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Cleft Lip Repair Transcribed Operative Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Complete left cleft lip and palate.

POSTOPERATIVE DIAGNOSIS:  Complete left cleft lip and palate.

OPERATION PERFORMED:  Left cleft lip repair.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia with orotracheal intubation.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  5 mL.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and placed in a comfortable reclining position.  General anesthesia was uneventfully instituted, including with orotracheal intubation.  Ampicillin was given for prophylaxis.  The operative site was prepped in the usual manner and sterile drapes were applied in the usual fashion.  With excellent illumination and loupe magnification, the procedure was undertaken.  A mouth pack was put in place and the tube was protected with gauze; this was removed at the end of the case.  Measurements and marks were undertaken with 1.3 cm from the oral commissure to the base of the philtrum, 3 mm the width of the philtrum  and 4 mm the width of the nasal floor.  The vertical height of the philtrum was marked out with a wire and kept equal on the left side to that on the right.  There was fortunately just enough tissue to allow for good closure planning on a nasal floor Z-plasty using the vermilion to constitute the nasal floor and rotate the ala by completely releasing it into the inferior meatus.  Note that the alveolar cleft had widened, as we have waited for the baby to be healthy enough to do the cleft lip repair.  Hopefully, now with the lip pressure over it, we will get better direction of the bone and close this cleft somewhat.  We were not able to attempt any soft tissue plugging across this alveolar defect just because of the substantial distance involved.  Key points were then tattooed with methylene blue and 3 mL of 1:100,000 epinephrine was injected through a 30 gauge needle for hemostasis.  We had excellent hemostasis through the procedure and really did not need cautery.  Once white blanching was seen, with an 11 blade, the skin incisions were made pretty much along the edges of the cleft but designed to allow closure as equal as possible to the location of the philtrum on the right side.  A 15 blade was used to incise the vermilion and the vermilion flaps were then elevated on good blood supply basis to the ala laterally and the columella medially.  We did dissect along the lower lateral cartilage, nasal surface, from both medial and lateral sides to try to free up the cartilage and give a better curvature to the ala.  Similarly, we did elevate along the maxilla towards the infraorbital nerve on the left side.  The ala was indeed dissected into the inferior meatus to get a complete release, and at this point, it manipulated well including forming a good curvature and a good location.  With the flaps all being dissected and the muscle completely removed from the columella base and the ala, attention was directed to closure.  The Z-plasty was now closed on the nasal floor with the left coming medial and the right going posterior.  These were sutured into place with 5-0 Vicryl sutures and the flaps were sutured one to the other to help reconstitute the nasal floor.  The ala was now brought towards the midline and held in place with a well-placed buried 5-0 Vicryl suture tightening this down just to the point of a 5 mm distance allowing for expected contracture in comparison with the 4 mm on the right side.  Additional intranasal closure was done with more 5-0 Vicryl sutures and additional buried 5-0 Vicryl placed in the lip; although, we did place one 5-0 clear nylon suture in the orbicularis muscle to try to keep it in proper orientation.  The vermilion border was now meticulously realigned with a vertical mattress suture of 6-0 Novafil.  Additional 6-0 Novafil was placed in interrupted fashion for the dry vermilion and the lip.  One buried 5-0 Vicryl suture was placed in the substance of the deep vermilion and then the vermilion itself was closed with multiple interrupted sutures of 5-0 Vicryl.  In order to hold the nasal ala cartilage in the desired curvature, a portion of red rubber catheter was placed along it intranasally and then tied to a similar piece of red rubber along the dorsum using a horizontal mattress suture of 4-0 nylon.  Excellent closure was seen, good symmetry, good vitality.  All areas were cleansed and then dressed with a light coat of Polysporin ointment.  Mouth pack was removed.  Needle and sponge counts were correct.  Anesthesia was ended.  The patient was extubated uneventfully and escorted to the recovery area, having tolerated the procedure and anesthesia in satisfactory condition.