Laparoscopic left salpingo-oophorectomy and lysis of adhesions

PREOPERATIVE DIAGNOSIS:                Ovarian cyst.

POSTOPERATIVE DIAGNOSES:           Ovarian cyst, left hemorrhagic ovarian cyst with pelvic adhesions.

PROCEDURE PERFORMED:                  Laparoscopic left salpingo-oophorectomy and lysis of adhesions.

ANESTHESIA:                                             General.

EBL:                                                               None.

SPECIMEN SENT:                                                 Left fallopian tube and ovary.

URINE OUTPUT:                                        Clear yellow urine throughout course of procedure.

FINDINGS:                                                    Operative findings revealed a completely normal right fallopian tube and ovary with a Falope-ring noted on the right fallopian tube consistent with the patient’s history of previous tubal ligation.  The left fallopian tube and ovary were encompassed by a large 6 cm hemorrhagic cyst and adhesed to the left pelvic side wall and the pelvic cul-de-sac.

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 with a 5-mm incision made in the umbilical fold and Veress needle introduced into the intraabdominal cavity where intraabdominal placement was confirmed by appropriate pressure reading.  The abdomen was insufflated with CO2 gas and the Veress needle was removed.  A 5-mm, 0-degree laparoscope was introduced with the findings noted above.  At this time, 2 further incisions were made in the left lower quadrant and the right lower quadrant respectively to accommodate a 10-mm trocar and a 5-mm trocar respectively under direct visualization lateral to the inferior epigastric vessels.  The patient was placed in steep Trendelenburg positioning with the bowel displaced superiorly.  At this time, attention was turned to judicious adhesiolysis of and around the left fallopian tube and ovarian cyst with the adhesions of the omentum and the bowel judiciously teased free utilizing the harmonic scalpel, and the infundibular pelvic ligament was able to be isolated and transected utilizing the harmonic scalpel.  The ovarian cyst was then again judiciously dissected free of its adhesions to the pelvic side wall until it was completely freed from its moorings in the pelvic cul-de-sac and the side wall.  The left fallopian tube and ovary replaced into a Endopouch and removed without difficulty through the left lower quadrant port site in the Endopouch.  At this time, the abdomen was copiously irrigated, cleared of all clots and debris with again the right ovary appearing completely normal and the abdomen completely hemostatic.  All instruments were subsequently removed from the patient’s abdomen.  The CO2 gas was expelled.  The 10-mm fascial defect in the left lower quadrant was closed with a 0-Vicryl interrupted stitch, and the patient’s 3 skin incisions were closed in a subcuticular fashion with 4-0 Monocryl.  The patient was taken to recovery room in stable awake condition with discharge home same day.

FOLLOWUP:  Follow up to be in our office in approximately 5 days with the patient to call for appointment and a script for Percocet given for pain.

Right knee arthroscopy with revision, ACL reconstruction complex

PREOPERATIVE DIAGNOSES:              Right knee ACL tear with medial meniscus tear with mild arthritis and retained hardware.

POSTOPERATIVE DIAGNOSES:           Right knee ACL tear with medial meniscus tear with mild arthritis and retained hardware.

OPERATIONS PERFORMED:

1.  Right knee arthroscopy with revision, ACL reconstruction complex.

2.  Partial medial meniscectomy.

3.  Microfracture with chondroplasty of the trochlear.

4.  Removal of deep hardware.

5.  Fluoroscopic guidance of procedure.

BLOOD LOSS:                                            Minimal.

FLUIDS:                                                        Crystalloid.

COMPLICATIONS:                                     None.

INDICATIONS:                                             The patient is a gentleman who has an ACL tear probably chronic after a reconstruction done elsewhere.  The risks, benefits and alternatives were discussed.  He notes of an MRI showing medial meniscal tear as well.  The risks, benefits, alternative treatments, allograft use etc., discussed preoperatively.  He wished to proceed.

PROCEDURE IN DETAIL:                        The patient was identified, brought to the operating room, and placed in a supine position.  After induction of general anesthetic, he received Ancef preoperatively.  Right lower extremity was prepped and draped in usual sterile fashion.  The knee was inflated with saline and portal sites were established.  The findings were as follows:  The patient noted to have a torn ACL.  There was no function to the ACL.  There was scars posteromedially and in the notch.  The patella actually looked to be in generally good shape considering, but the trochlear groove showed a grade III lesion.  The later compartment showed mild wear with an intact lateral meniscus.  At this point, we first performed partial medial meniscectomy using a full radius.  This was a non-repairable tear in the posterior horn.  It seemed that he may have had some meniscus removed previously.  At this time, we brought the fluoroscopy in sterilely.  We evaluated the knee.  We saw the two screws.  The tibial screw I felt could be bypassed, but the femoral screws needed to be removed in order to do an ACL reconstruction.  At this point, we performed a notch plasty.  We debrided back to the point where we could see the back wall.  We still did not see the screw.  We then used curette to finally see the screw and again using the fluoro, this was helpful to evaluate.  We then found the screw.  We carefully removed the surrounding bone.  This portion of procedure took about 45 minutes to carefully remove this tissue and then we were able to remove the screw.  The screw was then removed using a standard Arthrex screwdriver.  Next, the open top position was identified.  There were some osteophytes and we carefully had to debride this area to make sure that we have the over the top.

Next, we prepared a graft on the side table.  This was 95 mm graft.  Using the Biopunch technique and my assistant, Jessica Wheeler PA-C, prepared this with fiber wires to a 10/10 length approximately.  This was a good quality graft.  We then drilled the tibial tunnel from medial to lateral.  We tried to bypass the screw and we were able to do so using Arthrex guide set at 55.  We then overreamed with a 10-mm reamer.  We then went to the over the top 1 mm back wall and then reamed again to a depth of 40, we then placed our Transfix guide up and drilled across the knee with the wire over laterally and placed the wire down to the tibia.  We then placed the graft up, pulled it across through the knee and then fixed it with a 40-mm via Transfix, excellent fixation.  We _____ of the knee.  No notch impingement was noted.  We then fixated with a BioComposite screw, 11 x 35 delta with excellent fixation.  Once this was completed, we checked the knee once more.  The microfracture was then performed as follows:  The trochlear groove lesion was identified.  We gently debrided it using a curette and then we placed multiple punctate all of them to the lesion.  Once this was done, all instruments removed from the knee.  The knee was closed with simple nylon sutures with the portals, other surgicals with 2-0 Vicryl and subcuticular PDS.  The knee was injected with Marcaine for pain control and injected at all portal sites.  The anesthesia would then do a block following all procedure.  Sterile dressings applied for the knee.  The patient tolerated the procedure well.  My assistant was essential in this complicated case.

Right total knee replacement with lateral release

PREOPERATIVE DIAGNOSIS:                Right knee osteoarthritis.

POSTOPERATIVE DIAGNOSES:           Right knee osteoarthritis, advanced arthritis, tight lateral retinaculum.

PROCEDURE PERFORMED:                  Right total knee replacement with lateral release.

BLOOD LOSS:                                             Minimal.

FLUIDS:                                                        Crystalloid.

COMPLICATIONS:                                                 None.

HARDWARE USED:                                   Zimmer 'E' GSF right LPS femur, a 10 LPS Flex _____ poly, a 4 stem tibia, and a 29 prolonged patella.

DRAINS PLACED:                                      Medium Hemovac drain placed.

ANESTHESIA:                                            Epidural, regional and spinal.

INDICATIONS FOR SURGERY:              The patient is a woman with right knee arthritis. The risks, benefits, and alternative of the treatment discussed with the patient in detail, and she wished to proceed with surgery.  She was cleared medically by her primary physician, Dr. Castellanos and the patient wished to proceed with surgery.

PROCEDURE IN DETAIL:  The patient was identified, brought to the operating room, placed in supine position on the table.  After induction of a femoral nerve block on the right lower extremity as well as a spinal, the right lower extremity was prepped and draped in the usual sterile fashion.  Foley placed.  The patient's leg was exsanguinated, tourniquet inflated to 300 mmHg.  The patient had received Ancef preoperatively.  At this point, dissection carried down to the fascia.  The fascia was then identified and the medial parapatellar approach performed.  We released the medial side.  We then released some of the lateral side.  The patella was covered with a very thick fat pad, which was excised.  ACL and PCL were released and then we drilled our tibial and femoral tunnels.  We then first _____ our standard cut in the femur.  We then externally rotate 3 degrees and cut the distal femur sizing it to an ‘E.’  We then cut the PCL box.  We then went to the tibia.  The tibia was cut perpendicular to the shaft of the tibia.  The patient was quite large, and we used both the intramedullary guide as well as extramedullary guidance by using the alignment rods.  Once we cut it, we then checked our flexion and extension gaps, which was noted to be excellent and 10 mm in extension without difficulty.  We then checked our alignment once more.  Next, we rotated the tibia externally and we punched the tibia to a size 4, which covered the tibia nicely.  We then went to the patella.  We sized to a 29.  The patella was quite tight and we trialed it and then we realized we needed to release lateral retinaculum since we had had a tight retinaculum throughout the case.  Once we did this, we then placed our final cemented components in place.  We then trialed once more.  We selected the size 10 tibia since it fit nicely, gave good stability and excellent motion.  We then irrigated with saline.  We closed with #1 Vicryl, 2-0 Vicryl, and staples for the skin.  A medium drain had been placed out laterally.  The patient was then brought to recovery room.  My assistant was essential during this case.

ORIF of right hip Pinning and fluoroscopy of right hip.

PREOPERATIVE DIAGNOSIS:  Right hip subcapital impacted fracture.

POSTOPERATIVE DIAGNOSIS:  Right hip subcapital impacted fracture.

OPERATIONS PERFORMED:

1.  ORIF of right hip.

2.  Pinning and fluoroscopy of right hip.

BLOOD LOSS:  Minimal.

FLUIDS:  Crystalloids.

COMPLICATIONS:  None.

HARDWARE USED:  Three cannulated screws from Richards.

HISTORY:  The patient is a woman with a right hip impacted femoral neck fracture.  Risks, benefits, and alternatives of treatment discussed.  She wished to proceed with surgery.

PROCEDURE IN DETAIL:  The patient was identified, brought to the operating room, and placed in supine position on the table.  After induction of spinal anesthetic, the patient was positioned on a fracture table.  The fracture of the right hip was appropriately reduced and positioned.  The right hip was then sterilely prepped and draped in the usual fashion for the surgery.  The fracture was an impacted femoral neck fracture.  This was felt to be amenable to treating with screw fixation.  At this time, the bur was brought in and small incision was made on the lateral side of the right hip.  Dissection was carried down to the femur through the IT band and the vastus lateralis was elevated off the bone.  We then placed a guidepin up into the center of the femoral head.  We then used the _____ to place two additional pins trying to stay within the posterior and inferior aspects of the femoral head for the best purchase.  Three consecutive screws were then placed under fluoroscopic control into the femoral head with excellent fixation.  Once this was done and the fixation was solid, the wounds were irrigated.  We then closed in layers using 0 Vicryl, 2-0 Vicryl, and staples for the skin.  Sterile dressing was applied.  My assistant was essential during this case.