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General Surgery Samples

HERNIA REPAIR

 

PREOPERATIVE DIAGNOSIS:  Right inguinal hernia, reducible.

POSTOPERATIVE DIAGNOSIS:  Right inguinal hernia, direct, reducible.

PROCEDURE: Right inguinal hernia repair with the use of PerFix propylene mesh plug and patch.   

FINDINGS: Cord lipoma.

ANESTHESIA:  General anesthesia via oroendotracheal tube. 

ANESTHESIOLOGIST: 

ESTIMATED BLOOD LOSS:  10 mL.

IV FLUIDS:  1200 crystalloid.

ANTIBIOTICS:  Ancef.

COUNTS: Sponge and needle counts correct.

COMPLICATIONS: None encountered intraoperatively. 

SPECIMENS:  None. 

DRAINS: 

INDICATIONS FOR PROCEDURE: The patient is a 24-year-old African-American male who presents complaining of a right inguinal bulge that has been present for approximately two years.  The patient states the bulge has been increasing in size since that time and causing an increased amount of pain and desires repair of hernia at this time.  

DETAILS OF PROCEDURE:  The patient was brought to the Surgical Suite on July 6, 2005 and placed in a supine position on the Operating Table.  After the uneventful induction of adequate general anesthesia, the patient was orally intubated.  Ancef was given for perioperative antibiotic coverage.  The lower abdomen, groins, inguinal regions, and genitalia were prepped and draped in a standard sterile fashion.  Anatomic landmarks including the pubic tubercle and anterior-superior iliac crest were identified. 

An oblique incision was made about 2 cm superior to the inguinal ligament.  Dissection was carried down through the subcutaneous tissues including Camper’s and Scarpa’s fascia with a combination of sharp and blunt and electrocautery dissection.  External oblique aponeurosis was identified and cleared from the surrounding tissues and opened in a controlled fashion along the course of its fibers down to the external inguinal ring. 

The iliohypogastric nerve was identified and care was taken to not manipulate it.  It was not needed to retract the iliohypogastric nerve.  The ilioinguinal nerve was identified as well and spared.  The contents of the inguinal canal were examined.  The spermatic cord structures were identified and dissected free of the walls of the inguinal canal, encircled with a Penrose drain.  A small direct inguinal hernia was easily identified.  The hernia sac was dissected away from the cord structures bluntly.  Once the hernia was freed, it was then reduced back into the abdominal cavity through the defect in the inguinal floor.  The internal ring was then examined for an indirect hernia which was found to not be present. 

A mesh plug-and-patch technique was chosen. A PerFix polypropylene mesh plug was placed into the defect on the floor of the inguinal canal and expanded to cover the defect and sutured in place with multiple 2-0 Vicryl interrupted sutures. 

A tension-free mesh patch repair was then chosen.  It was performed using a polypropylene patch.  The mesh was sutured inferiorly to the inguinal ligament and superiorly to the conjoined tendon and medially to the pubic tubercle.  We slid the mesh laterally.  It was used to allow the spermatic cord structures to pass into the inguinal canal superficially.  The mesh repair leaflets were then joined with a 2-0 Prolene suture.

The surgical field was copiously irrigated with warm saline.  Excellent hemostasis had been obtained.  The spermatic cord structures, ilioinguinal nerve were allowed to return to their anatomical position in the inguinal canal.  The roof of the inguinal canal was reconstructed by reapproximating the leaflets of the external oblique aponeurosis down to the external inguinal ring using 2-0 Vicryl in a running continuous fashion.  Wound closure was then performed in layers with reapproximating the Scarpa fascia with several interrupted 3-0 Vicryl sutures.  The skin incision was closed with 4-0 Vicryl in a running subcuticular fashion.  Mastisol and Steri-Strips were applied.  A dry sterile dressing was placed over the incision.  The right testicle scrotal position was then confirmed. 

The drapes were removed and the patient was awakened from anesthesia, extubated in the Operating Room without difficulty, and taken to the Recovery Room in stable condition.  The patient tolerated the operation well.   

 

 

 

 

NEUROSURGERY - Left-sided vagal nerve stimulator

 

PREOPERATIVE DIAGNOSIS:  Depression.  

POSTOPERATIVE DIAGNOSIS:  Depression.

PROCEDURE: Placement of left-side vagal nerve stimulator.

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS: None.

ANESTHESIOLOGIST: 

ESTIMATED BLOOD LOSS:  Minimal.  

IV FLUIDS: 

SPECIMENS: 

DRAINS: 

INDICATIONS FOR PROCEDURE:  This patient is a 51-year-old gentleman referred by the Psychiatry Department for evaluation of a possible placement of a vagal nerve stimulator for recalcitrant depression. 

The patient had been medically maximized as far as antidepressants and felt to be a good candidate by the Psychiatry Service. 

The patient was seen preoperatively and the risks, benefits, and alternatives to the procedure were explained to the patient and he wished to proceed. 

DETAILS OF PROCEDURE:  The patient was given 1 g of Ancef preoperatively.  He was then brought to the Operating Room and placed in a supine position.  General anesthesia was begun and the patient was intubated.  A time-out was called and the patient was appropriately identified and the procedure agreed upon. 

The vagal nerve stimulator generator was then tested while it remained in its sterile package with the handheld wand and was shown to be working appropriately.  The patient was then placed in full extension and the planned incisions were marked.

At the same level of the cricoid cartilage overlying the sternocleidomastoid, a 4-cm transverse incision was marked out in a relaxed skin tension line also along the anterior axillary fold on the left.  The planned incision was marked extending along the overlying skin tension line as well. This was approximately two fingerbreadths below the clavicle.  The planned incisions were then infiltrated with 1% lidocaine with epinephrine for a total of 10 ml.  The Operating Table was rotated 180 degrees.  The patient was then prepped in a sterile fashion.  An Ioban sterile drape was also placed over the operative sites to prevent contact of any of the hardware with the skin.  The neck was addressed first. 

Again, a transverse incision was made through the skin, subcutaneous fat, and platysma muscle.  The external jugular vein was identified and preserved.  Superiorly based subplatysmal flap was raised approximately 2 cm.  This allowed identification of the fascia overlying the sternocleidomastoid muscle to be identified.  The anterior border of the sternocleidomastoid muscle was then further defined with blunt and sharp dissection.  The sternocleidomastoid muscle was then retracted and with palpation, the carotid artery was palpated.  Again, using blunt dissection, the internal jugular vein was identified.  Dissection was then carried medial to the internal jugular vein and the carotid sheath contents were entered.  As the internal jugular vein was retracted laterally, the carotid was seen deep and medially.  Between the internal jugular vein and the carotid artery, the vagus nerve was identified.  The vagus nerve was further skeletonized with care to avoid any damage to the nerve.  A nerve hook was then used to retract the vagal nerve and approximately 4 cm of the vagus was skeletonized in the field.  A moist sponge was then placed in the neck to prevent desiccation of the vagus nerve. 

Attention was now drawn to the chest.  The incision was then made with a 15 blade through the skin, subcutaneous fat, directly onto the fascia overlying the pectoralis major muscle.  Using blunt dissection, approximately a 3 x 3-cm pocket was made, again in a subcutaneous plane.  Hemostasis was achieved with electrocautery.  Now, using the provided tunneling device, the neck incision and the chest incision were connected with the plastic sheath and tunneling device.  The dissection was carried from the neck incision towards the chest incision to prevent any damage to the vessels in the neck.  This went superficial to the clavicle.  Examination through the chest revealed the end of the tunneling device and there was now connection between the neck and chest incision.  The still shaft of the tunneler was then removed, leaving the plastic sheath in place.  The electrode was now brought into the surgical field.  It was threaded through the plastic sheath and now the sheath was removed from the chest side bringing the electrode through the chest incision.  Now, the electrode is in neck and the connecting pin is in the chest all connected beneath the skin overlying the clavicle. 

Attention was now drawn towards placement of the electrodes on the vagal nerve.  The negative and positive electrodes as well as the ground were all placed carefully on the vagus nerve in appropriate fashion.  Again, care was taken to avoid handling of the nerve and also the electrodes were not handled, rather they were handled with DeBakey’s at their sutures only.  Again, care was taken to avoid damage to the electrodes.  Now, the electrodes were placed adequately on the nerve.  The locking pin in the chest was then connected to the vagal nerve generator.  The wand was now sterilely draped and it was placed over the device and it showed adequate functioning of the vagal nerve stimulator.  A 0.25 milliampere was delivered.  The patient had no adverse affects and the device was then turned off. 

The electrodes were now secured to the cervical fascia with the fasteners provided within the vagal nerve kit.  A strain-loop was also created and sutured to the sternocleidomastoid muscle with silk ties.  The vagal nerve generator device was also placed in the subcutaneous pocket in the chest.  Prior to closure of the skin, the device was tested one more time, again it was appropriately working.  The platysma of the neck was closed with Vicryl.  The deep dermis was closed with Vicryl.  The skin edges were reapproximated with Prolene in a running fashion.  The chest was closed with two layers.  Staples were used for the skin.  The patient tolerated the procedure well.  He was aroused from anesthesia and extubated.  He was sent to the Recovery Room in stable condition.  The patient’s information regarding the vagal nerve device as well as the serial number and future magnets were all provided to the patient’s wife in the Waiting Room.  

 

FACET BLOCK

PREOPERATIVE DIAGNOSIS:  Low back pain.

POSTOPERATIVE DIAGNOSIS:  Low back pain.

OPERATION:  Facet block.

ESTIMATED BLOOD LOSS:  None.

DRAINS:  None.

COMPLICATIONS:  None

SPECIMEN:  None.

INDICATIONS:  This is a 58-year-old woman with a history of low back pain refractory to conservative management. She was indicated for blocks. Risks of neurovascular damage and infection were discussed and she accepted these risks. We proceeded with intervention.

PROCEDURE:  The patient was placed prone on the fluoroscopic table. Her back was prepped with Betadine solution and sterile draping was performed. Two 22-gauge spinal needles were placed under fluoroscopic control at L4-5 and L5-S1 bilaterally and a mixture of 2 ml of 0.25% Sensorcaine and 2 ml of 1% lidocaine without epinephrine and 80 mg of Depo-Medrol were divided on both sides. After the needles were removed the patient stated pain had been improved. Sterile band-aids were placed and she was mobilized to the recovery area

VARICOSE VEIN EXCISION

PREOPERATIVE DIAGNOSIS: Symptomatic varicose veins, right leg.   

POSTOPERATIVE DIAGNOSIS: Symptomatic varicose veins, right leg. 

OPERATION: Ligation of saphenous vein and excision of varicose veins, right leg. 

ANESTHESIA: General anesthesia.

PROCEDURE: The patient was taken to the operating room and placed under general anesthesia through an LMA. The patient’s right leg was prepped and draped in the usual sterile fashion.

An incision in the groin crease was made sharply and the saphenofemoral junction was dissected out. Branches were hemoclipped and the main saphenous vein and the lateral accessory were suture ligated with 3-0 Prolene sutures. The incision was closed with 4-0 Vicryl subcuticular sutures and Steri-Strips.

The varicose veins were approached through multiple short stab incisions in the anterior-lateral thigh and lateral knee area. Varicose veins were dissected out bluntly and then evulsed. Hemostasis was maintained with pressure. These incisions were closed with Steri-Strips. A gauze dressing and Ace bandage were applied.

 

 

PORT-A-CATH PLACEMENT

PREOPERATIVE DIAGNOSIS: The patient will be undergoing chemotherapy starting December 28, 2005. The patient needs vascular access.

POSTOPERATIVE DIAGNOSIS: The patient will be undergoing chemotherapy starting December 28, 2005. The patient needs vascular access.

OPERATION:  Port-A-Cath placement.

ALLERGIES: The patient has no known drug allergies.

ESTIMATED BLOOD LOSS: Estimated blood loss was 10 ml.

INTRAVENOUS FLUIDS: Fluids given were 600.

COMPLICATIONS: There were no complications.

ANESTHESIA: MAC anesthesia and local.

INDICATIONS: The patient will be undergoing chemotherapy starting December 28, 2005. The patient needs vascular access. The patient presents to the operating room on December 27 for a scheduled Port-A-Cath placement.

PROCEDURE: The patient was given MAC anesthesia as well as 8 ml of Marcaine local. The patient was then prepped and draped in the standard sterile fashion in the left subclavian area. The left subclavian vein was accessed using an 18-gauge needle. A guidewire was then inserted and the needle was removed. A 3-cm incision was then carried next to the wire. A pocket was then formed underneath in the subcutaneous tissues for the Port-A-Cath. Hemostasis was achieved. The Port-A-Cath was flushed and then inserted in the pocket in the left anterior chest. A dilator was then introduced in the vein over the guidewire. The dilator was removed along with the guidewire. The catheter was then threaded into the subclavian vein. The Port-A-Cath was then aspirated with a good return of blood and then flushed with no resistance. A chest x-ray was then performed intraoperatively which showed the catheter tip to be at the junction of the superior vena cava in the right atrium. There was also no evidence of pneumothorax. The subcutaneous tissue was then reapproximated using 3-0 Vicryl. The skin was then closed using a running subcuticular 4-0 Monocryl stitch. A Huber needle was then inserted into the Port-A-Cath through the skin. Blood was aspirated and heparin was flushed with no resistance. A Tegaderm dressing was then placed over the Huber needle apparatus. Estimated blood loss was 10 ml. Fluids given were 600. There were no complications. Dr. XX was present and scrubbed throughout the entire procedure. The patient will be discharged with Lortab for pain. The patient is to follow up with Dr. XX in 2 weeks time.