#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.