Inferior Turbinate Submucosal Reduction Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Inferior turbinate hypertrophy.
2.  Nasal obstruction.

POSTOPERATIVE DIAGNOSES:
1.  Inferior turbinate hypertrophy.
2.  Nasal obstruction.

OPERATION PERFORMED:  Bilateral inferior turbinate submucosal reduction.

SURGEON:  John Doe, MD

 ASSISTANT:  Jane Doe, MD

 ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:
1.  Severely enlarging inferior turbinates bilaterally abutting the nasal septum.
2.  Minimal response to nasal decongestion.
3.  At the conclusion of the procedure, the left nasal airway was significantly larger and the right nasal airway was somewhat more narrow but significantly improved and able to visualize posterior nasal cavity.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the table in the supine position. A suitable plane of anesthesia was obtained, and the patient was endotracheally intubated by anesthesia personnel. Next, Afrin-soaked pledgets were instilled into the nasal cavity. The pledgets were then removed. The anterior inferior turbinate was injected with 1% lidocaine with 1:100,000 epinephrine. Afrin-soaked pledgets were then reinstilled into the nasal cavity. The patient was prepped and draped in standard fashion. The Afrin-soaked pledgets were removed.

The 0-degree endoscope was used to visualize the left inferior turbinate. The Colorado-tipped Bovie was used to make a vertical incision in the anterior head of the turbinate. Bovie cautery was used to dissect down to the level of the inferior turbinate bone.

Next, the Cottle was used to free the periosteum and submucosal tissue from the bone. Once this was adequately removed from the bone, a 2.9 inferior turbinate shaver blade was inserted, and the submucosal tissue was removed, taking care not to make any rents in the mucosa. The tissue was removed anteriorly, superiorly, medially and inferiorly back the entire length of the inferior turbinate. The mucosa was also freed from the lateral aspect of the inferior turbinate bone and isolating the inferior turbinate bone. This tissue was also shaved.

Once the submucosal turbinate tissue was removed and the inferior turbinate bone was free from the mucosa, Takahashi forceps were used to grasp the bone and fracture the bone and remove it. A significant portion of the anterior-inferior turbinate bone was removed. At this point, mucosa was lateralized and large nasal airway was achieved on the left side.

The procedure was then repeated on the right side anterior-inferior turbinate. An anterior-inferior turbinate incision was made with Bovie cautery. This was carried down to the level of the bone. Submucosal tissue was removed with the shaver blade. The inferior turbinate bone was found to be far lateralized, and a plane was not able to be achieved between the inferior turbinate bone and the lateral nasal wall. Therefore, the inferior turbinate bone was not removed. Submucosal tissue was completely removed with the shaver blade.

Since there were some mucosal abrasions along the septum on the right side, a cut Doyle splint was placed and sutured to the right nasal septum with 4-0 Prolene with the knot placed in the right nasal cavity to separate the septal mucosa from the inferior turbinate mucosa. The inferior turbinate was lateralized, and the procedure was terminated. There was no significant bleeding at the conclusion of the case.

Breast Needle Localized Lumpectomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Right breast cancer.

 POSTOPERATIVE DIAGNOSIS:  Right breast cancer.

 OPERATION PERFORMED:
1.  Right breast needle-localized lumpectomy.
2.  Sentinel node biopsy.
3.  Axillary node dissection.

 SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None.

 INDICATION FOR OPERATION:  This is a (XX)-year-old Hispanic female who underwent a needle biopsy, which showed right breast carcinoma.  After weighing options, the patient opted for right breast needle localization, lumpectomy, sentinel node biopsy, possible axillary node dissection.

The risks and benefits of the procedure were explained to the patient. Informed consent was obtained. The patient then underwent preoperative needle localization by the radiology department.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating suite and placed in the supine position. General anesthesia was given by the anesthesiology department. The right breast and arm area were prepped and draped in the normal sterile fashion. Lymphazurin was injected in the right retroareolar area. Breast massage was then performed.

A small incision was made directly in the right axilla. Dissection was carried down through the subdermal layers using cutting. Once the clavipectoral fascia was incised, there was clearly a very large synovial cyst, suspicious for possible malignancy, noted.

At this point, a formal axillary node dissection was done due to intraoperative findings. Clips were used to ligate the small veins. At this point, the specimen was submitted for pathology. The wound was copiously irrigated. There was no active bleeding noted. A #10 JP drain was brought in through a separate stab incision. The drain was sutured to the skin using #2-0 nylon. The wound was closed with a 4-0 Vicryl in a running subcuticular manner. The wound was injected with lidocaine and Marcaine solution.

A whole new setup was then used for the lumpectomy. A small incision was made directly at the exit site of the needle.  Dissection was carried out through the subdermal layers using cutting. The needle was then brought into the wound, and a small skin flap was then created, and a wide circumferential dissection was performed all the way to the pectoralis muscle.

Subfascial dissection was then performed. Specimen was appropriately tagged and forwarded to Radiology. The radiologist confirmed the presence of the malignancy in the specimen with a greater than 1 cm margin all the way around.

The wound was copiously irrigated. No signs of bleeding noted. Clips were placed for future radiation therapy in the cavity. Skin was injected with Marcaine and lidocaine solution. Then 4-0 Vicryl was used to close the skin in a running subcuticular manner. Steri-Strips and sterile dressings were then applied. The patient was sent to recovery room in satisfactory condition.

INTRAOPERATIVE FINDINGS:
1.  Right breast needle-localized lumpectomy and axillary node dissection.
2.  All needle, sponge, and instrument counts were noted to be correct.

Closed Reduction of Vertebral Fracture Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSES:
1.  C5-6 facet fracture. 
2.  Left C6 radiculitis. 

 POSTOPERATIVE DIAGNOSES:
1.  C5-6 facet fracture.
2.  Left C6 radiculitis.

 OPERATIONS PERFORMED:
1.  Attempted closed reduction of vertebral fracture and subluxation with traction. 
2.  Subsequent open reduction and treatment of vertebral fracture and subluxation. 
3.  C5-6 anterior cervical diskectomy and fusion. 
4.  Anterior cervical instrumentation C5-6. 
5.  Left anterior iliac crest structural bone graft harvest. 
6.  Use of operating microscope. 
7.  Application and removal of cranial tongs. 

 SURGEON:  Jane Doe, MD

 ASSISTANT:  John Doe, MD

 ANESTHESIA:  Local followed by general endotracheal.

 ESTIMATED BLOOD LOSS:  Approximately 100 mL.

 IMPLANTS:  DePuy Eagle plate with four screws. 

 COMPLICATIONS:  None.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and using 1% lidocaine and antibiotic ointment, Gardner-Wells tongs were placed in line with the external auditory meatus approximately a centimeter above the ear. The anesthesiologist provided some conscious sedation. The patient tolerated the placement of tongs very well.

 Ten pounds of traction were then added and a lateral C-arm image obtained, which showed persistent subluxation. Manual traction was then applied and maneuvers attempted with rotation as well as flexion and extension in an attempt to reduce the fracture. However, persistent subluxation was noted, and the decision was made to proceed with open reduction.

 The patient was then administered general anesthetic with use of in-line traction. SSEP and EMG monitoring leads were placed. A Foley catheter was in place. Preoperative antibiotics were administered. SCDs were applied. The patient's arms were tucked to the side. The cervical spine and the left anterior iliac crests were prepped and draped in the standard sterile fashion.

 A transverse incision was made overlying the C5-6 interspace. The platysma was divided in line with the incision. The anterior fold between the strap muscles, trachea and esophagus medially and the sternocleidomastoid and carotid sheath laterally was developed bluntly. The prevertebral fascia was incised and the subluxed level identified, both clinically as well as with a lateral C-arm image by placing a spinal needle within the disk space. The longus coli was elevated off of the C5-6 interspace bilaterally and self-retaining retractors placed below the longus coli muscles bilaterally.

 The operating microscope was then brought in for the decompression and preparation of the anterior space. The diskectomy was performed with a series of curettes and rongeurs. The PLL was torn off of the posterior aspect of the C5 body; however, it was in continuity and there was no tear within its substance. The fracture was reduced via application of Caspar distractor and applying posterior translational force to the C5 body. AP, lateral and oblique C-arm images were obtained and showed perhaps a millimeter of residual subluxation related to rotational instability. This reduced with posteriorly directed force and rotation to the left, and it was felt that it could be held with the plate applied in this position. The disk space was measured with a trial and an 8 mm graft fit well.

 An incision was made over the iliac crest over two fingerbreadths away from the ASIS. The fascia overlying the iliac crest was incised and the inner and outer tables exposed a couple of centimeters deep. Two Cobb elevators were placed within the wound to protect the soft tissues and an 8 mm by approximately 12 mm graft was harvested with an oscillating saw and osteotome. This was then placed within the C5-6 interspace and a single level Eagle plate applied with four screws, each of which had excellent purchase while holding the spine in a reduced position. The repeat C-arm images showed satisfactory alignment and placement of the instrumentation and graft.

 The wound was thoroughly irrigated with antibiotic irrigation. A Penrose drain was placed and the platysma closed with interrupted figure-of-eight 3-0 Vicryl stitches. The skin was then closed with 4-0 running Monocryl stitch. The iliac crest wound was closed with 0 Vicryl interrupted figure-of-eight stitches within the fascia followed by 2-0 Vicryl interrupted buried stitches in the skin and a 4-0 running Monocryl. Steri-Strips and sterile dressings were applied to both wounds. A new Philadelphia collar was applied, and the patient's tongs were removed. The patient was awakened without difficulty and was able to move bilateral upper and lower extremities to command. The patient was then taken to the recovery room in stable condition. There were no intraoperative complications.

 Neurosurgical Operative Samples #1     Neurosurgery Operative Sample Reports #2

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