Cystoscopy with right ureteroscopy and laser lithotripsy with stone basketing and right ureteral stent placement

PREOPERATIVE DIAGNOSIS:  Right ureteral stone.

POSTOPERATIVE DIAGNOSIS:  Right ureteral stone.

OPERATION PERFORMED: 

Cystoscopy with right ureteroscopy and laser lithotripsy with stone basketing and right ureteral stent placement.

OPERATIVE FINDING:  Right ureteral stone.

SPECIMEN:  Right ureteral stone.

COMPLICATIONS:  None.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  None.

PROCEDURE IN DETAIL:  The patient was brought to the operating room, placed in the operating room table.  After general anesthesia and IV Levaquin was given he was put in lithotomy position.  The external genitalia was prepped and draped in standard surgical fashion.  A #22-French cystoscope was introduced into his bladder.  His anterior urethra and prostate were within normal limits.  The bladder was then entered, there were no suspicious lesions, stones or foreign bodies.  Attention was turned to the right ureteral orifice, a sensor wire was used to intubate the right ureter.  This was passed proximally all the way up into the kidney is visualized under fluoroscopy.  At this point the cystoscope was removed while leaving the sensor wires in place.  A short semirigid ureteroscope was then passed into the bladder and into the distal right ureter.  The calculus was visualized.  There was small area of stricturing just distal to the stricture.  There were small area of stenosis just distal to the stone that was easily negotiated with the ureteroscope after the stone was visualized with a 325 micron fibre was used to fragment the stone into smaller pieces.  A 0-tip 3-wire basket was then used to extract all the stone fragments and the ureter was _____ and the specimen labeled right ureteral stone.  At this point #22-French cystoscope was then back loaded over the sensor wire, a 6x24 double-J ureteral stent were then passed through the cystoscope up the wire into the right kidney when the sensor wire was removed the proximal end of the ureteral stent was seen to coil in the renal pelvis under fluoroscopy and the distal end of the stent was seemed to coil in the bladder under cystoscopic vision.  The bladder was then emptied and the cystoscope was removed.  The ureteral stent was left with the string attached and this was brought out to the phallus.  There were no complications.  He was awaken and transported to the recovery room in stable condition.

Robotic-assisted right ureterolysis

DISCHARGE DIAGNOSIS:  Proximal right ureteral stricture with retrocaval ureter.

PROCEDURES:  Robotic-assisted right ureterolysis.

BRIEF HISTORY:  This is an 80-year-old female with a history of dementia, hypothyroidism, and spinal stenosis who was initially admitted to the West Boca Medical Center in 08/2008 after a fall.  She had continued pain along the left side along with gross hematuria which prompted a CAT scan of her abdomen and pelvis.  The CAT scan of her abdomen and pelvis revealed a calculus in the right ureter with severe proximal right hydronephrosis, perinephric stranding, and periureteral inflammation.  She was observed overnight; however, pain did not subside, and she was taken to the operating room on 08/31/08.  A right ureteroscopy was performed which revealed a markedly tortuous right ureter with medial deviation, and it was unable to be stented from below.  She required a percutaneous nephrostomy tube for renal drainage on the right side that day.  Additionally, multiple times by interventional radiology was unsuccessful at bypassing the stricture in an antegrade fashion.  She was subsequently discharged and brought back to the hospital on 10/01/08 for a repeat attempt of right ureteroscopy.  We were unable to bypass the stenosis, tortuosity, and stricture of her right ureter in a retrograde fashion as well as an antegrade fashion down her nephrostomy tube tract.  The patient and family was consented in all the risks, benefits, alternatives were explained and they agreed to undergo a robotic-assisted laparoscopy right-sided ureteroureterostomy and ureterolysis for this obliterative stricture of her ureter.

PAST MEDICAL HISTORY:  Alzheimer’s dementia, hypothyroidism, and spinal stenosis.

ALLERGIES:  None.

MEDICINES:  Naprosyn, temazepam, Actonel, gabapentin, Namenda, Synthroid, Razadyne, and Aricept.

SOCIAL HISTORY:  Denies alcohol or drug use.  She currently lives with her daughter, although has been under rehab facility more recently.  Her daughter’s name is Alda Keene, and the phone number for her is 561-483-4348.

FAMILY HISTORY:  Denies history of renal disease, ureterolithiasis, and nephrolithiasis.

HOSPITAL COURSE:  On 10/29/08, the patient underwent a robotic-assisted laparoscopic ureterolysis with replacement of her nephrostomy tube.

SURGICAL FINDINGS:  A dilated ureter that course proximally and medially.  It appeared as if the ureter was completely encompassed by a dense inflammatory area of desmoplastic reaction with possible location in a retrocaval fashion.  At this point, we felt we would be putting the patient in excess harm to carry dissection behind the inferior vena cava and decided to leave her with an indwelling nephrostomy tube.  She tolerated the procedure well and there were no operative complications.  She recovered uneventfully.  At the time of discharge, she had a creatinine of 0.5 and a hemoglobin and hematocrit of 10.1/29.8.  There was no discharge medication.  She was sent back to her rehab facility with an indwelling right nephrostomy tube.  The patient’s family and I discussed that should they want further workup, MR urogram could be performed to further delineate the course of her ureter, and I did refer them for a second opinion should they want further surgical intervention to address her ureter.  I explained to them what our surgical findings were and that there was indeed a possibility of her having a retrocaval ureter which although may have not caused her issue for her lifetime.  A small stone may have lodged itself in the ureter causing a stricture and perinephric inflammation.  At this point, the family said they would like to avoid other interventions or satisfy with leaving the nephrostomy tube in place.  The patient was given instructions how to care for the nephrostomy tube and for the urine bag.  She was discharged to rehab in stable condition.  They will follow up with me as an outpatient to either arrange for serial nephrostomy tube changes or to discuss further evaluation and workup should they desire.

Left laparoscopic radical nephrectomy

PREOPERATIVE DIAGNOSIS:  Left renal mass.

POSTOPERATIVE DIAGNOSIS:  Left renal mass.

OPERATION PERFORMED:  Left laparoscopic radical nephrectomy.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  300 mL.

DRAINS:  Foley catheter.

SPECIMENS:  Left kidney.

COMPLICATIONS:  None.

PROCEDURE IN DETAIL:  The patient was brought to the operating room and placed on the operating room table.  After general anesthesia and antibiotics were given, a Foley catheter was placed.  He then was placed in the lateral decubitus position with left side up.  Care was taken to pad all pressure points and joints.  Axillary roll was placed to protect his brachial plexus.  Additionally pillows had been placed between the legs.  Care was not taken not to have undue pressure on his shoulders, elbows, or his cephalus.  The abdomen was then prepped and draped in the standard surgical fashion.  Attention was turned to performing a horizontal 7 cm incision just above the umbilicus.  This was carried down to the skin and subcutaneous tissues.  The fascia was then identified and opened with Mayo scissors.  The fascia was then opened, the peritoneum was then entered, and the incision was further opened.  The Gelport hand-access device was placed into the incision.  Pneumoperitoneum was created through this port up to 15 mmHg.  Attention was then turned to _____ placing additional ports.  A 12-mm port was placed in the right lower quadrant.  Additionally, a 5-mm port was placed in the subxiphoid area for the camera, and an additional 12-mm assistant trocar was placed in between the camera port and the Gelport.  Using manual retraction and Harmonic scalpel the white line of Toldt was incised.  The left colon was then reflected all the way from the pelvic rim inferiorly all the way up to the spleen superiorly.  The splenorenal ligaments and splenocolic ligaments was divided.  Care was taken to not enter the spleen.  Further dissection was carried out medially until the ureter and gonadal vein was identified.  The ureter was dissected from surrounding structures.  The gonadal vein was then traced superiorly until its insertion into the renal vein was visualized.  The gonadal vein was doubly clipped and divided with Hem-o-lok clips.  The adrenal vein was then identified inserting into the left renal vein.  This was clipped and divided with Hem-o-lok clips.  The renal vein was completely isolated from the surrounding structures.  Posterior to the renal vein, the renal artery was identified.  A single Hem-o-lok clip was then placed to occlude the artery.  At this point, the renal vein was divided with endovascular GIA stapler device.  Following transection of the renal vein additional Hem-o-lok clips were placed on the renal artery.  Three clips were left on the patient’s side and one clip was left on the specimen side.  This was divided with EndoShears.  Attention was then turned to fraying the kidney further medially from the psoas muscle and hilar structures.  This was performed with Harmonic shears.  Similarly, the lateral attachments and posterior attachments were taken down.  The upper pole was also removed.  Care was taken down to enter the spleen over the stomach.  Additionally, care was taken to not enter the tail of the pancreas.  The adrenal gland was resected with the specimen as this was an upper pole to mid pole tumor.  The kidney was then freed from all the surrounding structures and it was removed from the hand port site, and it was passed off as a specimen labeled left kidney.  Hemostasis was then obtained.  The hilum and upper pole was inspected.  Surgicel material was placed in the adrenal bed remnant and upper pole.  Excellent hemostasis was obtained at the end of the case.  The lap counts were correct.  Obviously, prior to the kidney removal, the ureter was doubly clipped and divided.  Attention was then turned to closing the trocar site.  The right lower quadrant site was closed with a fascial closure device under laparoscopic vision.  Similarly, the 12-mm assistant port was then closed with the fascial closure device and a 0 Vicryl stitch under its laparoscopic vision.  The 5-mm trocar was removed under direct vision.  There was no bleeding.  Attention was then turned to closing the hand port at the midline, 0 PDS was used to close the fascia and peritoneum in a running suture, 2-0 chromic was used to re-approximate the subcutaneous fascial layer.  The skin incisions were closed with running 4-0 Monocryl.  Steri-Strips were applied and bandages were placed.  The patient was awake from anesthesia, transported to recovery room in stable condition.  There were no complications.

Left ureteroscopy, laser lithotripsy, and stent placement.

PREOPERATIVE DIAGNOSIS:  Left ureteral stone.

POSTOPERATIVE DIAGNOSIS:  Left ureteral stone.

OPERATION PERFORMED:

Left ureteroscopy, laser lithotripsy, and stent placement.

ANESTHESIA: General by LMA.

INDICATIONS:  The patient is an 80-year-old man with a history of previous kidney stone who presented through the Emergency Room several days ago with left renal colic.  The patient was found to have a 7-mm stone in the mid-to-proximal ureter.  He did well and was sent home, but came back because of constipation and more abdominal pain.  On the recent repeat CT scan, it was found that the stone had migrated in the distal ureter.  The patient was therefore recommended ureteroscopy, laser lithotripsy, and stent placement.  Risks and possible complications were discussed with him in detail including excessive bleeding, infection, retained stone fragment, damage to internal organ etc.  He understood that we would only be treating his ureteral stone, not the renal stone.  He agreed to proceed.

PROCEDURE IN DETAIL:  The patient was taken to the operating room.  He was given 500 mg of IV Levaquin.  He was given a general anesthetic by LMA and positioned on the operating table in the dorsal lithotomy.  His genitalia are prepped and draped in the usual sterile fashion.  The 22-French cystourethroscope was placed through the urethra into the bladder.  The urethra was normal, prostatic urethra was with moderate trilobar hypertrophy and visual obstruction.  The bladder itself was entirely normal and the left ureteral orifice was identified and cannulated with a 0.038 flexible glide wire under direct and fluoroscopic guidance.  No radiopaque stone was seen.  The wire was manipulated past the stone up the left ureter.  Subsequently, the left ureter was passively dilated with the inner sheath of the ureteral access sheath.  Once this was done, a mini ureteroscope was placed alongside the safety wire up the left ureter to the level of the stone.  The stone was identified.  The patient had a large stone in distal ureter.  Using the holmium laser, the stone was pulverized and fragmented in multiple small fragments, which were subsequently pulled using a stone basket.  At the completion of the procedure, the distal third of the ureter was reexamined.  There were no other stones seen.  At this point, a 6 French x 22 cm double-J stent was placed under direct and fluoroscopic guidance up the left ureter and left indwelling.  The patient’s bladder was drained.  He was awakened and taken to the recovery room in stable condition.  There were no complications.  Estimated blood loss was minimal.

Cystoscopy and TURBT

PREOPERATIVE DIAGNOSIS:  Bladder tumor.

POSTOPERATIVE DIAGNOSIS:  Bladder tumor.

PROCEDURE:  Cystoscopy and TURBT.

ANESTHESIA:  General.

INDICATIONS:  The patient is a 93-year-old man found to have gross painless hematuria.  The patient was found to have a large bladder tumor and recommended TURBT.  Risks and possible complications were discussed with him in detail.  He understood and agreed to proceed.

FINDINGS:  Normal penile urethra, prostatic urethra with trilobar hypertrophy, and visual obstruction.  The patient had a very large bladder tumor located on the trigone just posterior to the median lobe.  The remainder of the bladder was normal.

PROCEDURE IN DETAIL:  The patient was taken to the operating room.  He was given 500 mg of IV Levaquin.  He was given a general anesthetic by LMA and positioned on the operating table in the dorsal lithotomy.  His genitalia are prepped and draped in the usual sterile fashion.  The 22-French cystourethroscope was placed through the urethra into the bladder.  The bladder was thoroughly examined and findings as noted above.  Subsequently, the 27-Fernch resectoscope sheath was placed and the tumor was resected.  The tumor was resected down to the bladder muscle.  It became apparent that the tumor was invading deep into the bladder, and the resection was stopped when it was felt that we would never be able to completely resect this tumor.  Specimens were irrigated out of the bladder.  The bases of the tumor were then cauterized with electrocautery.  Adequate hemostasis had been achieved.  A 20-French Foley catheter was placed in the bladder and left indwelling.  The patient was awakened and taken to the recovery room in stable condition.  There were no complications.  Estimated blood loss was minimal.

Laparoscopic cholecystectomy

PREOPERATIVE DIAGNOSES:  Biliary colic and chronic  cholecystitis.

POSTOPERATIVE DIAGNOSES:  Biliary colic and chronic cholecystitis.

PROCEDURE:  Laparoscopic cholecystectomy.

ANESTHESIA:  General.

INDICATIONS:  The patient is a 41-year-old white female admitted yesterday with complaints of right upper quadrant abdominal pain.  She was found to have gallstones.  Plans were made for surgery.  She is aware of the procedure, risks, benefits, and alternatives and agreed to proceed.

PROCEDURE:  The patient was taken to the operating room and placed in the supine position.  After general endotracheal anesthesia was administered, her abdomen was prepped and draped in the usual sterile fashion.  The knife was used to make a small infraumbilical incision.  Dissection was taken down through the fascia.  It was incised sharply.  Figure-of-eight suture with 0 Vicryl was placed and blunt dissection accomplished in the peritoneal cavity.  The Hasson port was placed and CO2 insufflated until a pressure of 15 was reached.  Under direct vision, a 5-mm port was placed below the xiphoid and another 5-mm port below the costal margin on the right side.

The gallbladder was retracted cephalad.  There were some minor adhesions, which were taken down using careful blunt dissection.  Dissection continued at the neck of the gallbladder.  The cystic duct was identified and isolated.  Its junction with the gallbladder and common duct were noted.  Two clips were applied on the cystic duct proximally and one distally, and the duct divided.  The same was done with the cystic artery.  Electrocautery was used to separate the gallbladder from the liver bed.  It was placed into an Endopouch and later removed through the umbilical port site.  The liver bed was irrigated with saline and suctioned dry.  Hemostasis was good.

All instruments were withdrawn.  CO2 was allowed to escape.  Fascia of the umbilicus was closed with 0 Vicryl and all skin incisions with 4-0 Monocryl subcuticular sutures.  Steri-Strips and Tegaderm dressings were applied.  The patient tolerated the procedure well and there were no complications.  She was sent to recovery in stable condition.

Bilateral lateral rectus recession of 7.5 mm

PREOPERATIVE DIAGNOSIS:                Exotropia.

POSTOPERATIVE DIAGNOSIS:             Exotropia.

PROCEDURE:                                             Bilateral lateral rectus recession of 7.5 mm.

ANESTHESIA:                                             General.

COMPLICATIONS:                                     None.

PROCEDURE IN DETAIL:                        The patient was wheeled into the operating room suite, placed on the operating room table, where a routine preop cardiac monitoring was initiated.  IV was inserted into place.  The patient was induced with face mask anesthesia, intubated, and maintained on appropriate mixture of gases for general anesthesia.  Both eyes were prepped and draped in a sterile fashion.  Lid speculum was placed into the left eye.  Double-armed 6-0 silk was passed through the 6 and 12 o’clock limbus and clamped maintaining the eye in the abducted position.  Conjunctival incision was performed over the muscle and dissected posteriorly.  Lateral rectus was isolated on a muscle hook and a double-armed 6-0 Vicryl was passed through the muscle 1 mm from the insertion and locked at the superior and inferior poles.  Muscle was disinserted from the globe with blunt Westcott.  Hemostasis was maintained with a disposable cautery.  With 7.5 mm on the calipers as measured back from original insertion site, two needles were passed through sclera at this point.  Muscle was pulled up to the new position and tied.  Needles were cut.  Conjunctiva was passed back in place and sutured with 6-0 plain.  Bilateral sutures removed, lid speculum was removed.  The eye was cleaned and TobraDex was also instilled to the eye.  Then turning to the right eye, the exact same procedure was performed.  There is a lateral rectus recession of 7.5 mm.  The patient was weaned from anesthesia and returned to recovery room in good condition.

Repeat low-flap cesarean section and lysis of adhesions

PREOPERATIVE DIAGNOSIS:  Previous cesarean section, desires repeat.

POSTOPERATIVE DIAGNOSIS:  Previous cesarean section, desires repeat with adhesions.

PROCEDURE:  Repeat low-flap cesarean section and lysis of adhesions.

FINDINGS:  A live female infant with Apgars of 9 and 9.  The baby weighed 8 pounds even.  There were normal tubes and ovaries bilaterally, and there was a thick scar of the bladder and uterus to the anterior abdominal wall.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  800 mL.

PROCEDURE IN DETAIL:  The patient was brought to the Operating Room where anesthesia was obtained without difficulty.  She was prepped and draped in a normal sterile fashion in dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with blunt and sharp dissection.  The fascia was nicked on either side of the midline.  The incision was extended laterally with the curved Mayo scissors.  Inferior aspect of the fascial incision was grasped with the Kocher clamps and elevated off the rectus muscles.  Rectus muscles were dissected off bluntly and sharply.  Attention was turned to the superior aspect, which in a similar fashion was dissected off bluntly and sharply.  The rectus muscles were separated in the midline.  The peritoneum was entered sharply, and the incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder was noted to be adherent to the uterus and to the anterior fascial wall.  Wall of the bladder was pushed inferiorly.  The Metzenbaum scissors were used carefully to facilitate dissection of the bladder off the uterus.  A minimal bladder flap was able to be created because of this, and this was pushed inferiorly.  The uterus was then incised with the scalpel, and the incision was extended laterally with the bandage scissors.  A live female infant was delivered atraumatically.  The nose and mouth were suctioned on the field.  The cord was clamped and cut, and the infant was handed to pediatricians who signed Apgars of 9 and 9.  The baby weighed 8 pounds.  Placenta was delivered spontaneously.  The uterus was cleared of all clots and debris, and the incision was closed with 0 chromic in a continuous locking fashion.  The incision was noted to be hemostatic.  The Bovie cautery was used for hemostasis along the bladder and uterine edge.  The gutters were cleared of all clots and debris.  The tubes and ovaries were noted to be normal bilaterally.  The uterine incision was reinspected and noted to be hemostatic.  The fascia was then closed with 1 Vicryl in a continuous fashion.  Subcutaneous tissue was irrigated.  Bovie cautery was used for hemostasis, and the skin was closed with staples.  Sponge, lap, and needle counts were correct x2, and the patient was brought to the recovery in stable condition.

Repeat low-flap cesarean section and tubal ligation

PREOPERATIVE DIAGNOSES:  Previous cesarean section and labor and undesired fertility, A2 diabetes, two-vessel cord.

POSTOPERATIVE DIAGNOSES:  Previous C-section and labor and undesired fertility, A2 diabetes, two-vessel cord.

PROCEDURE:  Repeat low-flap cesarean section and tubal ligation.

FINDINGS:  A live male infant with Apgars of 9 and 9, the baby weighed 7 pounds 2 ounces.  There were normal tubes and ovaries bilaterally.  There was noted to be scar from the bladder to the anterior abdominal wall and the anterior uterine wall.

COMPLICATIONS:  None.

ANESTHESIA:  Spinal.

ESTIMATED BLOOD LOSS:  800 mL.

PROCEDURE IN DETAIL:  The patient was brought to the operating room where anesthesia was obtained without difficulty.  She was prepped and draped in normal sterile fashion in dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through the underlying layer of fascia with blunt and sharp dissection.  The fascia was nicked on either side of the midline, and the incision was extended laterally with the curved Mayo scissors.  Inferior aspect of the fascial incision was grasped with the Kocher clamps, elevated off the rectus muscles.  Rectus muscles were dissected off bluntly and sharply.  Attention was turned to the superior aspect, which in a similar fascia was dissected off bluntly and sharply.  The peritoneum was entered sharply, and the incision was extended laterally with blunt dissection.  The bladder blade was inserted, and the vesicouterine peritoneum was incised in a transverse fashion.  The Bovie cautery was used to help lower the adhered bladder from the anterior abdominal wall and the anterior uterine wall.  The bladder blade was reinserted.  The scalpel was used to make the uterine incision, and the incision was extended laterally with blunt dissection.  A live male infant was delivered atraumatically.  The nose and mouth were suctioned on the field.  The cord was clamped and cut, and the infant was handed to pediatricians who signed Apgars of 9 and 9.  The baby weighed 7 pounds 2 ounces.  Placenta was delivered spontaneously.  Uterus was cleared of all clots and debris, and the incision was closed with 0 chromic in a continuous locking fashion.  The repair of the uterus was done cautiously, as the bladder was pulled high on the lower uterine segment.  There was noted to be a small amount of bleeding in the midline and a figure-of-eight suture was placed there.  The Bovie cautery was used for hemostasis along the peritoneal edge where the bladder had been dissected off the anterior abdominal wall and the anterior uterine wall.  At this point, a lap was placed over the incision, and attention was turned to the tube.  The left tube was grasped with the Babcock clamp, elevated, and tied with 0 plain tie x2.  In the midportion, the Metzenbaum scissors were used to transect the tube and this was sent to Pathology.  The tube itself was noted to be hemostatic.  Attention was turned to the other tube where midportion of the tube was grasped with Babcock clamp; two 3-0 plain ties were placed.  The tube was transected with the Metzenbaum scissors, and the tube itself was noted to be hemostatic.  The ovaries were normal bilaterally on both sides.  Attention was returned to the incision where there was noted to be again some bleeding along the peritoneal edge where the bladder had been dissected.  The Bovie cautery was used as well as a figure-of-eight suture for hemostasis.  When all the areas were noted to be hemostatic, attention was then turned to the fascia, which was closed with 1 Vicryl in a continuous fashion.  Subcutaneous tissue was irrigated, Bovie cautery was used for hemostasis, and the skin was closed with staples.  Sponge, lap, and needle counts were correct x2

Incision and drainage

PREOPERATIVE DIAGNOSIS:                Chalazia, both upper and lower lids.

POSTOPERATIVE DIAGNOSIS:             Chalazia, both upper and lower lids.

PROCEDURE:                                             Incision and drainage.

ANESTHESIA:                                             General.

COMPLICATIONS:                                     None.

PROCEDURE IN DETAIL:                                    The patient was wheeled into the operating room suite, placed on the operating room table, where a routine preop cardiac monitoring was initiated.  IV was inserted into place.  The patient was induced with face mask anesthesia, intubated, and maintained on appropriate mixture of gases for general anesthesia.  Both eyes were prepped and draped in a sterile fashion.  Turning to the right eye, the lower lid was clamped, and lid was everted.  Chalazia was incised and drained.  Then turning to the upper lid, the same procedure was performed.  TobraDex ointment was instilled into the eye.  The eye was patched.  Then turning to the left eye, the exact same procedure was performed, i.e., incision and drainage of chalazion.

The patient was weaned from anesthesia, returned to recovery room in good condition.

Lid fold excision

PREOPERATIVE DIAGNOSIS:  Epiblepharon both lower lids.

POSTOPERATIVE DIAGNOSIS:  Epiblepharon both lower lids.

OPERATION PERFORMED:  Lid fold excision.

ANESTHESIA:  General.

COMPLICATIONS:  None.

PROCEDURE IN DETAIL:  The patient was wheeled into the operating room suite, placed on the operating room table, where a routine preop cardiac monitoring was initiated.  IV was inserted into place.  The patient was induced with face mask anesthesia, intubated, and maintained on appropriate mixture of gases for general anesthesia.  Both eyes were prepped and draped in a sterile fashion.  Turning to the right eye, the extra lid fold was excised from the medial canthus to mid lid.  Hemostasis was maintained with a disposable cautery.  The remaining lid was then _____ with 6-0 plain.  TobraDex ointment was instilled into the eye.  Then turning to the left eye, the exact same procedure was performed, i.e., lid fold excision.  The patient was weaned from anesthesia, and returned to recovery room in good condition

Primary low-flap cesarean section

PREOPERATIVE DIAGNOSIS:  Failure of descent.

POSTOPERATIVE DIAGNOSIS:  Failure of descent.

PROCEDURE:  Primary low-flap cesarean section.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  100 cc.

FINDINGS:  A live male infant with Apgars of 9 and 9, with a weight of 8 pounds and 1 ounce.  There was moderate meconium.  There were normal tubes and ovaries bilaterally.

PROCEDURE IN DETAIL:  The patient was brought to the operating room and anesthesia was obtained without difficulty.  She was prepped and draped in a normal sterile fashion in a dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was then made with the scalpel and carried through the underlying layer of fascia with blunt and sharp dissection.  The fascia was nicked in the midline and the incision was extended laterally with the curved Mayo scissors.  Inferior aspect of the fascial incision was grasped with a Kocher clamp and elevated off the rectus muscles.  Rectus muscles were dissected out bluntly and sharply.  Attention was turned to the superior aspect, which in a similar fascia was dissected out bluntly and sharply.  The rectus muscles were separated in the midline.  The peritoneum was entered sharply and incision was extended superiorly and inferiorly with good visualization of the bladder.  Bladder blade was inserted.  The vesicouterine peritoneum was incised in a transverse fashion.  The scalpel was used to make the uterine incision and this was extended laterally with the bandage scissors.  A live male infant was delivered atraumatically.  The nose and mouth were suctioned on the field.  The cord was clamped and cut and the infant was handed to pediatrician with an Apgars of 9 and 9.  The baby weighed 8 pounds and 1 ounce.  There was moderate meconium.  Placenta was delivered spontaneously.  Uterus was cleared of all clots and debris, and the incision was closed with 0 chromic in a continuous locking fashion.  One figure-of-eight suture was placed in the midline for hemostasis.  The incision was re-inspected and noted to be hemostatic.  The tubes and ovaries were normal bilaterally, and the gutters were cleared of all the clots and debris.  The fascia was then closed with 1-0 Vicryl in a continuous fashion.  Subcutaneous tissue was irrigated, Bovie cautery was used for hemostasis, and the skin was closed with staples.

Extended hysterectomy with bilateral salpingo-oophorectomy, proximal vaginectomy Bilateral retroperitoneal lymphadenectomy Pelvic washings Left ureterolysis Cystourethroscopy Robotic da Vinci ‘S’ system laparoscopy

PREOPERATIVE DIAGNOSES:

1.  Ovarian cyst.

2.  Uterine cancer.

3.  Postmenopausal bleeding.

4.  Pelvic pain.

5.  Intermittent urinary incontinence.

6.  Prolapse.

POSTOPERATIVE DIAGNOSES:

1.  Ovarian cyst.

2.  Uterine cancer.

3.  Postmenopausal bleeding.

4.  Pelvic pain.

5.  Intermittent urinary incontinence.

6.  Prolapse.

OPERATION PERFORMED:

1.  Extended hysterectomy with bilateral salpingo-oophorectomy, proximal vaginectomy.

2.  Bilateral retroperitoneal lymphadenectomy.

3.  Pelvic washings.

4.  Left ureterolysis.

5.  Cystourethroscopy.

6.  Robotic da Vinci ‘S’ system laparoscopy.

SURGEON:  Frank Cirisano, MD

ASSISTANT:  Richard Monti, PA-C.

ANESTHESIA:  General.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 300 mL.

DISPOSITION:  The patient was transferred to the recovery room in stable condition.

JUSTIFICATION:  The patient presented on 05/22/09 for the above procedures, for the above diagnoses.  The patient understands the indications, rationale, potential complications and risks.  She is aware that these risks include infection, bleeding, injury to adjacent structures such as the bowel or bladder as well as potential cardiac or pulmonary complications and risk of anesthesia.  The patient is aware of the potential of thromboembolic events including deep venous thrombosis, stroke, and pulmonary embolus.  She is aware that her risks may be elevated given her prior medical history, diagnosis of malignancy, and anticipated surgical procedures.  All of the patient's questions have been answered, apparently to her satisfaction.  The patient has elected to proceed with surgery and is medically cleared.

PROCEDURE IN DETAIL:  Following documentation of informed consent for the above procedures, the patient was brought to the operative suite where she was administered general anesthesia, prepped and draped in the usual sterile fashion in the low lithotomy position in Allen stirrups.  A supraumbilical incision was made with the 11 blade knife to accommodate the Veress needle.  Its location was established by saline drop test, infusion, and aspiration test.  The abdomen was insufflated with several liters of CO2 gas.  The Veress needle was removed.  The supraumbilical incision was dilated to accommodate the 12 mm port, which was placed.  The laparoscope was introduced into the abdominal cavity.  Initial examination of the abdomen and pelvis was conducted.  Findings were notable for adhesions involving the right and left adnexa, right and left pelvic sidewalls, uterine fundus, and rectosigmoid colon.   Accessory trocars were placed midway between the anterior superior iliac crest and the umbilicus on both sides using 8 mm ports.  A 12 mm port was placed two fingerbreadths above the umbilicus and two fingerbreadths to the left on the lateral aspect of the supraumbilical incision.  All ports were placed under direct visualization to avoid injury to underlying structures.  Abdominal wall transillumination was utilized to avoid regional blood supply.  A thorough and systematic exploration of the abdomen and pelvis was again conducted and the bowels were gently packed into the upper abdomen with Trendelenburg positioning aided by atraumatic grasping forceps.  The robotic da Vinci ‘S’ system was docked to the patient.  The round ligaments were divided on both sides.  The pararectal and paravesical spaces were thoroughly developed with identification of the ureters and major vessels in their pelvic course.  Right ureterolysis was carried out to mobilize the ureter from the medial leaf of the broad ligament from the level of the pelvic rim to the level of uterine vessels.  In the same manner on the left side, the ureter was freed from the medial leaf of the broad ligament and reflected laterally.  The IPL ligaments are isolated.  Bipolar cautery was used to secure exact hemostasis and the vessels are divided.  A bladder flap was developed by blunt and sharp dissection.  The uterine vessels were skeletonized, clamped, cauterized, and divided at the level of the uterine isthmus.  Pedicles are secured using bipolar cautery in the same manner with parametrial tissues taken down to the level of the proximal vaginal cuff, which is further mobilized and the proximal vagina is released by take down of the paravaginal tissues on both sides.  The colpotomy incision is carried out circumferentially incising the vaginal cuff utilizing the cervical _____ uterine manipulator as a guide.  The specimens were delivered via the vaginal vault and sent to Pathology.  The vaginal cuff was closed using a running suture of 0 Vicryl.  The abdomen and pelvis were irrigated.  Washings were also obtained prior to initiation of surgery.  Retroperitoneal lymphadenectomy was carried out mobilizing nodal tissue from the length of the external iliac artery and vein beginning caudad at the level of the circumflex iliac vein.  Dissection was carried out in a lateral to medial direction working to the level of the aortic bifurcation.  The ureters were reflected medially and held under direct visualization in the course of ongoing dissection to a level two fingerbreadths above the aortic bifurcation.  Care was taken to isolate or preserve vital structures with exact hemostasis noted upon completion.  The abdomen and pelvis were again generously irrigated.  Hemostasis noted at all pedicles.  All instruments removed from the abdomen and pelvis, and the robotic da Vinci ‘S’ system was undocked.  All trocar sites are closed using 0 Vicryl suture to re-approximate the fascial margins and 4-0 Monocryl to re-approximate skin margins.  Dressings were applied.  The perineum was approached.  The Foley catheter was removed.  Cystourethroscopy was performed.  The findings were notable for free spill of indigo carmine dye from both the right and left ureteral orifices.  The bladder mucosa and the urethral mucosa were free of gross suture violation, free of evidence of any injury or gross pathology.  All instruments were removed from the vagina and perineum, and the Foley catheter was replaced in the bladder.  The patient was awakened from anesthesia, returned to the recovery room in stable condition.