of the localizing wire and the circumareolar margin of the nipple.  Hemostasis was obtained with cautery.  Cutaneous flaps were developed on either side of the incision, and the wire was retrieved.  The wire, together with the subjacent breast tissue, was excised.  The specimen was sent to the radiologist, who confirmed  removal of the cluster of microcalcifications.  Permanent sections are pending.  Hemostasis was obtained throughout with cautery.  The wound was closed around a 1/4-inch Penrose drain using multiple subcuticular sutures of 4-0 Vicryl.  A dry dressing was applied.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.

 

 

Dialysis Graft Declotting

OPERATIVE NOTE:  The patient was taken to the operative suite and placed in supine position on the operating table.  The right arm was abducted onto the extremity table, and prepped and draped in a sterile fashion.  Lidocaine was used as a local anesthetic.  A small incision was made over the apex of the graft.  The graft was identified and isolated.  A transverse incision was made across the graft.  The graft was full of thrombus.  A #3 Fogarty catheter was used to clear the arterial limb of all thrombus.  Inflow was excellent.  This limb was heparinized and clamped.  The venous limb was freed of all thrombus, and this limb was heparinized and clamped.  The graft incision was closed using running 5-0 Prolene suture.  Following release of the clamps, there was good flow around the graft.  Hemostasis was achieved using Surgicel and thrombin.  The wound was closed using interrupted 3-0 Vicryl suture and interrupted 3-0 nylon suture.  The patient tolerated the procedure well.

Herniorrhaphy

OPERATIVE TECHNIQUE:  With the patient in the dorsal recumbent position and under general anesthesia, the right inguinal area was prepared and draped in routine sterile fashion.  A small transverse incision was made overlying the inguinal canal.  Hemostasis was obtained with cautery.  The underlying cord structures and sac were dissected out and cleared up to the internal ring.  The neck of the sac was circumcised.  The sac was closed with a ligature of 4-0 Ethibond and a suture ligature of 4-0 Ethibond, and excised.  The subcutaneous tissues were approximated with 4-0 Vicryl.  The skin edges were apposed with Steri-Strips.  A small, dry, waterproof dressing was applied.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.


OPERATIVE DESCRIPTION:  With the patient in the supine position and under spinal anesthesia, the left inguinal area was prepped and draped in routine sterile fashion.  An oblique incision was made overlying the inguinal canal.  Hemostasis was obtained with cautery.  The underlying external oblique aponeurosis was opened in the lines of the fibers down to the upper margin of the external inguinal ring.  The cord structures together with the ilioinguinal nerve were identified and preserved.  The sliding properitoneal fat along the lateral aspect of the cord was dissected up to the internal ring, where it was suture ligated with 2-0 Prolene and amputated.  The sac was closed with a pursestring suture of 2-0 Prolene and amputated.  A large plug of Marlex mesh was used to close the internal ring.  This was anchored in place with interrupted sutures of 2-0 Prolene.  A sheet of Marlex mesh, which had been cut to an appropriate configuration, was then placed to reinforce the posterior wall of the inguinal canal with the tail surrounding the cord laterally.  This was anchored in place with interrupted sutures of 2-0 Prolene.  The cord was replaced into the inguinal canal and the external oblique aponeurosis was closed using continuous sutures of 2-0 Prolene.  The subcutaneous tissues were approximated with 4-0 Vicryl.  The skin edges were apposed using a continuous subcuticular suture of 4-0 Vicryl.  A dry dressing was applied.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.


Laparoscopic Cholecystectomy

OPERATIVE TECHNIQUE:  With the patient in the dorsal recumbent position and under general endotracheal anesthesia, the abdomen was prepared and draped in routine sterile fashion.  A small transverse incision was made immediately above the umbilicus.  Hemostasis was obtained with cautery.  The midline fascia was opened between stay sutures of 0 Vicryl, and the peritoneum was entered.  A Hasson cannula was introduced and pneumoperitoneum was achieved using carbon dioxide.  The patient was placed on the left side and in the reverse Trendelenburg position, and a 10-mm cannula was introduced to the right of the midline below the xiphoid.  Two 5-mm cannulae were placed, one in the midclavicular line and the other in the anterior axillary line.  The fundus of the gallbladder was grasped, elevated, punctured percutaneously, and aspirated.  The punctured fundus of the gallbladder was closed with an Endoloop and displaced cephalad.  The neck of the gallbladder was displaced caudad, and the cystic artery and duct were dissected out.  Both structures were clipped twice on the common duct side, once against the gallbladder, and divided.  The gallbladder was removed from the adjacent liver bed using cautery for hemostasis.  The gallbladder was placed in an Endosack and retrieved through the umbilicus.  Additional hemostasis was obtained with cautery.  The wound was irrigated with warm saline until a clear return was obtained.  All cannulae were removed under direct vision and there was no continued bleeding from any puncture site.  The fascial incision at the umbilicus was closed with interrupted sutures of 0 Vicryl.  All wounds were closed using multiple subcuticular sutures of 4-0 Vicryl.  Skin edges were supported with Steri-Strips.  Small, dry, waterproof dressings were applied.  The patient tolerated the procedure well and was returned to the recovery in stable condition.

 

OPERATIVE PROCEDURE:  The patient was taken to the operative suite and placed in supine position on the operating table.  His abdomen was prepped and draped in a sterile fashion.  A subumbilical incision was made.  Stay sutures of 2-0 Vicryl were placed in the fascia, and the fascia was incised.  The peritoneal cavity was entered using a Visiport.  Pneumoperitoneum was established.  The laparoscope was introduced.  A 10-mm operating sheath was introduced to the right of midline in the epigastric area, and two 5-mm operative sheaths were introduced in the subcostal region under direct visualization.  Clamps were placed on the fundus and neck of the gallbladder for traction.  Dissection of the triangle of Calot was undertaken.  The cystic duct was identified at its junction with the gallbladder, clipped twice proximally, once distally, and divided.  Likewise, the cystic artery was clipped and divided.  The gallbladder was harvested from its fossa using scissors and the electrocautery device, taking care to achieve hemostasis as the dissection progressed.  The gallbladder was removed through the umbilical fascial defect.  Irrigation of the subhepatic space did not reveal any bleeding.  The sheaths were removed under direct visualization.  There was no bleeding from the anterior abdominal wall.  Pneumoperitoneum was released. The fascia was approximated using interrupted 2-0 Vicryl sutures. Subcutaneous tissue was approximated using interrupted 3-0 Vicryl sutures. The skin was approximated using skin staples.  The patient tolerated the procedure well.

 

Port-A-Cath Placement


PROCEDURE IN DETAIL:  The patient was taken to the operating room and placed on the operating table in the supine position.  IV sedation was obtained without difficulty.  She was prepped and draped in routine sterile fashion.  Lidocaine 1% without epinephrine was used for local infiltration. The right subclavian vein was cannulated and a wire was inserted into the superior vena cava.  Fluoroscopy was used to confirm position of the wire.  A dilator and peel-away sheath were placed over the wire, and the wire and dilator were removed.  A catheter was inserted into the superior vena cava, and the peel-away sheath was removed.  The catheter was connected to a port and flushed and aspirated easily.  It was flushed with heparin.  Fluoroscopy once again confirmed position of the catheter.  Attention was placed at securing the port to the subcutaneous tissues, which was done with 3-0 Prolene in an interrupted fashion.  Subcutaneous tissues were approximated with 4-0 Vicryl in an interrupted fashion.  Skin edges were approximated with a 4-0 subcuticular Vicryl stitch.  Steri-Strips and sterile dressings were applied.  Chest x-ray was obtained at the end of the procedure, which showed the Port-A-Cath to be in good position with no pneumothorax.  The patient tolerated the procedure well and was transported back to the outpatient department in stable condition.