A. Lysis of intranasal synechia.
B. Revision of right maxillary antrostomy with tissue removal.
C. Image-guided endoscopic transnasal transsphenoidal hypophysectomy.
DETAILS OF PROCEDURE: The patient was brought into the operating room and was placed on the operating room table in a supine position. After demonstration of adequate endotracheal anesthesia, the table was turned 90 degrees. The registration verification process was performed for the stealth image-guided system using MRI. The nose was prepped with Afrin-soaked neurosurgical pledgets. Greater palatine foramina were infiltrated with 1 mL of 1% lidocaine with 1:100,000 epinephrine bilaterally. The patient was then prepped and draped sterilely.
The left nasal cavity was inspected. There was evidence of previous partial middle turbinectomy and ethmoidectomy. There was a patent maxillary antrostomy. No evidence of polyp or purulence. On the right, similar postoperative changes were identified. The lateral wall was infiltrated with a local anesthetic. Prior to accessing the middle meatus, there was an adhesion between the anterior middle turbinate remnant and the lateral nasal wall. After local anesthetic, this was taken down with a Freer. This allowed access into the middle meatus. The antrostomy was enlarged anteriorly using backbiting forceps. It was approximately doubled in size with this technique as it showed evidence of scarring to some degree. Within the sinus, there was a soft polyp versus a mucus-retention cyst. This was grasped with Blakesley forceps and removed. Care was taken to limit the antrostomy, stopping short of the area of the tear duct.
Next, the right sphenoid sinus was cannulated with a beta probe. It was then enlarged with 1 and 2 mm Kerrison rongeurs. Access into the region, on both sides, was assisted by lateralizing the middle and superior turbinates. On the left, the sphenoidotomy was again made and enlarged with the Kerrison rongeurs. The posterior nasal septum was then infractured and taken down with backbiting forceps. Some fragments of bone were kept in saline for later use. The intrasphenoid sinus septum was partially removed with Takahashi forceps; this was done delicately. There was thick bone between the sphenoid sinus and the carotid artery.
Dr. John Doe then performed removal of mucosa from over the roof of the sinus and entry into the sella. Tumor resection will be dictated separately. CSF was encountered just left of the midline portion of exposure. Frozen section confirmed pituitary adenoma. When his tumor resection was completed, he then harvested abdominal fat. I used this to place directly into the sella. Two pieces measuring approximately 8 mm were used. They were slightly dehydrated with suction over a patty. Next, a bone fragment accommodating the size of the sellar defect was placed. This was followed by Tisseel. A separate layer of 2 Gelfoam patties followed by further Tisseel was then placed and more Gelfoam was positioned. The turbinates were medialized. Merogel was rolled and placed in the right middle meatus as a spacer. Merocel packs were then placed in both the right and left nasal cavity and tied loosely about the columella. The patient was turned over to the care of the anesthesia team. She was taken out of the pins. She was set for extubation and returned to the recovery room. She tolerated the procedure well without immediate complications.
PROCEDURE PERFORMED: Total thyroidectomy.
DETAILS OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating room table. After general anesthesia was induced, an IV inflating bag was placed horizontally on her shoulder blades and inflated, thereby extending her neck. Her neck and chest were prepped with Betadine solution and sterilely draped in the usual manner for procedure in this area.
An anterior cervical incision along natural skin lines was created and extended through subcutaneous tissues to the subplatysmal layer. Hemostasis was obtained with Bovie cautery. A superior subplatysmal flap was created to the level of the thyroid cartilage and inferior subplatysmal flap to the level of the clavicular heads. Dissection was done in the midline avascular plane between the strap muscles. Attention was first placed to the patient's right side.
The right strap muscles were retracted laterally. The right thyroid lobe was retracted medially. Blunt dissection of the loose fibroareolar tissue between the thyroid capsule and the undersurface of the strap muscles was done. Blunt dissection in the tracheoesophageal groove area revealed the recurrent laryngeal nerve along its entire extent throughout the thyroid fossa. Both superior and inferior parathyroid glands were identified and preserved intact from their vascular pedicles. Attention was placed to the superior pole vessels.
The right superior pole vessels were divided between 4-0 silk ligatures and small hemoclips. Mobilization of the right superior lobe allowed better mobilization of the right lobe medially. Small vascular pedicles were divided between 4-0 silk ligatures and small hemoclips. The inferior thyroid pole vessels were divided between 4-0 silk ligatures and small hemoclips. The thyroid was removed off of the trachea. The right thyroid fossa was irrigated with warm normal saline. Meticulous hemostasis was obtained. It was packed with a dry Ray-Tec gauze and attention placed to the patient's left side.
The left strap muscles were retracted laterally. The left thyroid lobe was retracted medially. Blunt dissection of the loose fibroareolar tissue between the thyroid capsule and the undersurface of the strap muscles was done. Blunt dissection in the tracheoesophageal groove area revealed the recurrent laryngeal nerve along its entire extent throughout the thyroid fossa. Both superior and inferior parathyroid glands were identified and preserved intact from their vascular pedicles. Attention was placed to the superior pole vessels.
The left superior pole vessels were divided between 4-0 silk ligatures and small hemoclips. Mobilization of the left superior lobe allowed better mobilization of the entire left lobe medially. Small vascular pedicles were divided between 4-0 silk ligatures and small hemoclips. The inferior thyroid pole vessels were divided between 4-0 silk ligatures and small hemoclips. The thyroid was removed off of the trachea. The left thyroid fossa was irrigated with warm normal saline. Meticulous hemostasis was obtained. The pyramidal lobe was removed in continuity with the isthmus. The specimen was submitted to the pathologist.
The strap muscles were approximated in the midline with a running suture of 3-0 PDS. The platysmal layer was closed with interrupted sutures of 5-0 PDS. The skin was closed with subcuticular sutures of 6-0 Prolene. A quarter inch Steri-Strip tape was applied and ice bag placed over the anterior neck.
The patient tolerated the procedure well and was transferred to the recovery room in stable condition. Estimated blood loss was 15 cc. Sponge, needle, and instrument counts were correct.
A. Right tympanoplasty with ossicular chain reconstruction.
B. Fascial graft.
C. Microdissection with the use of operative microscope throughout the procedure.
D. Facial nerve monitoring.
DETAILS OF PROCEDURE: The patient was taken to the operating room and was placed supine on the operating room table. After adequate general anesthesia had been obtained via endotracheal intubation, attention was then turned to the patient's right ear. The patient was then appropriately positioned and padded on the operating room table. Lidocaine 1% with 1:100,000 epinephrine was injected into the postauricular crease. Facial EMG electrodes were placed in the orbicularis oris and orbicularis oculi muscles. Facial nerve monitoring was used throughout the procedure. There were no abnormal EMG potentials. The patient's right ear was then prepped and draped in the standard surgical fashion. The operative microscope was used throughout the procedure. The patient's ear canal was cleaned. The patient was with normal tympanic membrane and middle ear space. Lidocaine 1% with epinephrine was injected into the 4 quadrants of the ear canal. A 2 cm stab incision was made in the postauricular crease. This was carried down to the level of the mastoid, periosteum, and temporalis fascia. A fascial graft was harvested, pressed, and passed off the table. Hemostasis was obtained in the postauricular incision and it was closed with absorbable sutures. Attention was then once again turned to the ear canal. A vertical incision was made at 12 o'clock and 6 o'clock followed by a connecting incision 6 mm lateral to the annulus. A tympanomeatal flap was elevated. The annulus was identified and elevated and the middle ear space was entered. The caroticotympanic nerve was identified and preserved throughout the remainder of the procedure. The posterosuperior canal was then curetted due to prominent overhang. This fully exposed the entire ossicular chain. Upon palpation of the malleus, it was noted to be mobile. The incus was noted to be significantly eroded. The long process tapered down onto a remnant of the head of the stapes. The stapedius tendon was present. The entire superstructure of the stapes was missing. There was not a single remnant of it present on the footplate. The footplate was noted to be mobile. The distance between the malleus and the stapes was measured. The ossicular chain was then reconstructed with a Kartush incus-stapes strut. This had to be trimmed further to fit. The strut was placed on the footplate and along the handle of the malleus. There was noted to be good mobility upon palpation of the malleus of the entire strut and footplate. Gelfoam was packed around the strut to support its position. A micrograft was used laterally at the level of the malleus to hold the strut's position. The prior fascial graft was then placed in an underlay fashion along the unilateral aspect of the strut. This was used as a buffer to prevent extrusion of the prosthesis. The tympanomeatal flap was then returned to its normal anatomical position along the posterior canal wall. Saline-soaked Gelfoam was used to pack the lateral one-half of the ear canal. This was followed by bacitracin ointment to the remainder of the ear canal. Bacitracin ointment was also placed along the postauricular incision. Facial EMG electrodes were then removed. The patient was then awakened by the anesthesia service, extubated and taken to the recovery room in a stable condition. Postoperatively, the patient had normal facial function. There were no intraoperative complications.
PROCEDURE PERFORMED: Bilateral otoplasty.
DETAILS OF PROCEDURE: The patient was brought to the operating room and was placed supine on the operating room table under general anesthesia. Her face and ears were prepped with Betadine solution and draped sterilely. The ears were marked appropriately and then infiltrated with 1% Xylocaine with epinephrine to improve hemostasis. A triangle of skin was removed posteriorly and the otoplasty rasps were inserted to score and release the pull of the antihelix cartilages. After this was softened with the otoplasty rasp, which was placed through a subcutaneous tunnel anteriorly, #4-0 wide Mersilene sutures were then placed in a horizontal suture fashion tacking the ear to the mastoid periosteum. The tension was adjusted to bring the ears back into proper anatomical position, after which interrupted #4-0 Vicryl was used to approximate the skin edges. A #5-0 running Vicryl Rapide was then used to close the skin. Identical procedure was carried out bilaterally, except on the left ear a small darwinian tubercle was removed and shaved down through a helical incision. The excess cartilage was properly excised and the skin closed with the running interrupted #5-0 Vicryl Rapide. Postoperatively, a damp cotton mold was applied to the ear to hold it in proper position after which a wraparound light fluffy head dressing was applied. The patient was then transferred from the operating table to the recovery area having tolerated the procedure without difficulty.
OPERATION PERFORMED: Tonsillectomy and adenoidectomy.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed on the operating room table in supine position. After intubation and adequate anesthesia was given, the patient was cleaned, prepped, and set up for tonsillectomy and adenoidectomy. Used the McIvor mouth gag to retract the tongue and endotracheal tube inferiorly, giving good exposure to the oropharynx. The tonsils were seen. The adenoids were directly palpated and indirectly visualized. A Foley catheter was used to retract the soft palate, and the adenoids were freely curetted out of the nasopharynx using adenoid curettes. A tonsil sponge was placed into the nasopharynx to control any bleeding. Attention was then focused toward the tonsils.
The right tonsil was grasped with a curved Allis, retracted medially, and dissected from superior to inferior pole using the coblator scalpel with settings of 7 and 4. In a similar fashion, the left tonsil was grasped with a curved Allis, retracted medially, and dissected from the superior to inferior pole using the coblator scalpel at settings of 7 and 4. All bleeding was controlled at the time of dissection using a coblator scalpel.
Attention was then refocused back towards the nasopharynx. The tonsil sponge was removed and any remaining bleeding was controlled with the handheld suction Bovie. Under indirect visualization of the adenoid mirror, nasopharynx and oropharynx were then copiously irrigated with saline and suctioned free. An orogastric tube was passed down the esophagus and into the stomach to remove any gastric contents. Then, 0.25% Marcaine was injected into each tonsillar fossa for postoperative pain. The patient was then awakened, extubated, and transferred to recovery room in stable condition. All postoperative instructions were given.
PROCEDURE PERFORMED: Uvulopalatopharyngoplasty with tonsillectomy.
DETAILS OF PROCEDURE: The patient was brought to the operating room and correctly identified. General anesthesia was induced using mask intubation followed by endotracheal tube intubation. IV steroids and IV antibiotics were administered. The table was turned to 90 degrees and the patient placed in slight reverse Trendelenburg. The patient was then draped in the usual sterile fashion following injection of 8 mL of 1% lidocaine with 1:100,000 epinephrine into the nose followed by placement of Afrin pledgets.
Following sufficient time for vasoconstrictive purposes, a hemitransfixion incision was created along the left side. A mucoperichondrial followed by mucoperiosteal flap was then elevated. A bone spur was noted posteriorly following separation of the bony cartilaginous junction. The mucosa was elevated on both sides of the bony spur and controlled cuts were made using heavy Mayo. A Takahashi was then used to extract the bony spur. The septum was noted to be well in the midline following this procedure. The inferior turbinates were then dressed. The #15 blade was used to create an incision along the anterior face of the inferior turbinate on both sides. A Freer was then used to elevate the mucoperiosteal flap along the medial surface. A suction Bovie was placed into this pocket and a reduction of the tissue was then performed.
Following this, a Boies elevator was used to outfracture the inferior turbinates. The hemitransfixion incision was then reapproximated using interrupted catguts.
Following this, a Crowe-Davis mouthgag was used to expose the oral cavity. There was evidence of +4 tonsils. The soft palate was palpated and found to be normal. A red rubber catheter was introduced through the nose into the oropharynx to retract the soft palate superiorly. Following this, each tonsil was individually grasped with a curved Allis and removed using Bovie cautery. There was noted to be a poorly defined tracheal tonsillar plane, and the tissue was sent for intraoperative frozen diagnosis. There was no evidence of any lymphoma.
Following this, under direct visualization with a laryngeal mirror, an adenoid curette was used to remove +3 adenoids. Tonsil packs were then placed, placed for temporary hemostasis. These were removed and suction Bovie was used to control and maintain hemostasis. Following this, the nasopharynx and oropharynx were irrigated and suctioned out with copious amounts of normal saline. Any noted bleeding was then controlled in the oropharynx using the suction Bovie.
The mouthgag was released and resuspended after several minutes with no evidence of any active bleeding. Following this, anterior pharyngeal tissue as well as the uvula and a small cuff of palate was then removed using Bovie cautery. There was no evidence of any active bleeding. The anterior and posterior pillars of the pharyngeal tissue were then reapproximated using interrupted #3-0 Vicryl suture.
The stomach contents were then suctioned out using an orogastric tube. There was evidence of fluid within the stomach contents. The nasal passages were reevaluated. There was no evidence of any active bleeding. A Doyle splint was placed and bacitracin ointment was then placed and secured anteriorly using a #3-0 nylon suture through the membranous portion of the septum. The patient was then returned to anesthesia and awoken without incident. There were no complications. Estimated blood loss was less than 100 cc.
PROCEDURE PERFORMED: Bilateral myringotomy and tympanostomy tube placement.
DETAILS OF PROCEDURE: The patient was brought to the operating room and identified. He was placed in the operating room table in supine position. General mask anesthesia was then administered. After adequate prepping, both ears were examined using binocular operating room microscope; the above findings were noted. Previously extruded tympanostomy tubes were removed using alligator forceps. Cerumen was removed using Buck curette. Myringotomies were then made in the anterior, inferior aspects of the tympanic membranes. Scant fluid effusions were then evacuated. New Armstrong beveled PE tubes were then placed through the myringotomies bilaterally. Floxin drops were then instilled in the ears. The patient's anesthesia was reversed and the patient was sent to the recovery room. There were no complications.
PROCEDURE PERFORMED: Bilateral myringotomy with tubes.
DETAILS OF PROCEDURE: The patient was brought to the operating room and put on the operating room table in a supine position. After adequate anesthesia was given, the patient was then set up for myringotomy with tubes. Using the operating microscope with 250 mm lens and ear speculum, the left ear canal was cleared of any debris giving good exposure to the tympanic membrane. A myringotomy incision was made in the anterior-inferior quadrant. An Armstrong grommet tube was passed into the myringotomy incision. Mild amount of mucoid fluid was suctioned from behind the eardrum and Ciprodex drops were put into the left ear canal. The patient was then repositioned for right myringotomy. Using the operating microscope with 250 mm lens and ear speculum, the right ear canal was cleared of any debris giving exposure to the tympanic membrane. A myringotomy incision was then made in the anterior-inferior quadrant. An Armstrong grommet tube was put into the myringotomy incision. Mild amount of mucoid fluid was suctioned from behind the eardrum using #2 suction. Ciprodex drops were put into the ear canal. The patient was then awakened and transferred to the recovery room in stable condition.
PROCEDURE PERFORMED: Bilateral upper and lower eyelid blepharoplasty.
DETAILS OF PROCEDURE: After identification of the patient and obtaining informed consent, she underwent the following procedure. In the preoperative holding area, the patient was marked; marked out the supratarsal creases, marked out planned excision of the skin in the upper eyelids, which is approximately 5 mm in greatest width, marked up the planned subciliary incisions with planned excision of the skin of about 3 mm in each lower eyelid. Marked out the level of the supraorbital rim bilaterally. The patient was taken to the operative suite and placed on the table in supine position. After induction and intubation, achieving full anesthesia, antibiotic prophylaxis given with Ancef and eye was lubricated with ophthalmic antibiotic ointment. Upper and lower eyelids anesthetized with 1% lidocaine with epinephrine.
Upper eyelid incision was performed in the skin with 15 blade scalpel. Symmetrically, the skin was excised using tenotomy scissors. Symmetrically, the redundant orbicularis muscle excised using electrocautery. Fat pads from the medial and central fat compartments in the upper eyelids were identified, teased out with Q-tips and then cauterized at the base and excised with electrocautery removing symmetrical amounts of the redundant tissue. Then, attention made towards hemostasis. Incision was closed in layers using 5-0 Vicryl sutures subdermally and subcuticular pullout sutures and 6-0 Novofil along the skin edges.
Addressing the lower eyelids, performed subciliary incisions and elevated skin and orbicularis muscle as flaps down to the level of the orbital rim. Identified the redundant fat pad compartments in the lateral, medial, and central areas of each lower eyelid. Tenotomy scissor was used to make incision in the septum. Fat pad compartments identified, teased out with Q-tips, and cauterized and divided at the bases with electrocautery and removed in symmetrical fashion. Attention was made to hemostasis with cautery. Incisions closed after removal of the redundant skin with tenotomy scissors using 5-0 Vicryl subdermally and 6-0 Novofil in subcuticular pullout fashion. Eyes could close completely without any undue tension and there was no sign of any eyelid ectropion. The patient was dressed with antibiotic ointment. Extubated and taken to recovery in stable condition.