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Ligation of AV fistula Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Status post renal transplant.

POSTOPERATIVE DIAGNOSIS:  Status post renal transplant.

PROCEDURE:  Ligation of left AV fistula.

SURGEON:  XXX XXX, MD

ANESTHESIA:  Local with intravenous sedation.

CONDITION:  Stable.

OPERATION IN DETAIL:  The patient was brought to the operating room and placed on the operating room table in supine position.  Following the induction of intravenous sedation, the left arm was prepped and draped in the usual sterile fashion.  The area overlying the proximal portion of the fistula was infiltrated with 1% lidocaine.  A transverse incision was then made overlying the fistula, dissecting any tissues using electrocautery.  Following this, with sharp and blunt dissection, the proximal outflow tract of the fistula was encircled.  This was then ligated with 0-Prolene ties.  The flow in the fistula was thus stopped.  Hemostasis was inspected and found obtained.  The wound was closed in two layers with 3-0 Vicryl and 5-0 PDS.  Stay sutures were applied.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Stenosis of right femoropopliteal distal anastomosis.
2.  Arteriovenous fistula coming off the saphenous vein graft.

POSTOPERATIVE DIAGNOSES:
1.  Stenosis of right femoropopliteal distal anastomosis.
2.  Arteriovenous fistula coming off the saphenous vein graft.

PROCEDURE PERFORMED:  Exploration of right femoropopliteal graft and revision of distal anastomosis followed by intraoperative angiography and ligation of AV fistula, right thigh.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia.

DESCRIPTION OF OPERATION:  The patient presented to the vascular lab and underwent vein mapping and arteriovenous fistula was marked on the skin. Then, the patient was brought to the operating room and was placed in the supine position. General endotracheal anesthesia was induced. A Foley catheter was inserted. The entire right lower extremity was prepped and draped in the usual sterile manner.

We then made an incision over the medial aspect of the proximal right calf extending into the lower thigh area. Subcutaneous tissues were incised. Two saphenous vein grafts were identified and dissected all the way down to the distal popliteal fossa. We went down and anastomosis was identified and popliteal artery was dissected proximal and distal to the anastomosis and vessel loops were placed. This dissection was tedious because of scar tissue. Before we revised the area of stenosis, we wanted to do intraoperative angiography. The AV fistula was identified over the lower medial thigh area, and this was dissected where it was joining the saphenous vein graft. Then, the distal end of this AV fistula was ligated with 2-0 silk tie and a small incision was made. Through this, we inserted a small needle into the saphenous vein graft.

Then, intraoperative angiography was performed using DSA technique with C-arm. This identified the area of stenosis just proximal to the popliteal anastomosis. The etiology of this was not clear. This narrowing was very significant causing about 80-90% stenosis. Then, we proceeded to revise this. The patient was given heparin. Then, we occluded popliteal artery proximally and distally by keeping the vessel loops tight. The saphenous vein graft itself was occluded with a bulldog clamp. We had taken down the distal anastomosis and found the area of stenosis to be just proximal to the anastomosis where there was a valve. There was fibrosis of the tissue just at the valve level. This valve was dissected and its narrowed segment was excised and the vein was moved down. We had enough laxity to accomplish new anastomosis.

Then, a new anastomosis was done to the same area and the popliteal artery using 6-0 Prolene running sutures. At the end of the anastomosis, flushing was done from all directions and suture was tied. Then, all clamps were removed. Then, we repeated the angiography through the saphenous vein graft and this showed widely patent anastomosis without any evidence of stenosis. We were satisfied with the procedure, ligated the AV fistula, and the needle was taken out. Heparin was reversed with protamine sulfate and hemostasis was obtained.

Subcutaneous tissues were closed with two layers of running 3-0 Vicryl sutures. Skin was closed with 4-0 Vicryl subcuticular suture followed by Dermabond. External dressings were applied, and the patient was transferred out of the operating room in stable condition.