#14. BRACHIOULNAR BYPASS GRAFT

PREOPERATIVE DIAGNOSIS: Right upper extremity ischemia; thrombosed right brachio-ulnar saphenous vein bypass graft.

POSTOPERATIVE DIAGNOSIS: Right upper extremity ischemia; thrombosed right brachio-ulnar bypass graft.

PROCEDURE:
1. Selective catheterization right brachial artery via right common femoral artery approach.
2. Selective right upper extremity angiogram.
3. StarClose right femoral artery.

SURGEON: Charles Wyble, MD

ASSISTANT:

ANESTHESIA: Conscious sedation (Versed 2.5 mg intravenous; fentanyl 75 mcg intravenous); 2% lidocaine solution.

ANESTHESIOLOGIST:

ESTIMATED BLOOD LOSS: Minimal.

SPECIMEN REMOVED:

COMPLICATIONS: None.

FINDINGS: Right upper extremity angiogram common femoral, mild irregularity in the mid right subclavian artery. An 8‑inch right axillary and brachial artery in the upper arm. Occluded right brachial artery near elbow. Occluded brachio‑ulnar bypass graft. Reconstitution of the probable interosseous artery in the forearm. Occluded right radial and ulnar arteries. Reconstitution of a possible radial palmar arch vessel.

INDICATIONS FOR THE PROCEDURE: The patient is a 19-year-old white male with a past medical history significant for right upper extremity ischemia experienced after a fall injury requiring right brachio-ulnar reversed greater saphenous vein bypass grafting and thrombectomy. His postoperative course was characterized by bypass graft thrombosis prompting thrombectomy. He was anticoagulated, but represented complaining of right arm pain with associated numbness and discoloration. Arterial duplex demonstrated a patent right brachial artery with an occluded bypass graft.

On physical examination, the right arm is viable, but ischemic. He now requires a right upper extremity angiogram for possible intervention and anatomic definition for possible repeat reconstruction. The risks and benefits were reiterated, not limited to bleeding, infection, artery injuring including thrombosis/dissection/embolism, needs for future reintervention, limb loss, and renal failure. He understands and wishes to proceed with the intervention.

DETAILS OF THE PROCEDURE: The patient was consented for right upper extremity angiography for possible intervention. He stayed in vascular institute and placed in a supine position on the table. After adequate conscious anesthesia was achieved, the right groin was prepped and draped in the usual sterile fashion. A 2% lidocaine solution was used to anesthetize the right groin region.

The right common femoral artery was access percutaneously with an 18-gauze Seldinger needle. A 0.035 Bentson wire was advanced without resistance into the infrarenal abdominal aorta. The needle was removed. A 6-French sheath was positioned within the right femoral artery. The inner dilator guidewire were removed. The sheath was irrigated with heparinized saline solution.

Selective catheterization of the right subclavian, axillary, and brachial arteries was performed using a catheter with a 0.035-angle guidewire. The patient was anticoagulated with heparin.

A selective right upper extremity angiogram was performed using sedations. Imaging revealed a patent right subclavian, axillary or brachial artery. There was mild irregularity in the mid right subclavian artery without evidence of dissection. The right brachial artery was occluded near the elbow. The right radial and ulnar arteries were also occluded. There was reconstitution of the interosseous artery in the forearm region. Images of the hand revealed reconstitution of a possible radial palmar arch segment. No intervention was recommended. Next, lytic therapy was contraindicated secondary to a recent cerebrovascular accident. The procedure was terminated.

The 5-F catheter was removed using the Bentson wire. StarClose of the right femoral common artery was performed. The right femoral sheath was removed and exchanged for the manufactured sheath. Inner dilator and guidewire were removed. The StarClose device was advanced in the port using the 4-step method. Pressure was applied with no hematoma formation. Sterile dressings were placed.

The patient tolerated the procedure well and was transported to the recovery area in stable condition. I was present for the entire procedure including selective catheter placement on the right brachial artery and selective right upper extremity angiography.

cc: Charles Wyble, MD office

#13. CORONARY ARTERY BYPASS GRAFTING

TITLE OF OPERATION: Coronary artery bypass grafting surgery.

DESCRIPTION OF OPERATION: The patient was delivered to the operating room and was placed upon the operating room table supine. Swan Ganz catheter and radial artery line were inserted. General endotracheal anesthesia was administered. The patient was prepared with Betadine and draped in a sterile fashion.
The saphenous vein was harvested from the lower extremity, sufficient for three bypass grafts. The tributaries of the vein were controlled with silk clips and silk ligatures. The venous bed was irrigated with antibiotic-containing saline and closed in layers.
The chest was opened through a median sternotomy incision. The left pleural cavity was opened and the left internal mammary artery was fully mobilized. The patient was heparinized systemically after which, the internal mammary was transected distally and prepared for anastomosis. The pericardium was opened. Arterial cannulation was achieved. The distal ascending aorta and venous were placed with a dual-stage venous cannula. Via the right atrial appendage, cardiopulmonary bypass was initiated.
The patient was cooled systemically to approximately 32 degrees C. With application of the aortic crossclamp, the cold blood cardioplegia solution was administered to effect a good cardiac arrest. Cardioplegia was administered in 15-20 minute intervals throughout the period of the aortic occlusion. After hypothermia was achieved, iced saline slush and phrenic nerve protector was employed. The distal anastomoses were accomplished first. Individual segments of reverse saphenous vein were sewn to the obtuse marginal, to the posterolateral branch of the circumflex artery, and to the distal right coronary artery respectively. Each of these anastomoses were carried out with running sutures of 7-0 Prolene. The left internal mammary artery was then brought through a window in the pericardium and was sewn to the left anterior descending vessel with a running suture of 8-0 Prolene. At the termination of this, warm blood cardioplegia was administered and the aortic crossclamp was then released. A partial occluding clamp was placed on the aorta. Three buttons of aortic tissue were excised and used as three proximal anastomoses for the saphenous grafts which were carried out with running sutures of 6-0 Prolene. Temporary pacing wires were placed on the surface of the right atrium and right ventricle.
With the patient fully re-warmed, the heart resumed a good contractility and resumed a normal sinus rhythm. The patient was weaned from cardiopulmonary bypass. This was tolerated without difficulty or need for inotropic support. Excellent Doppler signals were appreciated over all grafts. Protamine was administered to reverse the heparin effect. Decannulation was accomplished. All cannulation sites were reinforced. The patient's hemodynamics remained stable. The entire wound was inspected for hemostasis and was felt to be adequate. One mediastinal tube and one left pleural tube were placed.
The chest was closed in layers in the usual fashion and dry sterile dressing was applied. The patient tolerated the procedure well.

#12. CORONARY ARTERY BYPASS

TITLE OF OPERATION: Coronary artery bypass.

DESCRIPTION OF PROCEDURE: After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion. A median sternotomy incision was made and hemostasis was acquired with the electrocautery. The left internal mammary artery was harvested and prepared with papaverine and concurrent saphenous vein was harvested endoscopically.
After heparinization, deep pericardial retraction sutures were placed. A partial clamp was then placed on the ascending aorta and the saphenous vein graft was sewn end-to-side with a running 6-0 Prolene. It was then allowed to distend under arterial pressure.
The heart was elevated out of the pericardial cavity and the diagonal was isolated with the octopus stabilizer. The anastomosis was then performed utilizing a side-to-side 8-0 running technique with the left internal mammary artery. The continuation of the left internal mammary artery was then placed end-to-side to the left anterior descending artery with a running 8-0 Prolene technique.
The heart was strongly elevated out of the pericardial cavity and the anastomosis of the saphenous vein graft to the obtuse marginal one was completed end-to-side with a running 7-0 Prolene. The heart was then allowed to return to the pericardial cavity and preparations for wound closure were made.
The pericardium was loosely approximated with interrupted silk sutures. The mediastinum was drained with a single Silastic tube. The sternum was approximated with interrupted heavy wire and the presternal fascia was closed with a running 0-PDS. The skin was closed with a subcuticular 3-0 Monocryl.
Sponge and needle counts were correct. The technical aspects of the procedure were satisfactory and it is hoped that the patient will have a good operative result.

#11. HEMORRHOIDECTOMY

PREOPERATIVE DIAGNOSIS: Thrombosed hemorrhoids.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE PERFORMED: Hemorrhoidectomy times three.

SURGEON: Dr. Daffy Duck

ANESTHESIA: General.

FINDINGS: Large, circumferential prolapsed hemorrhoids, with partial thrombosis. Three of the largest hemorrhoids were excised, without complication. There was still hemorrhoidal tissue left at the conclusion, but I did not feel it was safe to do any further excision.

SPECIMEN: Hemorrhoids.

CULTURES: None.

DRAINS: None.

ESTIMATED BLOOD LOSS: 50 cc.

DRESSINGS: Xeroform pack and ABD.

COMPLICATIONS: None.

CONDITION: Stable.

OPERATIVE INDICATIONS: This is a 20-year-old female, one week postpartum, who presented to my clinic with excruciatingly painful hemorrhoids. She had had previous thrombosed hemorrhoid which was incised and drained in the clinic earlier in the pregnancy. She has not had a bowel movement in a week due to pain. On exam she had circumferential prolapsed hemorrhoids with partial thrombosis in multiple areas. I discussed hemorrhoidectomy with the patient and her sister. They understood and wished to proceed.

DESCRIPTION OF PROCEDURE: The patient was identified in the holding area and brought to the operating room where she was placed in the supine position. After induction of general anesthesia, she was prepped and draped in the usual sterile fashion. The legs were brought up in the lithotomy position and a retractor was placed in the anus. Very prominent, large, partially thrombosed, external hemorrhoid was identified at 7-8 o'clock in the lithotomy position. It was grasped with a hemorrhoidal clamp. A 2-0 chromic stitch was placed at the apex. The Bovie electrocautery was then used to elliptically excise the large hemorrhoid, staying superficial to the sphincter muscle. Hemorrhoid was then passed off as specimen. Further bleeding was controlled with Bovie electrocautery. The mucosa was closed with a running chromic stitch, leaving the end-point epidermis open.
Two other very large hemorrhoids with thrombosis were then identified, at the 5 o'clock position in lithotomy and at the 10-11 o'clock position. These two hemorrhoids were excised in the exact same fashion as the first hemorrhoid. At the conclusion, there was no evidence of bleeding. There was still some prominent hemorrhoidal tissue remaining. However, I did not feel any further excision would be safe at this time.
Xeroform wrapped around 4x4s was then placed in the anus as a dressing and ABD placed over the top. The patient was then awakened and taken to the recovery room in good condition. There were no operative complications.

#10. OPEN HEART SURGICAL PROCEDURES

PREOPERATIVE DIAGNOSIS: Severe coronary artery disease.

POSTOPERATIVE DIAGNOSIS: Severe coronary artery disease.

TITLE OF OPERATION: Coronary artery bypass grafting surgery.

ANESTHESIA: General.

DESCRIPTION OF OPERATIVE PROCEDURE: Under general anesthesia, the patient was prepped and draped in the usual sterile fashion. A midline sternotomy incision was made through the skin, the fascia was divided, and the sternum was divided with the use of the sternal saw.
The left internal mammary artery was harvested simultaneously with the video endoscopic harvesting of the right greater saphenous vein. Clips were placed on the branches.
The pericardium was opened. The patient was heparinized. Pericardial stays were used for retraction. The aortic pursestring was inserted. The atrial pursestring was inserted. The aortic line was inserted. The atrial line was inserted. The patient was placed on cardiopulmonary bypass. Cardioplegia was administered in an antegrade fashion via the aortic root. Crossclamp was applied. A good diastolic arrest was achieved and the clamp was placed on the surface of the right ventricle.
Attention was turned to the distal right coronary artery and origin of the acute marginal branch of the right coronary artery. An arteriotomy incision was made in the acute marginal branch. The saphenous vein was anastomosed to this in a running fashion using 7-0 Prolene. Attention was turned to the obtuse marginal of the circumflex artery. An arteriotomy incision was made and saphenous vein was anastomosed to this in a running fashion using 7-0 Prolene. Cardioplegia was administered at the end of each distal graft down through the graft and down through the aortic root to 250 cc. Attention was then turned to the left anterior descending artery. The left anterior descending artery was buried in the fat. The left internal mammary artery was anastomosed to the left anterior descending artery in a running fashion using 7-0 Prolene. A good flush was noted.
The flow was turned down. The crossclamp was removed. The side biter was applied to the aorta and the two proximals were anastomosed to the aorta, one from the obtuse marginal and one from the acute marginal. Prolene 6-0 was used to perform these anastomoses. Marking rings were placed on each of these. The flow was turned down. The side biter was removed. All grafts were deaired.
Flow was resumed to all grafts. The heart began in a normal spontaneous rhythm. The left chest was aspirated. The lungs were inflated. The patient was weaned from cardiopulmonary without difficulty. Pacing wires were placed on the right ventricle and brought out on the left lateral aspect of the incision. All lines were removed. Protamine was administered. Hemostasis was secured from all sites, including the skin fat, the mammary bed, and all cannulations, all proximal and distal anastomotic sites.
The incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 0-Vicryl suture used to approximate the muscle, 2-0 Vicryl to approximate the subcutaneous tissue, and 4-0 Vicryl subcuticular closure used to approximate the skin.
The patient tolerated the procedure well and returned to the recovery room in stable condition. All lap, instrument, and needle counts were correct

#9. KNEE ARTHROSCOPIC DICTATION

DESCRIPTION OF THE PROCEDURE: He was placed supine on the operating room table. After a suitable anesthetic was obtained by general anesthetic, the right lower extremity was prepped and draped in the usual sterile fashion for arthroscopic surgery. The right lower extremity was then exsanguinated with the use of an Esmarch bandage and the tourniquet was inflated to 350 mmHg.
The operation commenced with creation of the inferolateral portal. The arthroscope was directed into the suprapatellar pouch with the knee held in extension. A systematic examination of the right knee was begun arthroscopically. The patellofemoral articulation was visualized and the findings were as noted above. The majority of the patellar articulating surface was felt to be in good shape. The medial gutter was entered. No loose bodies were identified. The medial compartment was then entered and the inferomedial portal was established under direct visualization. The arthroscopic probe was used to inspect the contents of the medial compartment with the findings as noted above.
At this point, using a series of straight upbiting and curved meniscal punches, the posterior horn of the medial meniscus was resected to a stable base. This was further improved with the use of a 4.5 sucker shaver. The notch was then visualized. The anterior cruciate ligament was inspected with the findings as noted above. Intraoperative Lachman's testing was negative. The arthroscope was directed into the lateral compartment with the findings as noted above.
The instruments were then removed. The portals were closed with 4-0 nylon and Xeroform and a light compressive dressing was applied. A mixture of Marcaine and Astramorph was injected into the right knee and Ace bandage wrap was applied. The tourniquet was deflated and a Dura-Kold compression ice wrap was applied. The patient was recovered from his anesthetic and was returned to the recovery room in stable condition. There were no complications.

#8. TORN LIGAMENT REPAIR - KNEE

PREOPERATIVE DIAGNOSIS: Right knee pain and medial meniscus tear.

POSTOPERATIVE DIAGNOSIS: Right knee pain and medial meniscus tear.

PROCEDURES PERFORMED: (1) Right knee examination under anesthesia with diagnostic arthroscopy. (2) Partial medial meniscectomy, right knee.

DESCRIPTION OF OPERATIVE PROCEDURE: After placement of general anesthesia, the patient's right knee was prepped and draped in the routine fashion for knee arthroscopy. Examination revealed no instability and full range of motion. The knee was arthroscoped through the standard medial and lateral portals. The entire knee joint was evaluated. The suprapatellar region showed fairly normal appearing patella with minimal chondromalacia. There was a medial shelf plica present which was small and appeared to be within normal limits. The medial compartment, however, showed a complex horizontal cleavage tear of the medial meniscus, involving the posterior 40-50% of the undersurface of the meniscus. Fragmented tissue was present in the joint. Photographic record was made.
The anterior cruciate ligament was intact and the lateral compartment showed an intact lateral meniscus. With the motorized debrider and basket forceps, the meniscus was trimmed to a smooth, stable rim. Only the torn tissue was resected.
The knee was then copiously irrigated. All fragmented tissue was removed. The arthroscope was removed. The skin portals were closed with a single 4-0 nylon stitch. The knee was injected with 20 cc of Marcaine and 1 cc of Kenalog 40. The patient was awakened and taken to the recovery room in stable condition. There were no complications. All sponge and instrument counts were correct.

#7. REVISION OF KNEE REPLACEMENT

PREOPERATIVE DIAGNOSIS: Painful right total knee replacement.

POSTOPERATIVE DIAGNOSIS: Painful right total knee replacement.

OPERATION PERFORMED: (1) Revision right total knee patellar component. (2) Polyethylene exchange, right total knee. (3) Open arthrolysis, right knee.

ANESTHESIA GIVEN: Epidural.

INDICATIONS FOR PROCEDURE: See the History and Physical report.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room. He was placed supine on the operating room table. After a suitable anesthetic had been obtained by an epidural anesthesia, the right lower extremity was prepped and draped in the usual sterile fashion. The right lower extremity was then exsanguinated with the use of an Esmarch bandage and the tourniquet was inflated to 350 mmHg.
The operation commenced with a midline right knee incision that incorporated his previous right total knee replacement incision. This incision was deepened through skin and subcutaneous tissues and the extensor mechanism was exposed. A standard medial parapatellar incision was then made and a laterally-based quadriceps snip was performed to allow for safer mobility of the patella. Subperiosteal dissection was performed along the medial tibial plateau and remaining osteophytes were removed. The patellar tendon was seen to be fibrotic and thickened and the undersurface of the patellar tendon was debrided. With the patella everted, rongeurs and Bovie electrocautery were used to expose the patellar component. The polyethylene was removed, leaving the undersurface metal backing. This was seen to be extremely well affixed and it was felt that to downsize the patella to eliminate patellar overstuffing, that the patella would need to be revised. Flexible and rigid, straight and curved, osteotomes were utilized to separate the metal backing from the underlying bone. This resulted in a significant amount of fragmentation of the periphery of the patella.
The patellar component was ultimately removed, and again, was seen to be well affixed, including bone ingrowth on the three fixation pegs. Attention was now turned towards the tibial side. The tibial bone interface was exposed medially and laterally and there was seen to be no gross motion of the patella. This was performed after removing the rotating patellar platform. The osteotomes were used along the anterior edge and cephalad directed burs with mallet in several different positions were attempted, again without any evidence of tibial side loosening. At this point, it was felt that with the expected bone ingrowth along the tibial stem, that to remove the tibial component would create a significant undue stress on normal bone, and it was felt that the majority of the patient's complaints could be addressed by addressing patellar overstuffing and arthrofibrosis. Arthrolysis was completed in both medial and lateral gutters in the suprapatellar pouch region and in the parapatellar region.
A standard plus/large size 10-mm thick rotating platform trial was then implanted and the knee was taken through a range of motion. There was seen to be approximately 5-10 degrees of recurvatum and flexion easily to 120 degrees. There was good medial, lateral, and AP stability noted. It was felt that this would be the appropriate polyethylene sized insert to implant. The implant was removed and the knee was then copiously irrigated with pulsatile lavage containing antibiotic solution. Deep cultures were obtained for aerobic and anaerobic cultures. A DePuy LCS standard plus/large sized deep dish rotating platform insert was then placed. The knee was then brought back into extension and once again, range of motion and stability were checked.
Attention was now turned towards the patellar side. Using a three-peg polyethylene guide, three drill holes were made in the base of the patella and an LCS three-peg polyethylene patellar insert of standard plus size was cemented into position. Excessive cement was retrieved and loose bone from the patella as well as bone removed from the prominent tibial tubercle ossicle (history of Osgood-Schlatter disease), was morcellized and placed around the periphery of the polyethylene insert. These morcellized bone segments were then gently secured with 2-0 Vicryl by closure of soft tissues around the implant. Patellar tracking was checked and was felt to be excellent and preparations were made for closure.
Consta Vac drains were brought out superiorly and the medial parapatellar incision and lateral leg of the quadriceps snip were repaired with interrupted #2 Ethibond and interrupted 0-Ethibond suture. Once again, the wound was irrigated. The subcutaneous tissue was closed with 2-0 Vicryl. The skin was closed with staples. A light compressive dressing was applied followed by Ace bandage wrap. The tourniquet was deflated. A right lower extremity knee immobilizer was placed. The patient was recovered from the anesthetic and returned to the recovery room in stable condition. There were no complications.

#6. INTERTROCHANTERIC HIP FRACTURE

PREOPERATIVE DIAGNOSIS: Right hip comminuted intertrochanteric hip fracture.

POSTOPERATIVE DIAGNOSIS: Right hip comminuted intertrochanteric hip fracture.

OPERATION PERFORMED: Open reduction and internal fixation of right intertrochanteric hip fracture, with a four-hole, 135-degree DHS plate an 80-mm hip screw.

ESTIMATED BLOOD LOSS: Approximately 100 cc.

DRAINS: None.

ANESTHESIA GIVEN: Spinal.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is an 88-year-old female, who sustained a right intertrochanteric hip fracture after a fall. She was admitted for a preoperative medical clearance and to be taken to the operating room for an open reduction and internal fixation of the right hip fracture. Consent is signed on the chart. All risks and benefits regarding the procedure were explained: Risks of death, infection, nerve or blood vessel injury or bleeding, need for blood transfusion, blood clots, failure to heal, need for further surgery were all explained and consent was signed.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was given Ancef 1 gram intravenously in the holding area. She with then taken to the operating room where a spinal anesthetic was placed by the anesthesia service on the hospital bed. She was then transferred over to the fracture table in the supine position where a well-padded post was positioned. The left lower extremity with a thigh-high TED stocking was placed into the thigh/leg support with foam padding over all bony prominences. The left lower extremity had abundant padding placed around the foot and ankle region and was then placed in the foot and ankle support. Next, the right hip was visualized under AP and lateral fluoroscopic views. The femoral head and neck were well-visualized in both planes at this time. Next, the right hip was prepped and draped in the usual sterile fashion utilizing Betadine prep followed by toweling out and holding the towels with staples, followed by drying, followed by placement of a shower curtain. Next, a guidepin was placed over the hip and an AP fluoroscopic view taken.
Next, the proposed skin incision of approximately 12-cm in length was marked on the skin. The skin incision was then made with a #10 blade, going down through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. The IT-band was split longitudinally with electrocautery. Next, the vastus lateralis was elevated and the posterior one-third was split longitudinally with electrocautery, also with use of a Key elevator, followed by placement of a Bennett leg loose retractor. The vastus lateralis was further developed with electrocautery at this time to expose the lateral femoral shaft. Next, the 135-degree guide with the pin was placed on the lateral femoral shaft and the guidepin was advanced through the lateral cortex into the femoral neck and checked under the lateral view, found to be in good position, and advanced into the head region, again checked under AP view, and then advanced into subchondral bone, again checked on the lateral view, and found to be in good position. This was then measured. It measured 90-mm. We therefore decided to triple ream to 80-mm and place an 80-mm hip screw. Triple reaming was performed under AP fluoroscopic guidance. Next, the 80-mm hip screw was placed, again under fluoroscopic guidance, and once felt to be in the correct position, it was checked again under the lateral view and found to be within the femoral head nicely. Back to the AP view, it was again visualized. The fracture was well reduced. The screw was in good position. The four-hole, 135-degree plate was advanced over the connector onto the screw and gently seated against the lateral femoral cortex. The connectors and guidepin were then removed. The plate was gently impacted with a plastic impactor and mallet. Once fully seated, it was manually held in this position. The most distal hole in the plate was filled by drilling through both cortices, followed by depth gauge tapping, and placement of a propylene fully-threaded 4.5 cortical screw. The remainder of the holes in the plate were filled in a similar manner by drilling through both cortices, followed by depth gauge, and placement of the appropriate length 4.5, fully-threaded self-tapping screws. All screws were again securely tightened. The locking nut/screw was placed into the hip screw portion and was fully tightened. The entire contents were again checked under AP and lateral fluoroscopic views with hard copies printed off the C-arm. Everything looked nicely reduced and all hardware was in good position.
The site was again copiously irrigated with normal saline solution. The IT-band was closed with 0-Vicryl figure-of-eight interrupted sutures. The subcutaneous tissue was again irrigated with normal saline solution and the subcutaneous tissue was closed with 2-0 Vicryl interrupted sutures and the skin was closed with staples, followed by placement of Adaptic, 4x4s, ABD dressing, and elastic tape. The patient was then gently transferred back to the hospital bed and transferred to recovery without difficulty.

#5. CARPEL TUNNEL RELEASE

PREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.

OPERATION PERFORMED: Neurolysis of the median nerve, right carpal canal.

SURGEON: Michael Jones, M.D.

ANESTHESIA GIVEN: Local sedation.

DESCRIPTION OF OPERATIVE PROCEDURE: After adequate anesthesia was obtained, the patient's right arm was prepped and draped in the usual sterile fashion. After exsanguination with an Esmarch bandage, the tourniquet was inflated to 250 mmHg. At this point, an intrathenar incision was made from the level of the distal palmar crease and in line with the flexion crease. It was carried down to the subcutaneous tissue. The transverse carpal ligament was identified and incised. A hemostat was placed on the ulnar side of the carpal canal. The transverse carpal ligament was lysed from proximal to distal. The forearm fascia was split proximally. The median nerve was neurolysed in its entirety. The floor of the carpal canal was inspected and noted to be free of osteophytes and tumors. The wound was irrigated out and was infiltrated with Marcaine. The skin was then closed with 5-0 nylon sutures. A sterile dressing with a volar splint was applied. The patient was taken from the operating room to the recovery room in good condition.

FINAL DIAGNOSIS: Right carpal tunnel syndrome.

#4. ACROMIOPLASTY SAMPLE

PREOPERATIVE DIAGNOSIS: Impingement syndrome, left shoulder.

POSTOPERATIVE DIAGNOSIS: Impingement syndrome, left shoulder, with acromioclavicular spurs.

OPERATION: Arthroscopic evaluation of the glenohumeral joint, followed by arthroscopic bursectomy and anterior acromioplasty with co-planing of the acromioclavicular joint spurs.

ANESTHESIA: General.

SURGEON: Andrew Jackson, M.D.

ASSISTANT: A. Lincoln, S.A.

SUMMARY: The patient was given a general anesthetic and placed in the beach-chair position with the head rest. He was secured and strapped down. His shoulder was prepped and draped free in a standard sterile fashion.
A posterior approach was made to the glenohumeral joint and the probe and shaver were introduced through an anterior portal which was just medial to the coracoid. The shoulder was inspected and no undersurface tears were identified. There was some redundant synovitis in the joint superiorly along the labral attachment and that was debrided back. The long head was intact. We then withdrew and went into the subacromial space. A portal was established at the anterolateral corner and a shaver was introduced laterally. The shaver was introduced laterally and used to debride the bursa. The debridement was swept anteriorly and the subacromial space was opened up. The Bovie electrocautery instrument was introduced from the lateral portal and we started in the center of the acromion and worked our way anteriorly and medially to the acromioclavicular joint. The acromioclavicular joint was exposed because we knew that he had spurs there that needed debriding. The anterior edge of the anterior acromial space was identified and opened up. The coracoacromial ligament was divided. Hemostasis was achieved with the ArthroCare wand. Once the anterior acromial spur and the acromioclavicular joint spurs were well identified, the portals were switched and we placed the bur from the posterior portal and the scope anteriorly. The flat spot of the acromion was identified and an anterior acromioplasty was done, removing about 5-6 mm anteriorly. The ridge of spurs on the acromioclavicular joint were also debrided with the bur. We did the majority of the bony burring from the posterior portal and then switched the bur laterally to round off the anterior edge of the acromion and smooth out the acromioclavicular joint. The exterior of the rotator cuff was inspected and no defects or tears were encountered.
The wound was flushed out and the portals were closed with a single stitch. A sterile dressing was applied and the patient was recovered from his anesthetic and taken to the recovery room in good condition.

#3. SHOULDER - ACROMIOPLASTY / MUMFORD PROCEDURE

PREOPERATIVE DIAGNOSES: (1) Massive tear of the right rotator cuff. (2) Acromioclavicular arthritis. (3) Severe impingement syndrome of the right shoulder.

POSTOPERATIVE DIAGNOSES: (1) Massive tear of the right rotator cuff. (2) Acromioclavicular arthritis. (3) Severe impingement syndrome of the right shoulder.

OPERATION PERFORMED: (1) Manipulation under anesthesia. (2) Anterior and inferior acromioplasty. (3) Mumford procedure. (4) Repair of the right rotator cuff.

SURGEON: A. Lincoln, M.D.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 20 cc.

POSTOPERATIVE IMMOBILIZATION: Sling.

DESCRIPTION OF OPERATIVE PROCEDURE: Under satisfactory anesthesia, the patient was put in a semi-sitting position on the table and the right shoulder was prepped and draped in the usual sterile manner.
An anterior incision was made from the acromioclavicular joint distally and it was carried down through the subcutaneous fascia. The deltoid muscle and fascia were exposed. The portion between the anterior and lateral segment of the muscle was opened bluntly and anterior capsule of the joint was exposed. The incision was then extended proximally in a T-shape and the horizontal portion was on the acromion. This gave an access to the acromion laterally and also to the acromioclavicular joint medially. The joint was then cleaned, and protecting the soft tissue, 1-cm of the clavicle was excised. A significant impingement was encountered due to an overhanging anterior acromion. Acromioplasty was done using the oscillating saw and the anterior acromion was excised and this was followed by removal of the inferior acromion, creating a significant amount of room for the subacromial contents. After this was accomplished, the bursa was opened and a very large tear of the right supraspinatus was noted. The edge of the tendon was freshened with a fresh knife and approximately 1-mm of that edge was removed in order to gain fresh tissue. The greater tuberosity was then trimmed and a raw bone was produced by the oscillating saw. Two drill holes were introduced into the greater tuberosity from distal to proximal part, with the hole exiting just next to the ruptured portion of the cuff. Two #5 Ethibond were then passed through those holes and through the ruptured portion of the cuff and was tightly sutured. This completely closed the gap which he had due to the rupture. Several small 0-Ethibond sutures were used to reinforce the cuff on the lateral and medial side. The arm was put on internal rotation and no major tear was encountered in the infraspinatus and the teres minor.
Next, was repair of the deltoid back to the acromion two drill holes. A corner suture was applied on the acromion accommodating the two portions of the deltoid, medially and laterally. This was followed by closing the acromioclavicular joint and the rest of the tissue of the incision laterally, using 0-Ethibond suture. The rest of the deltoid fascia was closed using 2-0 Vicryl. The subcutaneous tissue was then closed using 2-0 Vicryl. The skin was closed using 4-0 Monocryl in a subcuticular fashion. Then a sterile dressing and a sling were applied. The patient returned to the postanesthesia care unit in satisfactory condition.

#2. OPEN REDUCTION AND INTERNAL FIXATION - ANKLE FRACTURE

PREOPERATIVE DIAGNOSIS: Right bimalleolar fracture.

POSTOPERATIVE DIAGNOSIS: Right bimalleolar fracture.

OPERATION PERFORMED: Open reduction and internal fixation.

SURGEON: George Washington, M.D.

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: The patient is a 59-year-old active female who sustained a displaced bimalleolar fracture a couple of days ago. She has been splinted and she has been elevating the extremity to control her swelling. She is brought to the operating room now to reduce her fractures and to restore her mortis congruity and stability. The risks and benefits as well as the alternatives to surgical treatment were discussed. The risks discussed included, but were not limited to, bleeding, infection, nerve or vessel injury, malunion, nonunion, failure of fixation, need for further operation, painful and retained hardware, as well as continued postoperative stiffness, pain, and inability to return to desired level of function. The risks associated with general anesthetic likewise were discussed and consent obtained to proceed.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room where, in a supine position, general endotracheal anesthesia was induced. The right lower extremity was then prepped and draped in the usual sterile fashion. The limb was exsanguinated with gravity and the tourniquet inflated to 300 mmHg. The surgical incisions were marked out with a pen, prior to inflation. Medially, she did have some fracture blisters proximally but they were proximal to the proposed medial incision, as anticipated.
Attention was turned to the lateral malleolus first. An approximately 10-cm longitudinal incision was made with the #15 blade. Dissection was carried down sharply to the level of the fracture site. Fracture hematoma and interposed soft tissue was cleared. A pointed reduction clamp was used to facilitate reduction and it was reduced nicely under direct visualization. Anteriorly, there was some comminution associated with a soft tissue attachment, but the primary fracture line was nicely reduced. An interfragmentary screw was then placed from anterior to posterior after overdrilling the proximal cortex. It was measured, tapped, and then a screw of appropriate length was placed. The fracture site was then stable. The mini C-arm was brought in and this demonstrated that the fibular link had been nicely restored. A six-hole one-third tubular plate was then contoured to fit the lateral aspect of the fibula. It was then affixed to the fibula using cortical and cancellous screws of appropriate length. All achieved good fixation. Titanium implants were used because the patient has a nickel allergy. The fluoroscan was brought in again and it verified again appropriate position of all the implants. A single distal screw was a little bit too long, about 1-mm or so into the ankle joint itself, so this was exchanged.
Attention was then turned medially. An approximately 3-cm longitudinal incision was made, centered over the medial malleolus. A #15 blade was used to create this and dissection was carried down sharply to the fracture site itself. Once again, fracture hematoma was cleared as well as some interposed soft tissue. After restoring the fibular length, the ankle mortis was nicely reduced. The medial malleolar fragment was then reduced directly using a sharp reduction instrument and it was nicely reduced externally. A 2-mm K-wire was introduced from distal to proximal to secure this fragment. A 2.5-mm drill was then used in a parallel fashion posterior to this. The C-arm was brought in and this verified that the medial malleolus was nicely reduced and the mortis was congruent. For that reason, the K-wire and the drill were both replaced using partially-threaded cancellous screws which achieved good interfragmentary fixation. The small C-arm was once again brought in and this verified once again that the fracture fragments were nicely reduced. The mortis was congruent and the implants were in appropriate position. The fixation was stable throughout a full passive range of motion. This was verified in all views. Both wounds were then copiously irrigated. The subcutaneous tissues were closed using interrupted 3-0 Vicryl. The skin was closed using interrupted 3-0 nylon, both medially and laterally. A sterile compressive dressing was applied. A very well-padded posterior splint was then applied with medial and lateral supports so as to keep the foot in a position of neutral dorsiflexion. The tourniquet was released. The foot was well perfused.
The patient was awakened, extubated, and transferred to a recovery room bed. She was transferred to the recovery room in stable condition.

#1. RETAINED ABDOMINAL SUTURES

PREOPERATIVE DIAGNOSIS: Retained abdominal sutures.

POSTOPERATIVE DIAGNOSIS: Same.

ATTENDING SURGEON: Dr. Elmer Fudd.

RESIDENT SURGEON: Dr. Daffy Duck.

ANESTHESIA: MAC.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None. The patient tolerated the procedure well.

PROCEDURE PERFORMED: Removal of abdominal sutures.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where she was placed comfortably supine on the operating table. She was then placed under the care of the anesthesiologist for monitored anesthesia. The abdomen was prepped and draped in the usual sterile fashion. A total of 4 cc of 1% lidocaine with 1:100,000 epinephrine was injected subcutaneously down the midline of the abdomen, over the previously-healed incision.
Using a #15 Bard-Parker surgical blade, six small incisions of approximately 1.5 cm in length were made over the previously-healed incision in the midline. Using hemostats, blunt dissection was performed in order to locate the abdominal sutures. In this manner, the sutures were located and subsequently removed from the abdomen. The incisions were then closed with a 4-0 Vicryl subcuticular suture. Steri-Strips were placed over the wounds, followed by placement of a bandage that was secured with tape.
The patient tolerated the procedure well. On being taken from the operating room, her vital signs were stable and she had spontaneous respirations.