CRNA provided the anesthesia care without medical direction.
CRNA provided the anesthesia care without medical direction. The patient’s physical status was -P3. The base for this procedure is 6 units. The anesthesia time is 0736 to 0816. Time units are based on 15-minute increments. Round up after 7-½ minutes. What are the total units for this case? LOCATION: Inpatient, Hospital PATIENT: Gretel Valance PHYSICIAN: Gregory Dawson, M.D. ANESTHESIOLOGIST: CRNA.
PREOPERATIVE DIAGNOSIS: Malignant right pleural effusion. POSTOPERATIVE DIAGNOSIS: Same.
INDICATIONS: The patient is an elderly lady with a history of cervical or endometrial cancer. She has now been found to have a large malignant pleural effusion and positive cytology. She presents to have definitive drainage of this. While additional procedures, such as open biopsy of enlarged lymph nodes in the groin and insertion of a Mediport catheter have been discussed with her, she preferred to have only the placement of the Pleurx catheter at this time.
OPERATION: Insertion of right Pleurx catheter under local anesthesia and sedation.
HISTORY AND FINDINGS: The patient is an elderly lady with a history of cervical or endometrial cancer, who has now been found to have a large malignant pleural effusion and positive cytology. She enters the operating room to have definitive drainage of this.
At surgery, 1000 ml of bloody fluid was easily removed from her chest. She tolerated this very well.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and sedated with intravenous sedation. She was kept supine and the right chest carefully prepped and draped in a standard manner. An area just caudal to the right breast was carefully selected, and this area was first numbed with 1% local Xylocaine. A 22-gauge needle was used to aspirate this space and revealed bloody pleural effusion. A wheal of anesthetic was carried out in this location and a long subcutaneous tunnel extending anteriorly along the lateral and anterior chest wall. A second skin wheal was made 6 cm anterior to this first opening. Two 1-cm incisions were now made in these 2 areas of skin wheals. The chest was entered with a finder needle and Angiocath posteriorly and then guidewire placed into the pleural cavity. Through the anterior wound, a tunnel was now created to connect through to the posterior wound, and then the Pleurx catheter was introduced with its blunt introducer through the anterior wound and threaded to the posterior wound, leaving the Velcro cuff in the subcutaneous position. The guided introducer sheath was now placed over the introducer wire into the chest. Once the introducer was removed, then the Pleurx catheter was threaded through the introducer sheath into the pleural cavity and the peel-away sheath removed. Function of the Pleurx catheter was assured by attaching it to suction, and it seemed that this functioned normally. Bloody fluid 1000 ml was drained and submitted for cytology and additional cytogenetic studies. Then the 2 small openings were closed using 3-0 Vicryl for the subcutaneous tissues and a 4-0 intracuticular Vicryl for the skin. Dermabond was placed onto the posterior opening, and a 3-0 silk suture was used to secure the Pleurx catheter anteriorly. A sterile dressing was applied, and the Pleurx catheter was capped.
The patient was now in stable condition and was fairly awake. She was transferred back to her room on the 4th floor in stable condition.
Pathology Report Later Confirmed: Large malignant pleural effusion and positive cytology.
2. The anesthesia service was provided by the CRNA with anesthesiologist medically directing 3 concurrent cases. The patient’s physical status was -P2. LOCATION: Inpatient, Hospital PATIENT: Carol Tigerton PHYSICIAN: Mohomad Almaz, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Right hallux valgus.
2. Right second metatarsophalangeal joint degenerative arthrosis.
3. Right metatarsalgia.
POSTOPERATIVE DIAGNOSES: Same.
PROCEDURES PERFORMED:
1. Right chevron osteotomy.
2. Right distal soft tissue procedure.
3. Right second MTP joint arthrotomy with synovectomy, debridement, and removal of multiple loose bodies.
4. Right second proximal phalanx base resection with excision of osteophytes from the second metatarsal head.
ANESTHESIA: Right ankle block plus intravenous sedation.
INDICATIONS: This patient is a 77-year-old woman with a long history of a painful bunion on her right foot associated with second metatarsophalangeal joint arthrosis with metatarsalgia. Patient has pain, loss of motion, and difficulty with shoe wear. She has failed conservative therapy and is functionally limited by her symptoms, and she is requesting operative intervention. The risks, benefits, indications, alternatives, and limitations of surgery were discussed with the patient, and all of her questions were answered. Informed consent was obtained for the above procedures. Patient had a preoperative history and physical and was cleared for surgery by anesthesia prior to the surgical date. Patient understands the elective nature of the procedure, and she wishes to proceed. She understands the risks of surgery, which include but are not limited to damage to blood vessels and nerves; wound complications and infection; nonunion or malunion; recurrence; persistent or worsening pain, deformity, or stiffness; and the possible need for future surgery.
PROCEDURE: The patient was seen in the preoperative holding area and was felt to be stable to undergo operative intervention. The appropriate operative limb was marked. She was given preoperative antibiotics. The patient was then brought to the block room, where a right ankle block was performed by the anesthesia service under sterile conditions, which she tolerated well, with no complications.
The patient was brought into the operating theater and placed supine on the operating table. All bony prominences were appropriately padded. Intravenous sedation was administered and monitored by the anesthesia service during the case. The right lower extremity was sterilely prepped and draped in the usual, standard fashion. An Esmarch bandage was used to exsanguinate the foot and was left wrapped above the ankle to provide a tourniquet effect during the case.
An incision was made dorsally in the 1st web space. This began just medial to the base of the second proximal phalanx and was extended down to the medial aspect of the second metatarsophalangeal joint, where it was curved more medially to overlay the web space. The incision was carried through the skin and subcutaneous tissue, with care being taken to avoid damage to small blood vessels and nerves. Hemostasis was controlled using Bovie electrocautery.
Attention was then directed to the first web space. The dissection was carried medially until the first web space was exposed. Dissection was carried through the adventitial bursa, which was released. Once this was performed, the transverse and oblique heads of the adductor tendon were noted. These were then released from their insertions.
Next, the transverse metatarsal ligament was identified and divided in its midline. Care was taken to prevent damage to the underlying neurovascular structures. The lateral capsule was then piecrusted, and the interval between the lateral sesamoid and 1st metatarsal head was incised open and mobilized. Once this was performed, the sesamoid complex was able to be passively reduced onto the 1st metatarsal head. No additional tight soft tissue structures were noted.
Attention was then directed to the medial aspect of the hallux metatarsophalangeal joint. An incision was made over the medial aspect of the joint beginning at the base of the proximal phalanx and extending to the neck of the first metatarsal. The incision was carried through the skin and subcutaneous tissue, with care being taken to avoid damage to small blood vessels and nerves. Hemostasis was controlled using Bovie electrocautery. Dissection was carried full thickness down to the capsule and dorsal and plantar flaps were elevated off of the capsule, with care being taken to avoid damage to small blood vessels and nerves. The dorsomedial cutaneous nerve was identified, mobilized, and retracted out of the surgical field. Once the capsule was fully exposed, a distally based, inverted L-shaped capsulotomy was performed. The vertical limb was created approximately 2 to 3 mm from the joint. It was begun on the dorsal aspect of the joint and carried down to the level of the abductor tendon. The dorsal limb was then extended proximally. The capsule was then dissected off of the metatarsal head.
At this point, the lst metatarsophalangeal joint was inspected. There was some synovitis, which was debrided with a rongeur. The articular cartilage was intact, without unstable cartilage or loose bodies. There were no full-thickness lesions, although the cartilage was thinned out centrally. Next, the medial eminence was excised approximately 1 to 2 mm medial to the sagittal sulcus from a distal to proximal direction using a Synthes flexible chisel. Once this was performed, the center of the metatarsal head was marked with a K-wire. Next, a 60-degree chevron cut was made using a sagittal saw. The apex was at the center of the metatarsal head. Once the cuts were made, the distal fragment was displaced approximately 4 to 5 mm laterally. This was then impacted manually. This was then stabilized using a 0.045 mm K-wire introduced from a dorsal to plantar direction. Position of the osteotomy and K-wire was checked using fluoroscopy in multiple planes, including an AP/lateral and oblique of the foot, and were felt to be good. The K-wire was removed and replaced with a 14-mm Ace breakaway screw. Once the screw was fully inserted, this resulted in excellent fixation and compression across the osteotomy. Final position of the osteotomy and hardware was checked using fluoroscopy in multiple planes, as above, and was felt to be excellent. The prominent medial bone was then debrided with a rongeur and smoothed off with a rasp.
Attention was then directed to the second metatarsophalangeal joint. A longitudinal capsulotomy was made just medial to the extensor digitorum longus tendon. This was carried through the extensor mechanism and dorsal capsule down to the skeletal plane. The joint was then exposed using subperiosteal and subcapsular dissection. In the dorsal joint space, 2 large loose bodies were noted, and these were excised. There were massive hypertrophic exostoses on both the head of the second metatarsal and the base of the proximal phalanx. These were excised using a Synthes flexible chisel. Once the joint was fully debrided of these osteophytes, the joint could be inspected. There was complete loss of articular cartilage on both the base of the proximal phalanx and the head of the second metatarsal. At this point, it was decided to proceed with resection arthroplasty of the joint. The base of the proximal phalanx was then excised using a sagittal saw. The cut was angled from a dorsal and distal to plantar and proximal direction, such that the plantar plate was left intact.
At this point, it was felt that the joint was adequately decompressed. Further debridement of the second metatarsal head was performed with a rongeur. The joint was then copiously irrigated with sterile saline. Note should be made that there was abundant fibrous tissue as well as hypertrophic synovium within the joint which was excised sharply. Next, the joint was stabilized using a 0.0625 mm K-wire. The K-wire was introduced into the base of the proximal phalanx and driven out the tip of the toe. Distraction was then made at the joint, and the K-wire was advanced across the metatarsophalangeal joint and into the second metatarsal. Clinically, the alignment of the toe was good, and this was confirmed fluoroscopically in multiple planes.
The hallux was positioned in slight varus overcorrection and in neutral dorsiflexion and rotation. Redundant capsule was excised sharply, and the capsule was repaired and imbricated using 2-0 Vicryl sutures. Once this was performed, the hallux was felt to be in good position clinically, and this was confirmed fluoroscopically in multiple planes, as above.
The second metatarsophalangeal joint capsule as well as the extensor hood were repaired with 2-0 Vicryl sutures. At this point, the tourniquet was released. Total tourniquet time was approximately 100 minutes. Please see the anesthesia and nursing records for the exact tourniquet time. Hemostasis was then controlled using Bovie electrocautery and digital pressure. All of the toes were pink and warm with brisk capillary refill after release of the tourniquet. At this point, clinically, the alignment of the first and second toes was felt to be good, with stable-appearing hardware. This was confirmed fluoroscopically in multiple planes, as above.
The wounds were then copiously irrigated with sterile saline. The wounds were then closed in layers using 4-0 Vicryl sutures to approximate the subcutaneous tissue and 4-0 nylon interrupted, simple sutures to reapproximate the skin. The wounds were then dressed with Xeroform, sterile 4 x 4’s, and sterile Webril. A soft forefoot dressing was applied and overwrapped with an Ace wrap, and the patient was placed into a postoperative shoe. The patient was then transferred to her hospital bed and was brought to the recovery room in stable condition without difficulty.
All sponge and needle counts were correct at the end of the case, and there were no perioperative or intraoperative complications.
Pathology Report Later Indicated: Bony osteophytes and tissue inflammation, benign.
3. The CRNA provided the anesthesia care with medical direction of the anesthesiologist who was directing this case and 3 other concurrent cases. The patient’s physical status was -P1. LOCATION: Inpatient, Hospital PATIENT: Sarah Simmers PHYSICIAN: Andy Martinez, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSIS: Chronic pelvic pain with history of adhesiolysis.
POSTOPERATIVE DIAGNOSES:
1. Chronic pelvic pain with history of adhesiolysis.
2. Thin pelvic adhesions.
PROCEDURE PERFORMED: Diagnostic laparoscopy with adhesiolysis. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Less than 1 ml. FLUIDS: 1200. URINE OUTPUT: 50 COMPLICATIONS: None.
INDICATIONS: Patient presents with chronic pelvic pain failed conservative management. Due to history of pelvic adhesions patient presents for diagnostic laparoscopy and treatment of adhesions if found. Risks were discussed and patient wishes to proceed.
FINDINGS: Thin film adhesions in the pelvis and the small-bowel which were lysed and then the omentum was adherent to the anterior abdominal wall.
PROCEDURE: The patient was prepped and draped in the lithotomy position under general endotracheal anesthesia and the bladder was straight catheterized. A sponge stick was placed in the vagina. A 1-cm transverse infraumbilical incision was made. The Veress needle was placed in the abdominal cavity. The abdominal cavity was insufflated with 3 liters of CO2. The Veress needle was removed and the sharp trocar and sheath placed in the abdominal cavity under direct visualization. Sharp trocar was removed. A lighted scope was reinserted in the abdominal cavity. Pelvic contents were inspected.
Findings were the omentum was then adherent to the anterior abdominal wall. However the small-bowel appeared normal. A 0.5-cm transverse mid abdominal incision was made and the sharp trocar and sheath were placed in the abdominal cavity under direct visualization. Sharp trocar was removed and the blunt probe was placed in the abdominal cavity and pelvic contents inspected. Findings documented in the photographs.
The liver and gallbladder could not be visualized because of adhesions of the omentum with the anterior abdominal wall. Appendix is surgically absent. The patient had thin film adhesions of the small-bowel to the vaginal apex. These were lysed with a blunt probe without difficulty and the operative site was hemostatic at the completion of the procedure. The CO2 was evacuated from the abdominal cavity. Instruments were removed from the abdominal cavity under direct visualization.
Skin incisions were closed with 4-0 plain suture. Incisions were injected with 0.5% Marcaine with epinephrine, 10 ml. Bandages were applied. Sponge stick was removed from the vagina. All sponges and needles were accounted for at the completion of the procedure. Patient left the operating room in apparent good condition after tolerating the procedure well.
4. The anesthesia service was provided by a CRNA with the anesthesiologist medically directing 2 concurrent cases. The patient’s physical status was -P3. The BVU for this case is 6. LOCATION: Outpatient Hospital PATIENT: Carmen Pitmen SURGEON: Loren White, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Sacral ulcer.
2. Osteomyetitis of sacrum/coccyx.
POSTOPERATIVE DIAGNOSES:
1. Sacral ulcer.
2. Pending.
INDICATIONS: Patient with history of sacral ulcer that has failed conservative management. The planned procedure was discussed in detail. Risks and benefits explained and questions answered. Patient elects to proceed with surgical intervention at this time.
PROCEDURES PERFORMED: 1. Excision of sacral ulcer. 2. Excision of coccyx.
SURGICAL FINDINGS: There was about a 4 cm deep pressure ulcer that went all the way down to the coccyx. The coccyx was separated from the sacrum and had very sclerotic bone in it. It was very vascular around the coccyx.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 150 cc. DRAINS: One #10 Jackson-Pratt.
PROCEDURE: The patient was intubated and turned to the prone position. The buttocks were prepped with Betadine scrub and solution and draped in routine sterile fashion. The ulcer was excised elliptically by following a hemostat to the bottom of the wound which ended in the lower end of the sacrum/upper end of the coccyx. We took a piece of the coccyx and placed it in a culture tube. I then removed the coccyx which was quite vascular, clamping bleeders with 2-0 Vicryl and putting in one stick tie of 2-0 Vicryl. The coccyx was removed and submitted for specimen. A piece of Gelfoam with some topical thrombin spray was placed in the depth of the wound, and the wound was closed in two layers with interrupted 0 Monocryl for the deepest fascial layer over the drain and over the bed from which the coccyx had been dissected. We also closed the skin with #2 Protene. The drain was sutured in with 0 Monocryl. Dressing consisted of Kertix fluffs and Elastoptast. The patient tolerated the procedure well and left the operating room in good condition.
Pathology Report Later Indicated: Sclerotic bone, coccyx.
5. The anesthesiologist was medically directing 4 concurrent cases including this CRNA. The patient’s physical status was -P1. LOCATION: Outpatient, Hospita PATIENT: Kayla Adams PHYSICIAN: Mohomad Almaz, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Right fifth toe metatarsophalangeal joint dislocation. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Open reduction of right fifth toe metatarsophalangeal joint dislocation with application of long leg cast. ANESTHESIA: General.
INDICATIONS: The patient is an 8-year-old girl who injured her right fifth toe while jumping on a small trampoline. She had an attempt at closed reduction of the dislocation in the office, which was unsuccessful. I have recommended open reduction. I have discussed the situation with the mother. She wished to proceed as recommended. I have discussed the possibility of repeat dislocation, need for fixation implant, and neurovascular injury, scarring, stiffness, and pain. I have discussed the options for treatment including continued nonoperative management.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. Once general anesthesia was administered and the patient was intubated, the right leg and foot were prepped and draped in usual sterile manner. A curvilinear incision was made over the dorsal aspect of the right fifth toe overlying the metatarsophalangeal joint. The dissection was carried down on to the proximal metatarsophalangeal joint. The metacarpal head was identified. There was soft tissue interposed, which was not allowing reduction at the metatarsophalangeal joint. Once this was removed and the proximal portion of the proximal phalanx was identified, the joint was then reduced. It was felt that the joint would be very difficult to pin because the joint surfaces were so small: Therefore, no pin fixation was performed. It was felt that the location of the joint was now appropriate and was relatively stable. The wound was irrigated with normal saline. Routine wound closure was performed using interrupted 4-0 nylon sutures. Routine soft dressings were applied. The tourniquet was deflated and the toe had excellent capillary refill. She was placed in a long leg cast. She tolerated the procedure well and left the operating room in stable condition. Postop plan is to have the patient return for removal of sutures. The cast will be windowed for this procedure. The cast will be on for a minimum of 4 weeks.
6. The anesthesiologist was medically directing one CRNA. The patient’s physical status was -P2. LOCATION: Inpatient, Hospital PATIENT: Marsha Gale PHYSICIAN: Jeff King, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Maxillary hypoplasia. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: A 2-piece Le Fort I maxillary osteotomy. ANESTHESIA: General. ESTIMATED BLOOD LOSS: 250 cc.
INDICATIONS: Patient initially seen in the office for evaluation of maxillary hypoplasia. We had discussed options, determined a surgical plan, discussed the risks and benefits of the planned procedure and date for procedure scheduled. She now presents and consents to proceed as planned.
PROCEDURE: The patient was identified, she was placed on the operating room table in supine position. After she was anesthetized, intubated nasotracheally, nasotracheal tube was fixed by our service in a standard fashion. Oral cavity and face was prepped and draped. Nasopharyngeal pack was placed carefully.
Lidocaine 1% with epinephrine was infiltrated in the mucobuccal fold to the right and left of the midline of the maxilla. Using an electrocautery knife, a standard Le Fort I mucosal incision was made from the right maxillary buttress across the midline to the left maxillary buttress. Periosteum was elevated inferiorly and superiorly to expose the maxilla, the bodies of the zygomas, and the piriform apertures bilaterally. Periosteum was now elevated posterior to the buttresses to the junction of the pterygoid plates of the tuberosities. Nasal mucosa was now elevated toward the lateral nasal walls and down the floors, and in the cartilaginous and bony septum. Starting on the right-hand side, retractor was placed between nasal mucosa and the lateral nasal standard Le Fort I osteotomy was made with a reciprocating saw, directed to the left-hand side. Another malleable retractor was lateral nasal wall and the nasal mucosa. On the left-hand side, I osteotomy was made with a reciprocating saw. A single-guarded osteotome was used to complete the lateral nasal walls posteriorly. A double-guarded osteotome was used to elevate the cartilaginous and the bony septum. Curved 10-mm osteotomes were used to transect between the pterygoid plates and the tuberosities bilaterally. The maxilla was downfractured with the aid of Rowe disimpacting a thin malleable wall, and an Attention was now placed between the a standard Le Fort osteotome was used forceps. Greater palatine vessels bilaterally were visualized, were decompressed superiorly to allow for the planned expansion. Periosteum was now elevated between the 2 central incisors, #8 and #9, to the alveolar crest. A thin oscillating blade was used to perform the vertical osteotomy between the teeth, up through the nasal spine, and onto the horizontal portion of the palate. A #2 round bur now was utilized to the right and left of the nasal maxillary crest on the horizontal portion of the hard palate to perform the 2 osteotomies to connect to the vertical osteotomy. The rthodontic wire was cut in the midline. Maxilla was now mobile and the periosteum on either side of the nasal maxillary crest was elevated on the undersurface of the palate for release of the tension. A prefabricated surgical stent was brought to the field. It was used to position the 2 maxillary segments in the expanded position. Once it was passively expanded, they were fixated to the splint with 25-gauge stainless steel wires x5. Intermaxillary fixation was now completed to the mandibular dentition and maintained this position with 25-gauge stainless steel loops x4. Auto rotation was performed and the posterior interference bilaterally were removed with a low-speed handpiece and a carbide bur with constant irrigation. Once I was satisfied with the final position of the maxilla, that is, in its widened position and it was anteriorly repositioned, it was then fixated with 4 L-shaped 1.5-mm fixation plates with a combination of either 4 or 6-mm long 1.5-mm fixation screws. Intermaxillary fixation was released, simulated auto-rotation once again. There was no interference with the splint.
At this time, the surgical site was irrigated thoroughly. The cartilaginous septum was fixated to the maxillary crest with a single 2-0 Mersilene suture. The nasal musculature was repositioned and maintained in its appropriate anatomical position with 2-0 Mersilene suture. Midline mucosal closure was gained with interrupted 4-0 Vicryl suture. The closure, bilaterally, from the midline posteriorly on either side was closed with a running 4-0 Vicryl suture. Nasopharyngeal cavity was inspected and found to have no bleeding. The oral cavity was inspected. Needle count and sponge count were correct. The nasopharyngeal pack was removed, and she was taken to the recovery room in a stable condition.
7. The anesthesia service was provided by the CRNA with an anesthesiologist medically directing 3 concurrent cases. The physical status of the patient was -P2 . The CRNA performed a foot block from 0903 to 0915, prior to the start of the case. The anesthesia time was 0953 to 1209. The base unit value for the case is 3. What are the total units? LOCATION: Inpatient, Hospital PATIENT: Jeannette Majors PHYSICIAN: Mohomad Almaz, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Left hallux valgus.
2. Left second and third hammertoes.
3. Left second metatarsalgia.
POSTOPERATIVE DIAGNOSES: Same.
PROCEDURES:
1. Left proximal metatarsal osteotomy.
2. Left distal soft tissue procedure:
3. Left second metatarsal shortening osteotomy.
4. Left second and third hammertoe corrections.
ANESTHESIA: Left ankle block intravenous sedation.
INDICATIONS: This patient is a 70-year-old woman with pain associated with the above deformities. She has failed conservative therapy, is functioning limited by her symptoms, and is requesting operative intervention. The risks, benefits, indications, alternatives, limitations of surgery were discussed with her, and all of her questions were answered. Informed consent was obtained for the above procedures. The patient had a preoperative history and physical as well as anesthesia clearance and gait training prior to the surgical date. The patient understands the elective nature of the procedure, and she wished to proceed. She understands the risks of surgery, which include but are not limited to damage to blood vessels and nerves, wound complications and infection, nonunion or malunion, persistent recurrent or worsening pain or deformity, and the possible need for future surgery.
PROCEDURE: The patient was seen in the preoperative holding area and was felt to be stable to undergo operative intervention. The appropriate operative limb was marked, and she was given preoperative antibiotics. The patient was then brought to the block room where a left ankle block was performed by the anesthesia service under sterile conditions, which she tolerated well without complications. The patient was brought into the operating theater and was placed supine on the operating table. All bony prominences were appropriately padded. Intravenous sedation was administered and monitored by the anesthesia service during the case. The left lower extremity was sterilely prepped and draped in the usual standard fashion. An Esmarch bandage was used to exsanguinate the foot and was left wrapped above the ankle to provide a tourniquet effect during the case.
Attention was directed to the dorsal first web space. A curvilinear incision was made beginning over the medial aspect of the second metatarsophalangeal joint and then curved as it was extended proximally over the 1st web space. The incision was carried through the skin and subcutaneous tissue with care being taken to avoid damage to small blood vessels and nerves. Hemostasis was controlled using Bovie electrocautery.
Attention was directed to the web space release. Dissection was carried through the adventitial bursa. A laminar spreader was placed between the first and second metatarsals in order to improve exposure. The transverse and oblique ends of the adductor tendon were then released at their insertion. The transverse ligament was then identified and was divided in its midline after being mobilized with care being taken to avoid damage to any underlying neurovascular structures. The lateral capsule was then pie crusted and the interval between the lateral sesamoid and first metatarsal head was exposed and mobilized. Once this was performed, a varus stress was placed at the joint, which allowed for reduction of the sesamoid complex back into the first metatarsal head.
A medial incision was made over the 1st metatarsophalangeal joint beginning at the base of the proximal phalanx, and extending over the medial aspect of the metatarsophalangeal joint, and then along the first metatarsal shaft to begin to end proximally at the dorsal aspect of the first metatarsocuneiform joint. The incision was carried full thickness down to the capsule and dorsal and plantar full-thickness flaps were created. Care was taken to avoid damage to small blood vessels and nerves. The dorsomedial cutaneous nerve was mobilized and retracted out of the surgical field. A longitudinal capsulotomy was then performed, and the capsule was dissected off the head of the first metatarsal. This was then carried proximally along the metatarsal shaft, which was exposed using subperiosteal dissection. Care was taken to avoid destabilizing the distal attachment of the capsule. The medial eminence was then excised from a distal to proximal direction using a sagittal saw. The cut was made approximately 1 to 2 mm medial to the sagittal sulcus and was directed parallel to the shaft of the 1st metatarsal. Next, an oblique osteotomy was made over the first metatarsal in the manner of Ludloff beginning proximally at the level of the first metatarsocuneiform joint dorsally and extending distally to end at the plantar aspect of the shaft just proximal to the neck. Once this was performed, the distal fragment was rotated laterally. An attempt was made to fix this with Acutrak screws, but there was significant osteomalacia, and adequate screw purchase could not be obtained. The metatarsal was then held in a corrected position using a reduction forceps. The position of the osteotomy was checked using fluoroscopy in multiple planes including an AP, lateral, and oblique of the foot and felt to adequately correct the elevated uni-metatarsal angle. The prominent bone was then excised.
A 5-hole quarter tubular plate was present to contour to the metatarsal. A single 2.7-mm cortical screw was inserted on either end of the plate. This construct appeared to hold the reduction adequately and stability.
Attention was directed to the second metatarsophalangeal joint. The extensor digitorum longus and brevis tendons were identified and mobilized. Tenotomies were performed as there was fixed hyperextension at the metatarsophalangeal joint. Once this was performed, dissection was carried down to the level of the capsule, which was divided in its midline. The head and neck of the second metatarsal was then exposed using subperiosteal and subcapsular dissection.
An osteotomy was made in the second metatarsal in the manner of Weil with a sagittal saw. This began distally and dorsally approximately 1 to 2 mm below the edge of the dorsal articular margin. The osteotomy was then carried proximally and plantarly at approximately a 45-degree angle. Once the osteotomy was completed, a second small 1-mm wedge of bone was excised from the proximal fragment. This allowed for some elevation of the metatarsal head. The distal fragment was then advanced proximally in order to shorten the metatarsal. This was then stabilized using a 0.045-mm K-wire. Position of the osteotomy and K-wire was checked using fluoroscopy in multiple planes as above and was felt to be excellent. The K-wire was then removed and replaced with an Ace-DePuy breakaway screw of appropriate length. This resulted in excellent fixation and compression across the osteotomy. The dorsal overhang of bone was then removed with a rongeur and smooth off with a rasp.
Attention was directed to the second and third hammertoes. A dorsal elliptical incision was made over the proximal interphalangeal joint of the second and third toes. This was carried full thickness down to the skeletal plane with excision of the skin and subcutaneous tissue, as well as the extensor hood. Soft tissue was dissected off the head and neck of the proximal phalanx sharply. The head of the proximal phalanx was then excised through the neck using a sagittal saw while Homan retractors were used to protect the surrounding soft tissues. Once this was performed, the second and third toes were able to be brought into a nice neutral position. Next, a 0.045 mm K-wire was introduced in the base of the middle phalanx and driven out the tip of the toe. The K-wire was then advanced into the proximal phalanx with reduction of the toe. K-wire was then advanced across the proximal phalanx and into the metatarsal. An identical procedure was performed on the second and third toes. Final position of the reduction and K-wire was checked using fluoroscopy in multiple planes as above and was felt to be excellent.
At this point, the tourniquet was released. Total tourniquet time was less than 2 hours. Please see the anesthesia nursing records for the exact tourniquet time. Hemostasis was controlled using Bovie electrocautery and digital pressure. All the toes were pink and warm with brisk capillary refill after release of the tourniquet.
Attention was then directed back to the first metatarsophalangeal joint. Redundant dorsal capsule was excised. Next, with the hallux held in slightly varus over correction as well as neutral dorsiflexion and rotation, the capsule was repaired and imbricated using 2-0 Vicryl sutures. Final position of the hallux as well as the second and third toes was checked using fluoroscopy in multiple planes as above and was felt to be good. There was no impingement of the hallux on the second toe, and no Akin osteotomy was felt to be necessary.
The capsule of the second metatarsophalangeal joint was also repaired with 2-0 Vicryl sutures. The wounds were then closed in layers using 4-0 Vicryl sutures to reapproximate the subcutaneous tissue, and 4-0 nylon interrupted simple sutures were used to reapproximate the skin.
The wounds were then dressed with Xeroform and sterile 4 x 4’s. A soft forefoot dressing was applied and over wrapped with an Ace wrap. The patient was then placed into a postoperative shoe. She was then transferred to a hospital bed and was brought in the recovery room in stable condition. All sponge and needle counts were correct at the end of the case and there were no perioperative or intraoperative complications or difficulties.
8. Anesthesia personally performed by anesthesiologist. The patient’s physical status was -P1. LOCATION: Inpatient, Hospital PATIENT: Jordyn Moore PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Bilateral cleft lip and palate. POSTOPERATIVE DIAGNOSIS: Bilateral cleft lip and palate. PROCEDURE: Bilateral cleft lip repair. ANESTHESIA: General with endotracheal intubation. ESTIMATED BLOOD LOSS: 20 ml. COMPLICATIONS: None.
INDICATIONS: Briefly, this 11-month-old with bilateral cleft lip and palate has shown slow growth but is generally in good health. She underwent attempted preliminary closure with bilateral lip adhesions, which dehisced. She subsequently underwent unilateral lip adhesion, which also dehisced. She presents now for definitive repair.
FINDINGS: Limited scar formation from previous lip adhesions; radically displaced premaxillary segment anteriorly with no obvious lock out; no columella.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. After she was intubated with an oral RAE, she underwent exam under anesthesia.
Next, the table was turned 90 degrees, and her face was prepped and draped in standard fashion. Standard markings for a Millard type rotation advancement bilateral repair were inked into the skin, and the key points tattooed with methylene blue. The area was then infiltrated with 0.25% Marcaine with epinephrine. The philtral column was deliberately planned to be slightly wide given the high-tension closure anticipated, and the philtral columellar skin was elevated off the bed. There was an extremely shallow sulcus because of the short prolabial segment, but this was also dissected down. The bilateral tines on either side of the columella that represented the remaining cutaneous portion of the prolabium were left intact initially.
Next, bilateral L-flaps were developed and based off the intranasal mucosa. The incision was continued into the nasal vestibule to release it, and dissection continued into the supraperiosteal plane bilaterally to completely mobilize the alar bases and allow for medial translocation of the lateral lip segments. The orbicularis was dissected off its aberrant insertions into the premaxilla bilaterally, a 9-0 Vicryl Monocryl suture in horizontal mattress fashion was used to re-approximate the muscle in the midline. This was successfully accomplished. Small backcuts laterally in the mucosa were added to increase mobility. Next, the suture was removed and the L-flaps were inserted into the nasal vestibule with 5-0 chromic suture. Once again, the muscle was reapproximated and after several horizontal mattresses were used to re-establish the oral sphincter, it was anchored into the prolabial segment to provide for maximal force to remodel the premaxilla into an anatomically correct position.
Next, deep dermal 5-0 Monocryl was used to reapproximate the skin, and a 5-0 chromic suture was placed in the dry vermilion followed by interrupted 4-0 Vicryl on the wet mucosa of the upper lip as well as the lateral segments. Finally, interrupted 6-0 nylon was placed in the skin. No attempt at nasal dissection was undertaken.
The patient was awakened from anesthesia, extubated, and transferred to the recovery room in stable condition.
9. Anesthesia was provided for multiple procedures in this case. Anesthesia by Anesthesiologist and CRNA. The anesthesiologist was medically directing 4 concurrent cases. The physical status of the patient was -P1. LOCATION: Outpatient, Hospital PATIENT: Barbara Williamson PHYSICIAN: Jeff King, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Left cerumen impaction.
2. Tonsillar hypertrophy with upper airway obstruction.
POSTOPERATIVE DIAGNOSES: Same
PROCEDURE PERFORMED:
1. Tonsillectomy.
2. Removal of cerumen from left ear.
ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Less than 1 cc
FINDINGS: The right ear canal was clear, the left ear canal had a cerumen plug which was removed. The tympanic membranes were clear bilaterally. Patient had 3 to 4+ tonsils and no significant adenoid regrowth.
SPECIMEN: Two tonsils COMPLICATIONS: None apparent at the time of this dictation.
INDICATIONS: Barbara is a 15-year-old girl with a history of Eustachian tube dysfunction who has undergone bilateral myringotomy and tube placement and adenoidectomy by me in the past. Her tubes have since fallen out and she has done great however she has been noted to have large tonsils on her last several exams. Mom also has noticed that she has had increasing upper airway obstructive symptoms at night, including snoring and pauses which get worse when she gets an upper respiratory infection. She now presents for tonsillectomy and removal of cerumen from her left ear, possible secondary adenoidectomy if her adenoids have grown back at all.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room by Anesthesia and placed in supine position after informed consent was obtained from the parents in the holding area. General anesthesia was initiated by an orally placed endotracheal tube. The right ear was examined under the microscope. The ear canal and tympanic membrane were completely clear. The left ear was also examined under the microscope. A cerumen plug was removed from the ear canal and she had a clear tympanic membrane. The bed was rotated 90-degrees and a shoulder roll was placed. The head and face were then draped in the usual sterile fashion. A McIvor mouth retractor was then placed intraorally.
Inspection of the palate revealed no evidence of a submucous cleft. Two red Robinson catheters were passed through the nose to retract the soft palate and a throat pack was placed. Marcaine 0.25% was then injected into the superior and inferior poles of each fossa. The right tonsil was then grasped with a curved Allis and Bovie electrocautery was used to develop a plane between the tonsillar capsule and pharyngeal musculature. After the tonsil was removed, the superior and inferior poles of the fossa were cauterized. A similar procedure was performed on the left tonsil.
The mouth was then irrigated and suctioned out. Hemostasis was achieved. The mouth retractor was then relaxed for several minutes and the area was reinspected. There was no further bleeding. The throat pack was removed, the stomach was suctioned out and the red Robinson catheters and mouth retractors were removed respectively. The patient was then awakened, extubated and transferred to the recovery room in stable condition.
Pathology Later Indicated: Hypertrophy of tonsil.
10. Anesthesia by: Anesthesiologist and CRNA. The anesthesiologist was medically directing 3 concurrent cases. This is an otherwise normal healthy 17-year-old male. The patient’s physical status was -P1
LOCATION: Outpatient, Hospital PATIENT: Phillip Jamison PHYSICIAN: Gary I. Sanchez, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSIS: Acute left scrotum.
POSTOPERATIVE DIAGNOSES:
1. Intermittent torsion, left testis.
2. Bell clapper anomaly of right testis.
PROCEDURES:
1. Scrotal exploration.
2. Detorsion of left testis.
3. Bilateral scrotal orchidopexy. Orchiopexy and orchidopexy are both correct spelling
ANESTHESIA: General, plus local. ESTIMATED BLOOD LOSS: Less than 5 ml.
DESCRIPTION OF PROCEDURE: After meeting the mother in the preop holding area, examining the patient, and addressing her concerns, we proceeded back to the operating room where a “time-in” was held and general anesthesia was induced without difficulty.
The midline of the scrotum was opened with a cutting current after sterile prepping and draping, and the left hemiscrotum was entered easily and safely. The testis was “upside down,” it was basically torsed to 180 degrees. The appendix of epididymis was black, the appendix of testis was normal. The testis was pink and healthy, and there was a lot of edema above the testis in the cord. The testis was oriented properly and pexed with interrupted 5-0 Prolene, 1 medial, 1 lateral.
The right hemiscrotum was entered through the same incision. This testis was upside down and was a “bell clapper,” there was also a “pearl” in the right hemiscrotum, there were no vestigial appendages seen: This testis was oriented properly and pexed with interrupted 5-0 Prolene.
The vestigial appendages were removed from the left testis with light electrocautery, and then the scrotum was closed with 2 layers of interrupted 4-0 chromic. Dry gauze and See Pro Net were applied and the procedure was discontinued, the patient being tolerated it well. The needle and sponge counts being reported as correct.
In summary, scrotal exploration for this 17-year-old boy who awoke with scrotal pain approximately 3 days ago, but then did not have pain 2-1/2 days ago, was undertaken emergently today after a scrotal ultrasound indicates diminished flow to the left testis. This testis had indeed been torsed, it was detorsed and pexed, the right testis was a bell clapper, and it was pexed, a pearl was removed from the right side and both vestigial appendages were removed from the left side.
Pathology Report Later Indicated benign tissue.
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