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Concha Bullosa Resection and Ethmoidectomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Pituitary tumor.
2.  Left concha bullosa of the middle turbinate.

POSTOPERATIVE DIAGNOSES:
1.  Pituitary tumor.
2.  Left concha bullosa of the middle turbinate.

OPERATIONS PERFORMED:
1.  Endoscopic resection of left concha bullosa.
2.  Endoscopic left anterior and posterior ethmoidectomies.
3.  Endoscopic transsphenoidal hypophysectomy with Stealth image guidance.

SURGEON:  John Doe, MD

NEUROSURGEON:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  The patient is a pleasant (XX)-year-old female who presented with visual loss. Despite the findings of glaucoma and cataract, suspect this may have been related to suprasellar extension of a pituitary tumor found on MRI imaging. Therefore, the patient elected to proceed with surgical intervention. The risks, benefits, alternatives, and indications were reviewed in detail with the patient and informed consent was obtained from the patient.

DESCRIPTION OF OPERATION:
The patient was brought into the operating room and placed on the OR table in the supine position. After demonstration of adequate endotracheal anesthesia, the table was turned 90 degrees. Next, the infrared camera and image-guidance wand were used to perform the registration of fiducial points. The system was utilized for intraoperative navigation and preoperative 3-dimensional planning of approach. CT scans were also reviewed in the room. There did appear to be a possible small area of dehiscence over the right carotid in the lateral aspect of the sphenoid sinus. The left carotid was well covered though the intersinus septum was obliquely oriented toward the left side. After Dr. Jane Doe and and I reviewed these films, the nose was prepped with Afrin-soaked pledgets bilaterally and 0.5 mL of 1% lidocaine with 1:100,000 epinephrine was infiltrated into both greater palatine foramina transorally. The patient was then prepped and draped sterilely.

A 0-degree endoscope with Endo-Scrub was placed in the left nasal cavity. It was clear that the left nasal turbinate was obstructive and would prevent adequate view and instrumentation in the sphenoid sinus. Local anesthetic was then applied to the superior attachment and the turbinate removed with curved endoscopic scissors, being one-third down from the anterior superior attachment. It was extended posteriorly and excised from the space with straight through-biting forceps. It appeared otherwise normal and it was not sent to Pathology.

Next, the superior turbinate was lateralized and sphenoid os identified. It was dilated with Freer and then further open medially and inferiorly with a 2 mm Kerrison rongeur. On the right, we observed the septal spur. I was able to medialize the middle turbinate and superior turbinate and visualize the sphenoid sinus. It was also opened in a similar fashion with Kerrison rongeur.

Next, the posterior septum was fractured with a Cottle and backbiter and straight through-bite used to perform a crescent-shaped posterior partial septectomy. This allowed visualization and instrumentation from both right and left nasal cavity. The sphenoid was widely opened. Dr. Jane Doe felt, for visualization, she needed to get further on the left. Therefore, a portion of the superior turbinate was removed with the straight through-bite forceps.

Next, the posterior ethmoid cells were entered and removed with straight through-bite forceps. The skull and basal lamina were identified and preserved in these areas. This allowed for further widening of the anterior wall of the sphenoid sinus laterally. The sphenoid sinus was notable for a septum, which extended obliquely to the left. Midline was marked using the image-guidance wand. The lateral and medial opticocarotid recesses were identified. The sphenoid was aerated underneath the sella, right of the septum.

Next, Dr. Jane Doe proceeded to meticulously remove mucosa from the sphenoid, taking care particularly around the region of the carotid arteries. The septum was removed with a straight through-bite and drill. The floor was removed and hypophysectomy performed. Please see Dr. Jane Doe's dictation for further details. Some spinal fluid was noted. We were able to identify this coming from the superior aspect behind the diaphragma. It was treated with a small amount of abdominal fat. Next, inlay and overlay DuraGen grafts were placed followed by obliteration of the anterior sphenoid sinus with fat. These layers were included with Tisseel placement.

Next, a Stammberger sinus dressing was applied to the cut edge of the middle turbinate. The posterior cut edge of the middle turbinate had been previously cauterized with suction Bovie and hemostasis well maintained. Some of the Stammberger dressing was then placed in the right middle meatus, after replacement of the middle turbinate to its native position. The patient was then turned over to the care of the anesthesia team for extubation and return to the ICU, having tolerated the procedure well without complications.

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