Caudal epidural steroid injection with Racz catheter Fluoroscopy IV sedation

PROCEDURES:

1.  Caudal epidural steroid injection with Racz catheter.

2.  Fluoroscopy.

3.  IV sedation.

Left hip bipolar hemiarthroplasty with Stryker Accolade

PREOPERATIVE DIAGNOSIS:  Femoral neck fracture and displaced left hip.

POSTOPERATIVE DIAGNOSIS:  Femoral neck fracture and displaced left hip.

PROCEDURE:  Left hip bipolar hemiarthroplasty with Stryker Accolade #5 stem, 45-mm Centrix +8 neck press fit.

Right hip bipolar hemiarthroplasty with Stryker Accolade press-fit

PREOPERATIVE DIAGNOSIS:  Subcapital femoral neck fracture, right hip.

POSTOPERATIVE DIAGNOSIS:  Subcapital femoral neck fracture, right hip.

PROCEDURE:  Right hip bipolar hemiarthroplasty with Stryker Accolade press-fit #4, 132 degree Accolade TMZF stem, and 26 V40 head 45 mm UHR Centrax.

IM roding Gamma nail, long Gamma

PREOPERATIVE DIAGNOSIS:  Peritrochanteric proximal femoral shaft subtrochanteric fracture, right femur.

POSTOPERATIVE DIAGNOSIS:  Peritrochanteric proximal femoral shaft subtrochanteric fracture, right femur.

OPERATION PERFORMED:  IM roding Gamma nail, long Gamma 125-degree, right femur with 11 x 380 nail, 90-mm lag screw, and 40 x 5 distal locking screw.

PREOPERATIVE DIAGNOSES:

1.  Left breast carcinoma.

2.  Status post bilateral mastectomy performed by Dr. Marla Dudak.

POSTOPERATIVE DIAGNOSES:

1.  Left breast carcinoma.

2.  Status post bilateral mastectomy performed by Dr. Marla Dudak.

OPERATION PERFORMED:

1.  First stage right breast reconstruction using Mentor tissue expander, catalogue #354-6211, serial #5859430-043, initially inflated to 100 mL.

2.  Creation of right chest wall muscle flap resulting in complete tissue expander coverage as well as prevention of lateral migration of the implant.

3.  First stage left breast reconstruction using Mentor 354-6211 implant, serial #5859430-007, initially inflated to 100 mL.

4.  Creation of left chest wall muscle flap consisting of pectoralis minor and serratus anterior musculature with result in complete lateral and inferior muscular implant coverage as well as prevention of lateral migration of the implant.

Advancement of flap/U-shaped pedicle flap reconstruction of a left brow defect

PREOPERATIVE DIAGNOSES:

1.  Nodular basal cell carcinoma of the left forehead, left brow region.

2.  Acquired defect, left forehead brow region status post Mohs resection.  Defect measures 1.5 x 1 cm in size.

POSTOPERATIVE DIAGNOSIS:  

1.  Nodular basal cell carcinoma of the left forehead, left brow region.

2.  Acquired defect, left forehead brow region status post Mohs resection.  Defect measures 1.5 x 1 cm in size.

OPERATION PERFORMED:  Advancement of flap/U-shaped pedicle flap reconstruction of a left brow defect.

Removal of exposed intact silicone implant

PREOPERATIVE DIAGNOSES:

1.  Exposed right breast implant.

2.  Right breast carcinoma.

3.  Status post chemotherapy.

4.  Status post radiation therapy to right breast.

POSTOPERATIVE DIAGNOSES:

1.  Exposed right breast implant.

2.  Right breast carcinoma.

3.  Status post chemotherapy.

4.  Status post radiation therapy to right breast.

OPERATIONS PERFORMED:

1.  Removal of exposed intact silicone implant.

2.  Irrigation of pocket and debridement of skin edges.

3.  Replacement of implant using Mentor 350-4001 BC implant, serial #5768292-147.

Capsulotomy and release of tight pocket of her left breast implant

PREOPERATIVE DIAGNOSES:

1.  Symptomatic left breast reconstruction secondary to capsular contracture.

2.  Left breast cancer, status post left mastectomy many years ago.

POSTOPERATIVE DIAGNOSES:

1.  Symptomatic left breast reconstruction secondary to capsular contracture.

2.  Left breast cancer, status post left mastectomy many years ago.

OPERATION PERFORMED:

1.  Capsulotomy and release of tight pocket of her left breast implant resulting in symptomatic complaints of tenderness.

2.  Removal of implant per patient’s request.

Complete excision of right medial eyebrow lesion

PREOPERATIVE DIAGNOSIS:  Papular changing lesion, right medial brow.

POSTOPERATIVE DIAGNOSIS:  Papular enlarging lesion right medial brow.

OPERATION PERFORMED:  Complete excision of right medial eyebrow lesion with complex repair, total length 1 cm, lesion measured approximately 6 mm in diameter.

OPERATIVE INDICATIONS:  The patient is a 54-year-old hospital employee at West Boca Medical Center who was concerned about a several-month history of enlarging lesion to her right medial brow.  She presented to her dermatologist, who recommended plastic surgical excision.  It is for this reason that she presents today.  It is a papular lesion, raised, palpable, and fairly discreet.  It is unclear whether it is mobile.

The findings discussed with the patient preoperatively.  I informed her that essentially this lesion can be excised, however, we are turning off this lesion for a scar, only time will tell how significant that scar will be.  In this manner, realistic expectations were provided.  I discussed potential complications included, but not limited to bleeding, infection, dehiscence to wound, all of which may require further procedures.  Depending on pathology reports, she may require further excisions.  As stated, I again reminded her of the scar today in the preoperative holding area.  Despite this, however, she wishes that I proceed.

PROCEDURE IN DETAIL:  The patient was taken to main operating room, placed supine on the operating table.  The entire area prepped and draped in _____ standard fashion.  A 1% lidocaine with epinephrine used for local anesthesia.  After satisfactory local anesthesia, chief complete excision carried out, using a 15C scalpel blade.  Operative findings revealed what appears to be an epidermal inclusion cyst.  It was completely excised including a cyst wall.  Specimen was sent to the Pathology including the overlying skin as it was densely adherent.  Irrigation carried out, hemostasis assured using low-power needle-tip cautery.  Reapproximation of deep and dermal layer performed using interrupted 7-0 Vicryl suture.  Skin closed using interrupted 7-0 Prolene suture.  Mastisol and Steri-Strips applied.  The patient tolerated the procedure well without complications.  She was transferred back to recovery room in good condition.  Estimated blood loss minimal.  All sponge, instruments, and needle counts correct.

Removal of ruptured silicone implant with gross leak of silicone and disintegrated implant shell.

PREOPERATIVE DIAGNOSES:

1.  Severe capsular contracture right breast reconstruction, status post mastectomy for breast carcinoma performed 28 years ago.

2.  History of right breast carcinoma, status post right breast mastectomy.

3.  MRI findings suggesting right breast implant rupture.

POSTOPERATIVE DIAGNOSES:

1.  Severe capsular contracture right breast reconstruction, status post mastectomy for breast carcinoma performed 28 years ago.

2.  History of right breast carcinoma, status post right breast mastectomy.

3.  MRI findings suggesting right breast implant rupture.

OPERATION PERFORMED:

1.  Removal of ruptured silicone implant with gross leak of silicone and disintegrated implant shell.

2.  Simpulse pressure irrigation 3 liters resulting in complete evacuation of silicone content from the capsule.

3.  Correction of severe capsular contracture resulting in distortion with circumferential and radial capsular release and revision of right breast reconstructive pocket.

4.  Replacement of previous implant using mentor 350-401 BC implant, serial number 5861506-017.

ANESTHESIA:                                             General.

INDICATIONS:                                             The patient is a 65-year-old female referred to me for correction and replacement of right breast reconstruction implant.  The patient has severe capsular contracture with distorted pockets resulting in significant asymmetry between the reconstructed right breast and her left breast.  Additionally, MRI findings preoperatively suggest silicone implant.  The patient would like improved symmetry and would like to have these implants replaced after removal of the ruptured implant.  The findings discussed with the patient preoperatively, I discussed her options.  I do recommend removal of the ruptured silicone implant.  I discussed the potential complications, which include, but not limited bleeding, infection, severe capsular contracture again recurring, rupture of implant, all of which may require further procedures or at times need for possible temporary or permanent removal of implant.  I have answered all her questions to her satisfaction, she was comfortable with that, and she wished that I proceed.  I have met with this patient on more than one occasion in my office where we addressed all her questions.  However, despite this upcoming procedure, I stressed her that perfect symmetry is not achievable.  I wanted her to have realistic expectations.  At this point, she understands fully.  I have answered all her questions and she wishes that I proceed.  The patient was met in the preoperative holding area today where the nursing staff was present.  She was marked in the upright standing position.  She received prophylactic antibiotics prior to skin incisions.  SCD boots placed per my routine.

PROCEDURE IN DETAIL:                                    The patient was taken to the main operating room and placed supine on the operating table.  Both arms placed on well-padded arm boards and secured in a non-constricting fashion to prevent neuropraxic injuries.  The entire chest was then prepped and draped sterilely in the standard fashion after satisfactory general anesthesia achieved.  A 5-cm incision made through the previous mastectomy scar.  Incision carried down through the underlying layers using cautery technique.  Operative findings revealed grossly ruptured implant with silicone gel oozing upon entering the capsule.  A disintegrated shell was identified.  This was removed from the capsule and with the implant being placed on the back table.  Because of the gross contamination of silicone gel, Simpulse pressure irrigation antibiotic solution with a total of 3 liters then carried out.  This pressure lavage resulted in complete evacuation of silicone remnants as noted intraoperatively.

At this point, a lighted retractor was then used to inspect the pocket.  Operative findings revealed severe capsular contracture with a significantly contracted pocket.  Using cautery, circumferential and radial capsular release was carried out and the inframammary fold was lowered by at least 2 cm to the preoperative markings.  The inframammary fold was reconstructed using Vicryl sutures and capsule to periosteum were available.  Meticulous hemostasis was assured throughout under direct visualization with the lighted retractor.  Completing hemostasis, irrigation carried out.  Sizer placed within the pocket created with operative findings revealing 400 mL implant _____ markedly improved appearance without having any tightness with respect to closure of the skin and capsule muscle layers.

At this point, a 10-20 drape placed overlying the skin incision after removal of the sizer.  New gloves placed from my routine.  A Mentor 350-401 BC implant was chosen.  It was bathed in antibiotic solution.  It was inspected and was noted to be completely intact.  One final check of the pocket was performed with the lighted retractor, and once hemostasis assured, the implant was placed within the pocket created.  Operative findings revealed marked improvement compared to preoperative state.  The patient placed in the upright sitting position with operative findings revealing a pleasing shape.  The patient then placed against supine and subsequent closure of the muscle and capsule layers performed using interrupted 3-0 Vicryl pop-off suture.  Dermal layer closed using interrupted 4-0 Vicryl suture.  Skin closed using 4-0 Vicryl subcuticular suture.  Mastisol and Steri-Strips were applied and surgical bra applied.  All sponge, instrument, and needle counts were correct.  The patient tolerated this procedure well without difficulty or complications.  She was extubated easily and was transferred back to the recovery room in good condition.

ESTIMATED BLOOD LOSS:  Minimal.

Upper endoscopy and colonoscopy procedure

PROCEDURE:  Upper endoscopy and colonoscopy.

INDICATIONS:  Reflux, rule out gastroesophageal reflux disease, rule out Barrett, and diarrhea.

PROCEDURE IN DETAIL:  Indications, risks, benefits, alternatives, and limitations were explained to the patient in the office.  Risk of anesthesia, perforation, bleeding, infection, colitis, cardiopulmonary risk, morbidity, and mortality were discussed.  Possibility of missing a lesion, a polyp, a growth, a mass, and cancer was discussed.  Risk of cold biopsy, hot biopsy, and polypectomy was discussed.  Risk of the prep was discussed.  Oropharyngeal injury, sore throat, bronchitis, aspiration, aspiration pneumonia, and sinusitis were discussed.  Esophageal, pharyngeal injury, and perforation discussed.  All these discussions were done in the office.  She understood all of the above.  All her questions were answered.  She agreed to the procedure.  She came to the endoscopy unit today.  She had no further questions or concerns.  She said she has prepped well.  Physical exam was grossly negative.  She then gave an informed consent.

PROCEDURE IN DETAIL:  She was taken to the endoscopy room.  Anesthesia provided sedation.  Scope was advanced into esophagus, stomach, and duodenum.  Third portion, second portion, and bulb was normal.  Small bowel and duodenal biopsies were taken to rule out celiac sprue and Giardia.  Pylorus was normal.  Antral gastritis was noted.  Biopsy was taken for H. pylori.  On retroflexion, lesser curvature, greater curvature, fundus, and cardia were carefully examined.  The stomach insufflated very well.  No abnormal folds were seen.  Findings were that of a large pedunculated polyp in the fundus, which was removed completely by snare polypectomy.  No bleeding.  No complications.  There was another small polyp less than 5 mm in the body, which was biopsied.  Esophagogastric junction was normal.  Small hiatal hernia was noted.  Esophageal mucosa was normal.  Procedure completed.  The patient tolerated the procedure well.

PROCEDURE:  Colonoscopy.  The colonoscope was advanced into the rectum all the way to the cecum and terminal ileum.  Photographs were taken for documentation.  Mucosa was then examined.  On withdrawal, minimal liquid stool throughout the colon as much as possible was cleaned out.  Small lesions or flat lesions could have been missed.  The terminal ileum, the cecum, the ascending colon, transverse colon, descending colon, sigmoid colon, and rectum were examined. Retroflexion was done in the rectum.  Over 6 minutes was taken to evaluate the colon on withdrawal.  Findings were that of grossly negative colon, normal vasculature, normal mucosa, very small internal hemorrhoids were noted.  A few random biopsies of the colon was taken on the way out to rule out microscopic colitis.  Procedure completed. The patient tolerated the procedure well.

IMPRESSION:

1.  Reflux.

2.  Diarrhea workup so far negative.

Endoscopy showed mild gastritis.  Biopsy taken, small bowel biopsy, and duodenal biopsy taken for celiac sprue and Giardia.  Large gastric polyp noted in the fundus which was pedunculated and removed completely by snare polypectomy and another small polyp less than 5 mm was noted in the body of the stomach, which was biopsied.  Small hiatal hernia was noted.  Colon mucosa was grossly negative.  Terminal ileum was grossly negative.  Random biopsies for microscopic colitis was taken and very small internal hemorrhoids were noted.

PLAN:  Continue recommendations in the office for the above conditions as she was advised.  The patient has to see me next week in the office to review the biopsies and then we will make further recommendations.

Screening Colonoscopy

PROCEDURE:  Colonoscopy.

INDICATION:  Screening

PROCEDURE IN DETAIL:  Indications, risks, benefits, alternatives, and limitations were explained to the patient in the office.  Risk of anesthesia, perforation, bleeding, infection, colitis, cardiopulmonary risk, morbidity, and mortality were discussed.  Possibility of missing a lesion, a polyp, a growth, a mass, and cancer was discussed.  Risk of cold biopsy, hot biopsy, and polypectomy was discussed.  Risk of the prep was discussed.  All these discussions were done in the office.  She understood all of the above.  All her questions were answered.  She agreed to the procedure.  She came to the endoscopy unit today.  She had no further questions or concerns.  She said she is prepped well.  Physical exam was grossly negative.  She was given informed consent.  She was then taken to the endoscopy room.  Anesthesia provided sedation.  Scope was advanced into the rectum all the way to the cecum.  Tortuous colon application of pressure was required to get to the cecum.  Cecum was identified by the ileocecal valve and appendix.  Photographs were taken for documentation.  Small bowel could not be intubated.  Mucosa was then examined on withdrawal.  There was some liquid and pasty stool throughout the colon, as much as possible was cleaned out.  Small lesions or flat lesions could have been missed.  The cecum, the ascending colon, transverse colon, descending colon, sigmoid colon, and rectum were carefully examined.  Retroflexion was done in the rectum.  Over 6 minutes was taken to evaluate the colon on withdrawal.  Findings were that of grossly negative colonoscopy.  Small-to-moderate internal hemorrhoids.  Procedure was completed.  The patient tolerated the procedure well.

IMPRESSION:  Screening colonoscopy grossly negative, small-to-moderate internal hemorrhoids.

PLAN:  Fiber supplement.  Hemorrhoid suppositories.  She can buy OTC.  The patient to do annual Hemoccult screening with primary care doctor.  Colonoscopy in 5 to 10 years, unless otherwise indicated.  Follow up in my office.  Follow up with PCP

Endoscopic retrograde cholangiopancreatography, sphincterotomy, and removal of bile duct stone

PROCEDURE:

1.  Upper endoscopy.

2.  Endoscopic retrograde cholangiopancreatography, sphincterotomy, and removal of bile duct stone.

The indication, risks, benefits, alternatives, and limitations were explained to the patient and husband yesterday in the office and again today at the bedside to the patient.

INDICATIONS:  Possible common bile stone, possible bile leak, abdominal pain, rule out upper GI causes, and abnormal LFTs.

The indication, risks, benefits, alternatives, and limitations were explained to the patient and her husband.  The risk of anesthesia, perforation, bleeding, infection, cardiopulmonary risk, morbidity, and mortality were discussed.  Possibility of missing a lesion, a polyp, a growth, a mass, or cancer was discussed.  The risk of cold biopsy, hot biopsy, and polypectomy was discussed.  The risk of oropharyngeal injury, sore throat, bronchitis, aspiration, aspiration pneumonia, and sinusitis were discussed.  Esophageal and pharyngeal injury and perforation discussed.  Duodenal injury and perforation discussed.  The risk of sphincterotomy, bleeding, perforation, and need for surgery discussed.  The risks of bile duct injury, bile duct leak were discussed.  The risks of mild-to-severe pancreatitis, consequences of pancreatitis, morbidity, and mortality were discussed.  The risks of cholangitis were discussed.  The need for antibiotics was discussed.  All these discussions were explained in detail yesterday, they both understood everything.  Today, I explained everything to the patient again, she understood everything and she gave an informed consent both for the endoscopy and for the ERCP.

PROCEDURE IN DETAIL:  She was then brought to the Radiology suite.  Anesthesia of the intubated and anesthetized the patient and the endoscopy was first procedure.  The gastroscope was advanced into the esophagus, stomach, and duodenum.  Third portion, and second portion bulb was normal.  Pylorus was normal.  Antrum was normal.  On retroflexion, lesser curvature, greater curvature, fundus, and cardia were normal.  The stomach insufflated very well.  No abnormal folds were seen.  Esophagogastric junction was normal.  Esophageal mucosa was normal.  Procedure completed.  The patient tolerated procedure well.

Next procedure ERCP, the ERCP scope was advanced into the esophagus, stomach, and duodenum.  Ampulla was identified.  Using a wire only the bile duct was easily cannulated.  Cholangiogram showed common bile stone confirmed by Dr. Michael Katz, radiologist present in the room.  Following which, a sphincterotomy was done safely without any complications.  Following which without any difficulty using a balloon, the stone was removed.  Following this, an occlusion final cholangiogram was done, bile duct was clear and the bile duct drained very quickly and very well.  Procedure completed. The patient tolerated the procedure well

Upper endoscopy

PROCEDURE:  Upper endoscopy.

INDICATION:  Epigastric pain.

Indications, risks, benefits, alternatives and limitations explained to the patient.  Risk of anesthesia, perforation, bleeding, infection, cardiopulmonary risk, morbidity, and mortality was discussed possibly missing a lesion, polyp, growth, mass, and cancer was discussed.  Risk of cold biopsy, hot biopsy, and polypectomy was discussed.  Oropharyngeal injury, sore throat, bronchitis, aspiration pneumonia, and sinusitis were discussed.  All these discussions were done in the office.  She understood all of the above.  All her questions were answered.  She agreed to the procedure.  She came to the endoscopy unit.  She had no further questions or concerns.  Physical exam was grossly negative.  She then gave an informed consent.

She was taken to the endoscopy room.  Anesthesia provided sedation.  The scope was advanced to esophagus, stomach and duodenum.  Third portion, second portion, and bulb were normal.  Pylorus was normal.  Antrum and body was examined.  There was presence of gastritis.  Biopsy was taken.  On retroflexion, _____ fundus and cardia were normal.  The stomach insufflated very well.  No abnormal folds were seen.  Esophageal gastric junction was normal.  Esophageal mucosa was normal.  Procedure completed.  The patient tolerated the procedure well.

IMPRESSION: Gastritis and epigastric pain.  Workup so far was negative.  Etiology was unclear.

PLAN:  Continue Protonix and I have recommended, she do DISIDA scan with ejection fraction and we will follow up in the office in 2 weeks.  We will make further recommendations depending on the clinical course and findings of the above results and the biopsy.

Upper endoscopy and colonoscopy

PROCEDURE:                                             Upper endoscopy and colonoscopy.

INDICATIONS:                                             Iron deficiency anemia.

PROCEDURE IN DETAIL:                                    Indications, risks, benefits, alternatives, and limitations were explained to the patient.  He gave an informed consent.  He was then brought to the endoscopy room.  Anesthesia provided sedation.  Scope was advanced into esophagus, stomach, and duodenum.  Third portion, second portion, and bulb was normal.  Pylorus was normal.  Antral gastritis was noted and biopsy was taken.  On retroflexion, lesser curvature, greater curvature, fundus, and cardia were normal.  Stomach insufflated very well.  No abnormal folds were seen.  There was a small nodule in the antrum next to the pylorus, which was biopsied.  Otherwise, rest of the stomach was grossly negative.  Esophagogastric junction was normal.  Esophageal mucosa was normal.  Procedure completed.  The patient tolerated the procedure well and then I reintroduced the scope all the way down to the small bowel in order to take biopsies to rule out celiac sprue and then the procedure was completed.

PROCEDURE:  Colonoscopy.

The colonoscope was advanced into the rectum all the way to the cecum and terminal ileum.  Photographs were taken for documentation.  Mucosa was then examined.  On withdrawal. minimal liquid and pasty stool throughout the colon as much as possible was cleaned out.  Small lesions or flat lesions could have been missed.  The terminal ileum, the cecum, the ascending colon, transverse colon, descending colon, sigmoid colon, and rectum were examined.  Retroflexion was done the rectum.  Over 6 minutes was taken to evaluate the colon on withdrawal.  Findings were that of grossly negative terminal ileum and grossly negative colon, small-to-moderate internal hemorrhoids.  Procedure completed.  The patient tolerated the procedure well.

IMPRESSION:  Iron deficiency anemia.  Endoscopy showed gastritis.  Biopsy taken a small nodule in the antrum.  Biopsy taken.  Small bowel biopsy taken to rule out celiac sprue.  Colonoscopy grossly negative.  Terminal ileum grossly negative.  Small-to-moderate internal hemorrhoids.

PLAN:  The patient can be discharged home.  Follow up in my office next week to review the biopsies.  Check the celiac sprue workup and then we will plan small bowel series followed by capsular endoscopy.

Operative laparoscopic ablation of endometriosis

PREOPERATIVE DIAGNOSIS:                Pelvic pain, suspicion of endometriosis.

POSTOPERATIVE DIAGNOSIS:             Pelvic pain with confirmed endometriosis.

PROCEDURE PERFORMED:                  Operative laparoscopic ablation of endometriosis.

ANESTHESIA:                                             General.

EBL:                                                               None.

COMPLICATIONS:                                                 None.

SPECIMEN SENT:                                                 None.

URINE OUTPUT:                                        Clear yellow urine throughout the course of the procedure.

PROCEDURE IN DETAIL:                        The patient was taken to the Operating Room where she was identified as herself, placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the vagina, and Deaver was placed anteriorly.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  Cervix was dilated to accommodate a HUMI uterine manipulator, which was introduced into the uterine cavity, and the intrauterine balloon was insufflated.  The Deaver and speculum were removed from the patient’s vagina, and attention was turned to the patient’s abdomen.  A 5-mm incision was made in the umbilical fold, and the Veress needle introduced into the intraabdominal cavity.  Intraabdominal placement was confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas.  The Veress needle was removed, and a 5-mm trocar was introduced.  The patient was placed in steep Trendelenburg positioning with the bowel displaced superiorly, and a second incision was made in the left lower quadrant to accommodate a 5-mm trocar under direct visualization.

Findings that were appreciated were a normal-appearing uterus with normal fallopian tubes and ovaries that bilaterally spilled indigo carmine dye during the chromotubation without any compromise.  Of note, was significant evidence of retrograde menstrual flow that was actively occurring at the time of laparoscopy secondary to the patient’s menstrual cycle being in progress.  Endometriosis implants were noted specifically most concentrated along the right uterosacral ligament with the largest percentage of these lesions identified there but also disbursed amongst the posterior pelvic cul-de-sac.  No other specific abnormalities.  No fibroids.  No other pathology or adhesions or compromise of the fallopian tubes were appreciated.  At this time, utilizing the Carpenter bipolar cautery, the lesions along the right uterosacral ligament were cauterized judiciously, and then the abdomen was copiously irrigated and cleared of all clots and debris.  All instruments were subsequently removed from the patient’s abdomen and vagina.  Again of note, chromotubation utilizing indigo carmine dye instilled through the HUMI uterine manipulator was done with bilateral spillage from both fallopian tubes without any compromise appreciated.  The two skin incisions were closed with 4-0 Monocryl for excellent hemostasis and reapproximation.  One-twelfth CO2 gas was expelled from the patient’s abdomen.  Sponge, needle, and instrument counts were correct x2.  The patient was taken to the recovery room with the Foley discontinued in the Operating Room and the Foley bag having shown clear yellow urine.  The patient’s instructions had been discussed with her prior to surgery with plans for discharge home today, over-the-counter pain medication, and followup in our office in approximately a week.

FINDINGS:  The findings showed a normal-sized and normal-appearing uterus, normal fallopian tubes and ovaries bilaterally with active retrograde menstrual bleeding into the pelvic cavity and endometriosis implants specifically concentrated in the posterior pelvic cul-de-sac and specifically along the right uterosacral were identified.

Robotic-assisted total laparoscopic hysterectomy

PREOPERATIVE DIAGNOSIS:  Symptomatic fibroid uterus.

POSTOPERATIVE DIAGNOSIS:  Symptomatic fibroid uterus.

PROCEDURE PERFORMED:  Robotic-assisted total laparoscopic hysterectomy.

ANESTHESIA:  General.

EBL:  Minimal.

URINE OUTPUT:  Clear yellow urine throughout the course of the procedure with blue-tinged urine at the end of the procedure secondary to administration of indigo carmine dye.

SPECIMENS SENT:  Uterus and cervix.

COMPLICATIONS:  None.

PROCEDURE IN DETAIL:  The patient was taken to the operating room where she was identified as herself, placed in the dorsal lithotomy position with general anesthesia administered without difficulty.  She was prepped and draped in the usual sterile fashion and a weighted speculum was placed in the vagina and a Deaver was placed anteriorly.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and the cervix was dilated to accommodate the VCare uterine manipulator, which was introduced into the uterine cavity with the intrauterine balloon insufflated and the appropriately sized colpotomy cup placed around the cervix snugly.  The Deaver and tenaculum and speculum were removed from the patient’s vagina, and attention was turned to the patient’s abdomen.  A 12-mm incision was made approximately two fingerbreadths above the umbilicus, and a Veress needle was introduced into the intraabdominal cavity.  Intraabdominal placement was confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas.  The Veress needle was removed, and a 12-mm trocar was introduced with a 0-degree laparoscope confirming intraabdominal placement.  Findings were that of slightly enlarged multifibroid uterus about 9 to 10 weeks in size, boggy in appearance, suspicious for adenomyosis, it was otherwise completely normal fallopian tubes and ovaries bilaterally.  The patient was placed in steep Trendelenburg positioning and the bowel was displaced superiorly with the robotic trocar arms placed in the left lower quadrant and right lower quadrants respectively under direct visualization accommodating the 8-mm robotic trocar site.  A final fourth incision was made in the right upper quadrant to accommodate a 12-mm surgical assistant port site.  The da Vinci robot was subsequently docked without any complications, and I removed myself _____.  After the surgical console, the surgery began with my identification of the utero-ovarian ligaments on either side.  These were cauterized and transected with the bipolar cautery and then the EndoShears.  This was followed by the round ligament, which was cauterized and transected in a similar fashion.  The anterior leaf of the broad ligament was entered and the bladder flap dissected off of the lower uterine segment and cervix without complications.  The uterine arteries bilaterally were skeletonized, cauterized, and transected.  At this time, the uterus was blanched effectively demonstrating that the blood supply to the uterus had been terminated.  The colpotomy cup was made with the monopolar spatula and carried around the entire cervicovaginal junction until the cervix and uterus were released from its moorings to the vagina.  The cervix and uterus were pulled into the vagina where it provided pneumo-occlusion while I proceeded to close the vaginal cuff with a running #0 Vicryl suture for excellent hemostasis and reapproximation.

The abdomen was copiously irrigated, cleared of all clots and debris, and the pedicles were examined and noted to be hemostatic.  The ureters were examined bilaterally and noted to be peristalsing normally with again indigo carmine dye noted to be draining into the Foley catheter with no extravasation into the pelvic cavity.  All the instruments were subsequently removed from the patient’s abdomen and vagina, and the two 12-mm fascial defects in the right upper quadrant and the above the umbilicus were closed with #0 Vicryl stitch, and the four skin incisions were closed with #4-0 Monocryl for excellent hemostasis and reapproximation.  The patient was taken to recovery room in stable and awake condition with plans for discharge home tomorrow morning.  Surgery was discussed in depth with the patient’s family with all questions answered.

Dilation and curettage, hysteroscopy, and diagnostic laparoscopy

PREOPERATIVE DIAGNOSES:              Dysfunctional uterine bleeding and fibroid uterus.

POSTOPERATIVE DIAGNOSES:           Dysfunctional uterine bleeding and fibroid uterus.

OPERATION PERFORMED:                    Dilation and curettage, hysteroscopy, and diagnostic laparoscopy.

ANESTHESIA:                                             General.

EBL:                                                               None.

SPECIMEN SENT:                                      Endometrial curettings.

COMPLICATIONS:                                     None.

OPERATIVE FINDINGS:                           Hysteroscopic findings revealed a bilaterally normal tubal ostia, which were visualized without difficulty with what appeared to be a lush endometrial lining and some evidence of potential synechiae in the uterus, but the uterus was otherwise completely uniform in its cavity, and no evidence of polyps or impinging fibroids in the uterus itself.  Laparoscopically, the uterus appeared to be normal size with potential of a slight irregularity on the anterior surface consistent with possible intramural fibroids, but otherwise normal appearing fallopian tubes and ovaries bilaterally with no other pelvic pathology appreciated.

PROCEDURE IN DETAIL:                        The patient was taken to the operating room where she was identified as herself, placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion after general anesthesia was administered without difficulty.  A weighted speculum was placed in the vagina and the Deaver was placed anteriorly.  The anterior lip of the cervix was grasped with a single-tooth tenaculum, and the cervix was dilated to accommodate a 30-degree hysteroscope.  The 30-degree hysteroscope was introduced into the uterine cavity with the findings noted above, specifically normal tubal ostia visualized bilaterally, some evidence of possible synechiae in the uterus, but no other pelvic pathology appreciated with a lush endometrial lining and no polyps or fibroids in the uterine cavity.  The hysteroscope was removed, and the uterus was curetted until sufficiently gritty texture was noted throughout.  Once this was done, all instruments were removed from the patient’s vagina, and attention was turned to the patient’s abdomen.  A 5-mm incision was made above the umbilical fold, and the Veress needle was introduced with intraabdominal placement confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas.  The Veress needle was removed, and attention was turned to introducing a 5-mm trocar.  The 5-mm laparoscope introduced with the above finding.  Once the pelvis was visualized to our satisfaction with again no specific pathology noted inside the pelvis, all instruments were removed from the patient’s abdomen and vagina.  Sponge, needle, and instrument counts were correct x2.  The patient was taken to recovery room in stable and awake condition.  The findings were discussed in depth with the patient’s partner in the waiting room with the patient to be discharged home on the same day of surgery with followup in our office in approximately a week.

Laparoscopic myomectomy, lysis of adhesions, and chromotubation

PREOPERATIVE DIAGNOSIS:                Fibroids.

POSTOPERATIVE DIAGNOSES:           Fibroids with lysis of adhesions and chromotubation.

OPERATION PERFORMED:                    Laparoscopic myomectomy, lysis of adhesions, and chromotubation.

SPECIMENS REMOVED:                         Morcellated segments of fibroids.

ANESTHESIA:                                             General.

EBL:                                                               Minimal.

URINE OUTPUT:                                        Clear yellow urine throughout the course of the procedure.

FINDINGS:                                                    Operative findings revealed a 5 to 6-cm pedunculated right cornual fibroid that was adhesed to the right fallopian tube and compressing the right fallopian tube with otherwise normal-appearing right fallopian tube and ovary.  On the left, there was a 3-cm pedunculated left cornual fibroid with otherwise completely normal left fallopian tube and ovary.  The uterus itself appeared normal configuration with maybe a 1-cm intramural fibroid noted in the posterior wall of the uterus.  Otherwise, normal liver edge, normal appendix, and normal gallbladder.

PROCEDURE IN DETAIL:                        The patient was taken to the operating room where she was identified as herself, placed in the dorsal lithotomy position after general anesthesia was administered without difficulty.  She was prepped and draped in the usual sterile fashion and a weighted speculum was placed in the vagina with the anterior lip of the cervix grasped with a single-toothed tenaculum.  The cervix was dilated to accommodate a HUMI manipulator.  The HUMI manipulator was introduced into the uterine cavity and insufflated with all instruments removed from the patient’s vagina.  Attention was turned to the patient’s abdomen where a 5-mm incision was made in the umbilical fold, and a Veress needle introduced into the abdominal cavity where intraabdominal placement was confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas and the Veress needle was removed with the 5-mm trocar introduced and appropriate intraabdominal placement confirmed by the 0-degree laparoscope.  The two further incisions were made in the left lower quadrant and right lower quadrant to accommodate 10-mm trocars under direct visualization lateral to the inferior epigastric vessels.  At this time, again the findings noted above prompted us to proceed with first excising the adhesions of the right subserosal 5 to 6-cm fibroid that were compressing the right fallopian tube.  These were judiciously dissected free and then the pedunculated stalk was cauterized, and transected with the Gyrus instrument and the entire fibroid was removed with complete hemostasis of the pedunculated stalk.  The left subserosal pedunculated cornual 2 to 3-cm fibroid was similarly excised, cauterized at its stalk, and noted to be hemostatic.  At this time, the Gynecare morcellator was introduced to the left lower quadrant port site and both fibroids were morcellated with all specimens removed to the left lower quadrant.  The abdomen was copiously irrigated, cleared of all clots and debris, and the pedunculated stalks of attachment from the two fibroids that have been removed were noted to be hemostatic.  Methylene blue chromotubation was performed with bilateral spill of the methylene blue to the pelvic cavity showing that there was complete patency of both fallopian tubes.  At this time, again, the abdomen was copiously irrigated, cleared of all clots and debris.  All instruments were removed from the patient’s abdomen and vagina, and CO2 gas was expelled.  The two 10-mm fascial defects in the right lower quadrants and left lower quadrants respectively were closed with interrupted 0-Vicryl suture, and the skin was closed with 4-0 Monocryl in subcuticular fashion for excellent hemostasis and reapproximation.  Sponge, needle, and instrument counts were correct x2.  The patient was taken to the recovery room in stable and awake condition, with discharge to home plan for the same day.  Discharge instructions were reviewed with the patient prior to surgery and with the patient’s husband in the waiting room at the time that I discussed the findings.  The patient will follow up in my office on 12/23/08.