Needle and Lump
Preop Dx - invasive breast cancer left breast
Procedure -
1) needle localized lumpectomy of the left breast
2) sentinel lymph node biopsy left axilla
3) interpretation of lymphoscintigraphy and lymphatic mapping
4) layered closure of the entire incision, length is about 6 cm
Surgeon - Dr. Dan Tran
Complication - None
Specimen - tumor
Blood Loss - Minimal
Anesthesia - general
Patient is a 63 year-old female patient with diagnosis invasive ductal cancer.
Long discussion was carried out with the patient in the office regarding treatment plans and options.
The patient has agreed to undergo a lumpectomy with sentinel lymph node biopsy.
Patient was brought to Radiology suite where she underwent lymphatic mapping
She also underwent placement of the needle for localization in the left breast
I reviewed the film with the radiologist prior to surgery.
Patient was given preop antibiotics, she was marked with a consent. Was brought to the operating room and she underwent general anesthetic.
She is prepped and draped in sterile fashion.
Sentinel lymph node biopsy
1 cc of Lymphazurin blue was injected intradermally around the nipple areolar complex. We massaged this area for about 2-3 minute.
Using a Geiger counter along with the imaging, the isolated location in the left axilla with the highest count based on the Geiger counter reading
A 4 cm incision was made in the axilla fold. Dissection was carried down to lymph node. The node was hot and blue and removed using the Harmonic scalpel.
No recent for pathology.
Lumpectomy
Next we turned our attention to the breast. This is the left breast.
A semicircular incision was made close to the area where the needle was inserted. This was done using 10. Scalpel.
Dissection was carried down to the subcutaneous tissue using the knife.
Lumpectomy was performed using the electrocautery
Specimen was sent for intraoperative mammographic evaluation
Once we confirmed that we have removed the specimen including the clip. The wound was closed.
Before closure of the wound, we irrigated the wound bed with sterile saline.
Perform hemostasis using electrocautery.
The wound was then closed, the entire length which was about 6 cm with multiple layer of absorbable suture in a layered closure fashion.
Patient tolerated procedure well
At the end the case, all instrument as well as sponge and needle counts were reported correct
She was transferred to recovery in stable satisfactory condition.
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Component separation
PREOPERATIVE DIAGNOSIS:
Recurrent ventral hernia.
POSTOPERATIVE DIAGNOSIS:
Ventral hernia of the midline
PROCEDURE PERFORMED:
1. Repair of ventral hernia utilizing a component separation technique. The length of the component separation was 15 cm on both sides. With Placement of the biologic mesh for the hernia repair.
2. Application of negative pressure dressing to the wound
ANESTHESIA:
General.
UNANTICIPATED EVENTS/COMPLICATIONS:
No complication.
ESTIMATED BLOOD LOSS:
50 mL.
INDICATION:
The patient is a 78-year-old female who is status post abdominal exploration and bowel resection.
She has a recurrent ventral hernia
She presents today for repair of hernia
DESCRIPTION OF PROCEDURE:
The patient was seen in preop holding area. The patient was then brought back to the OR, where she was placed supine position. Foley catheter was placed. She underwent general anesthetic and he was prepped and draped using DuraPrep. The hernia is palpable as it is towards the upper midline and incision was performed on the skin using #10 scalpel.
Dissection was carried down to the fascia, was performed using electrocautery. The hernia itself is roughly 12 cm in dimension. The entire length of the previous incision was extended to expose the fascia. The anterior surface of the fascia was skeletonized to create a skin flaps lateral on each side of the hernia above the rectus muscle. This was done carefully using the electrocautery. Once this was accomplished, then the hernia edges were cleaned out using electrocautery, until the 2 edges were identified.
The fascia was mobilized superiorly to near the xiphoid process superiorly to well below the incision and laterally to the lateral sidewalls. The external oblique aponeurosis was divided on each side lateral to the rectus sheath for a distance of 15 cm resulting in a tissue transfer about 5 cm each side. With this maneuver it was possible to bring the fascial edges at the site of the hernias together using interrupted #1 Prolene sutures.
Finally we selected the HD mesh, which is a biologic mesh. We then soaked the mesh as instructed. The measurement of the mesh is about 12 x 16 cm
we placed the mesh on top of the repair and we meticulously anchored the edge of the mesh to the far side of the fascia that we created using the component separation technique. We anchored the mesh in this way in circumferential fashion, to secure the mesh all the way down. Finally, we irrigated the wound and then we closed, we placed 2 JP drains on top of the mesh through separate small skin incision and we closed the skin using multiple levels of absorbable suture for layered closure for the dermis, and skin was stapled.
Finally we closed the skin with skin staples.
A negative pressure dressing was then placed over the entire wound.
The patient overall tolerated the procedure well, transferred to recovery room in stable and satisfactory condition.
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lap chole with GIA
Date of Surgery -
Pre-op Diagnosis: Cholecystitis.Post-op Diagnosis: Same as Preoperative Diagnosis. Procedure: Laparoscopic Cholecystectomy. Indication: CholecystitisSurgeon(s): Dan Tran, MD.Anesthesia: General.Findings: Cholecystitis.Description of Procedure:
Laparoscopic Cholecystectomy
Standard 4 port laparoscopic incisions were created using a #11 scalpel. The trocars were placed either through the open technique, or through direct vision. Carbon dioxide was used to insufflate the abdominal cavity. The gallbladder was identified. The gallbladder itself had some adheions around he infundibulum indicating chronic inflammation. The atraumatic grasper was used to elevate the gallbladder towards the head. The infundibulum was retracted in the lateral direction. Electrocautery was used to carefully skeletonize the area around the cystic duct and cystic artery. There were too much adhesion so the gallbladder was then taken down from it's dome. Once the neck was reached, the GIA stapler was used to divide the GB neck and cystic duct Once. The gallbladder was then removed from the gallbladder bed using electrocautery. The gallbladder was removed from the abdominal cavity using laparoscopic retrieval bag. Suction irrigation was used wash out the area around the liver bed. Hemostasis was obtained using electrocautery. Once hemostasis was completely obtained, then the carbon dioxide was released from the abdominal cavity. Trocars were removed. The umbilical fascia was closed using a 0-Prolene suture. All skin incisions were closed using absorbable stitch.
The patient tolerated the procedure well and was transferred to the recovery room in stable and satisfactory condition.Specimens: Gallbladder.Wound Type: Clean-contaminated.Drains: None.Complications: None.Estimated blood loss: None.Patient Condition: Stable.
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Lap left Colectomy
SURGEON:
DAN NICOLAS TRAN, MD
PREOPERATIVE DIAGNOSIS:
Diverticulitis
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE PERFORMED:
1) Laparoscopic low anterior resection with primary anastomosis using 25 EEA stapler
2) Takedown splenic flexure
UNANTICIPATED EVENTS/COMPLICATIONS:
No complication.
ESTIMATED BLOOD LOSS:
Minimal.
SPECIMENS REMOVED:
Sigmoid rectum
FINDINGS:
Diverticulitis between the 2 tattooed mark area
The patient was given preop antibiotics and the patient was brought to the operating room. Consent was signed, placed supine on the OR table. Time-out was performed, prepped and draped using DuraPrep.
A 5 mm trocar was placed directly under direct visualization in the patient's right paramedian location. Next, CO2 gas was used to insufflate the abdominal cavity. Next, 2 additional ports were placed and another 12 trocar was placed in the right lower quadrant and a 5 was placed in the epigastric region, 12 was placed under direct vision.
There was some adhesions due to the inflammation.
I was able to identify 2 tattoo marks signifying the proximal distal part of the bowel that has the disease. This and the proximal rectum and distal sigmoid colon.
I took down the left line of Toldt using the Harmonic Scalpel, working away from the lateral aspect of the colon all the way down to the pelvis. The splenic flexure had to be taken down to increase the length for anastomosis.
Once the lateral mobilization has been completed, then the mesenteric defect was created below the area of stricture using Harmonic Scalpel. Next, the Endo surgical stapler was used to divide the colon basically at the mid section of the rectum and transected completely across. Next, the Echelon stapler was then used to also divide mesentry of the more proximal bowel, working from that point towards the more proximal bowel. Finally, once the diseased segment was mobilized completely, then a small extraction incision was made in the midline abdomen, the incision is about 5 cm. We extracted the mobilized segment of bowel.
Next, I divided the diseased bowel, but before dividing it, I did place the 25 EEA stapler in the proximal healthier segment of bowel and then divided the bowel. In this way I was able to secure the stapler angle in the proximal bowel. The specimen was sent for pathology. We placed the proximal healthy colon section back into the abdominal cavity. We closed the midline fascia. We re-insufflated the abdominal cavity. We then performed anastomosis connecting the rectum to the healthier sigmoid colon under direct vision, this without any problem.
Once the anastomosis was completed, we removed the stapler, we irrigated the abdominal cavity. We flushed across the anastomosis under water to make sure there was no bubbling, there was no leakage, there was none. Finally, we irrigated the abdominal cavities with copious saline and we removed excess fluid. The anastomosis was healthy without any sign of devascularization or tension. Hemostasis was completely obtained. Once this was confirmed, we placed the omentum back into position. We removed the trocars. We released the CO2 gas. We changed gloves and gowns and closed all skin incision using skin staples. The patient tolerated the procedure well, transferred to recovery room in stable and satisfactory condition.
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Lap Right Colectomy
Date of Surgery -
Pre-op Diagnosis: Post-op Diagnosis: Same as Preoperative Diagnosis. Procedure: Laparoscopic right colectomy Indication: Surgeon(s): Dan Tran, MD.Anesthesia: General.Findings:
Description of Procedure:
DESCRIPTION OF PROCEDURE:
He was given preop antibiotics in the operating room, placed supine on the operating table. Time-out was performed. He was prepped and draped using DuraPrep. The abdominal cavity was entered at the right paramedian location using the trocar under direct vision. This was done using the 5 mm trocar. There was no complication during the entry.
Once we entered the abdominal cavity, CO2 gas was used to insufflate the abdominal cavity. Two additional ports were placed, a 12 mm trocar was placed in the upper left upper quadrant and a 5 mm was placed in the mid pelvis lower abdomen. The procedure began by taking down the white line of Toldt starting from the cecum working towards the hepatic flexure. This was done using the Harmonic scalpel.
Next, The omentum was taken off starting at the mid transverse colon going toward the right side. Next, the hepatic flexure and proximal transverse colon were also freed up laterally using the Harmonic Scalpel. This completes the lateral mobilization.
Once this was completed, then the mesenteric of the colon was divided starting from the hepatic flexure towards the terminal ileum. The avascular window was identified at the hepatic flexure. From there the GIA stapler was used to divide the mesentery. I proceeded from the hepatic flexure towards the terminal ileum.
Any region of the staple line that shows some bleeding, will reinforce with surgical clips.
Once the mesenteric of this segment of colon was mobilized, then the segment of interest is completely mobilized.
Next a small extraction incision was made in the mid upper abdomen. The incision was made with skin knife.
The fascia was opened using electrocautery carefully to avoid injuring any structures below. The incision is about 4-5
Through this incision, I then extracted the mobilized bowel. I then performed the resection and anastomosis using the the GI stapler.
A side-to-side anastomosis was performed using the stapler. 1st, the 2 segments of bowel to be anastomosed was lined up using 2 silk sutures.
Next, enterotomies were made at both limbs of the bowel to be anastomosed. Finally the GI staple was used to perform the side-to-side anastomosis.
To seal the hole, and to remove the bowel proximal to the anastomosis, therefore removing the bowel with the specimen of interest, different loads of GIA stapler was used to then crossed divide the bowel distal to the enterotomies.
I removed the right colon including terminal ileum that was sent for pathology. The anastomosis was then placed back into the abdominal cavity. I then closed the extraction incision fascia using #1 Prolene suture.
Next, we changed gowns and gloves. I re-examined intracorporeally the anastomosis to make sure it was healthy, it was, there was no bleeding. We washed and irrigated the area of dissection and removed any excess fluid. Once we confirmed complete hemostasis and the anastomosis appeared healthy, we performed instrument, needle, and sponge counts. When this was reported to me as correct per the OR staff, I removed the trocars, and released the CO2 gas. All skin incisions closed using staples. The patient tolerated the procedure well, transferred to recovery room in stable and satisfactory condition.
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Mastectomy
Preop: Left breast cancer
Postop: Left breast
Procedure: Left simple mastectomy,
left axillary node biopsy
Interpretation of lymphoscintigraphy
Clear closure of the entire incision using absorbable sutures
Surgeon: Dr. Tran
Assistant: Dr. Smith, D.O.
Complication: None
Blood loss: Minimal
This is a 65-year-old patient with left breast cancer.
Patient has multiple centric lesions, and therefore we decided to proceed with simple mastectomy and sentinel lymph node biopsy.
She presented for the procedure today.
After lymphoscintigraphy was performed, I evaluated the film with the radiologist.
She was then brought back to the operating for surgery.
The site was marked with a consent in the preop holding area. She was given preop antibiotics.
In the operating room, 1 cc of Lymphazurin blue was injected intradermally around the nipple areolar complex.
Using the Geiger counter, I identified the area that has a high count in the left axilla. This corresponds to the imaging.
A small linear incision was performed in the left axilla. This was done using 10. Scalpel.
Dissection was carried down to the subcutaneous tissue.
Using the Geiger counter, I directed my dissection towards the hottest area.
Eventually we were able to identify a blue node that was hot.
The node was removed using the Harmonic scalpel.
This was the sentinel lymph node and was sent off for pathology.
The axillary wound was irrigated and closed using absorbable sutures.
Next item attention to the left breast.
An elliptical incision was performed using 10. Scalpel.
Incision was performed to encompass the entire nipple-areolar complex.
After the incision was made down to the skin subcutaneous tissue, then we raised the flaps superiorly and inferiorly.
The superior margin for mastectomy was taken all the way to the clavicle. Inferiorly it was taken down to the abdominal rectus muscle.
Medially was taken to the sternum. We took the breast all the way to the tail of the breast.
In addition, the breast was taken off the pectoral muscle to include the fascia.
We sent the entire breast for touch prep since the patient has multicentric disease.
Because the tumor approach is the 1 to 2 o'clock position, we excise additional margins superiorly.
This was also sent for pathology.
Re-evaluate for hemostasis.
In the bleeding edges of vessel was ligated using silk sutures or cauterized.
One JP drain was placed into the wound cavity and brought out through a small incision.
The skin incision was then closed using 3 Vicryl suture, followed by 4 Monocryl suture in the layered closure fashion.
Entire incision is about 22 cm.
A in the case, all instrument as well as needle and sponge counts were reported correct.
The patient tolerated procedure well, was transferred recovery room stable satisfactory condition.
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Date of Surgery -
Preop Dx - cancer of the right breast
Procedure -
1) needle localized lumpectomy of the right breast
2) sentinel lymph node biopsy right axilla
3) interpretation of lymphoscintigraphy and lymphatic mapping
4) layered closure of the entire incision, length is about 6 cm
Surgeon - Dr. Dan Tran
Complication - None
Specimen - tumor
Blood Loss - Minimal
Anesthesia - general
Patient is a -year-old female patient with diagnosis invasive ductal cancer.
Long discussion was carried out with the patient in the office regarding treatment plans and options.
The patient has agreed to undergo a lumpectomy with sentinel lymph node biopsy.
Patient was brought to Radiology suite where she underwent hepatic mapping.
She also underwent placement of the needle for localization in the right breast.
I reviewed the film with the radiologist prior to surgery
Patient was given preop antibiotics, she was marked with a consent. Was brought to the operating room and she underwent general anesthetic.
She is prepped and draped in sterile fashion.
Sentinel lymph node biopsy
1 cc of Lymphazurin blue was injected intradermally around the nipple areolar complex. We massaged this area for about 2-3 minute.
Using a Geiger counter along with the imaging, the isolated location in the right axilla with the highest count based on the Geiger counter reading
A 4 cm incision was made in the axilla fold. Dissection was carried down to lymph node. The node was hot and blue and removed using the Harmonic scalpel.
No recent for pathology.
Lumpectomy
Next we turned our attention to the breast
A semicircular incision was made close to the area where the needle was inserted. This was done using 10. Scalpel.
Dissection was carried down to the subcutaneous tissue using the knife.
Lumpectomy was performed using the electrocautery
Specimen was sent for intraoperative mammographic evaluation
Once we confirmed that we have removed the specimen including the clip. The wound was closed.
Before closure of the wound, we irrigated the wound bed with sterile saline.
Perform hemostasis using electrocautery.
The wound was then closed, the entire length which was about 6 cm with multiple layer of absorbable suture in a layered closure fashion.
Patient tolerated procedure well
At the end the case, all instrument as well as sponge and needle counts were reported correct
She was transferred to recovery in stable satisfactory condition.
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open sigmoid
Date of surgery
SURGEON:
DAN NICOLAS TRAN, MD
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
PROCEDURE PERFORMED:
Patient with low anterior anastomosis
ANESTHESIA:
General.
UNANTICIPATED EVENTS/COMPLICATIONS:
No complications.
ESTIMATED BLOOD LOSS:
Minimal.
SPECIMENS REMOVED:
Sigmoid colon
INDICATION:
Diverticulitis
DESCRIPTION OF PROCEDURE:
The patient was brought to the OR, placed supine on the OR table. The patient was placed in supine position. The patient was prepped and draped using DuraPrep. A standard midline incision was performed using 10. Scalpel. Dissection down to the fascia using electrocautery. The fascia was opened. Once we entered the abdominal cavity, there was minimal adhesion that we took down using the Harmonic scalpel. The Bookwalter retractor was placed for exposure.
Care was taken during the placement of required to retract to to avoid injuring any important structures.
Headlight were used for proper illumination
The patient has sigmoid diverticulitis.
Description the finding here...........................
Mobilization was performed mainly using blunt dissection to separate the sigmoid colon and rectum from the pelvic sidewall.
Next, the upper left colon was taken down using the electrocautery along the left line of Toldt
This was performed starting at the mid sigmoid and working up towards the healthier proximal sigmoid.
The splenic flexure was taken down to help increase the length and mobilization for the anastomosis and resection.
This was done using the electrocautery as well as the Harmonic scalpel.
If anastomosis is done with the EEA stapler ...........................................
The segment of diseased bowel was divided proximal and distal to where disease start in ends.
This leaves behind healthy rectal stump and healthy sigmoid colon status more proximal.
The EEA stapler anvil was then placed into the proximal bowel. The tip of anvil was brought out to the bowel wall.
The opening was closed using a perpendicular stapler. In this way, the anvil was locked into the proximal sigmoid colon in preparation for the anastomosis
Finally, anastomosis was performed, connecting the proximal sigmoid colon down to the rectal stump without any problem. The end of the stapler was placed into the rectal stump it was allowed to connect with the anvil. Once we performed the anastomosis, we tested the anastomosis under water to make sure there was no bubbling indicating any leakage and there was none.
Incidental appendectomy
The clinical decision was made to remove the appendix since any future surgery for appendectomy may be complicated by adhesions and may not be achievable by laparoscopic method.
The appendix was identified, the mesentery was mobilized using Harmonic scalpel. The base of the appendix was divided using a GI stapler.
The appendix was passed off as specimen.
Closure
Finally, we changed gowns and gloves again and we irrigated the abdominal cavity, removing excess fluid.
Before closing the fascia, we performed instrument, needle, and sponge counts.
When these were reported to me as correct, then I began closing the fascia.
The midline incision was closed using running looped PDS suture. The skin was stapled.
The patient tolerated the procedure well. At the end of the case, all instruments, sponge, and needle counts were reported to me as correct. The patient was transferred to the recovery room in stable and satisfactory condition.
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Perianal Abscess
Date of Surgery:
Preop: Perianal abscess
Postop: same
Procedure:
1) evaluation on anesthesia
2) debridement of perianal abscess, complex requiring postoperative packing
Surgeon: Dr. Dan Tran
Complication: none
Blood Loss: minimal
Specimen: tissue and culture
Anesthesia: General
PROCEDURE: See above
The patient is a year old patient. The patient presents with severe pain in the perianal area
Workup including imaging study indicates an abscess in this region
The patient was brought to the OR today for debridement and evaluation
In the operating room the patient underwent general anesthesia. The patient was placed in lithotomy position.
A thorough evaluation anesthesia with rectal examination was performed.
There are no suspicious mass or lesion.
There is a large indurated area.
Using a scalpel, a sharp incision was made directly over the palpable indurated area.
A large amount of pus was retrieved
The pocket of the abscess was lavaged and irrigated using sterile saline.
Hemostasis was obtained using electrocautery.
Counter incision.... If any
Once all the pus and infection was washout from the wound,
Then the wound was packed using sterile gauze.
The plan is to continue antibiotics and wound care.
Hemostasis was obtained,. Patient tolerated procedure well. Was transferred to recovery in stable and satisfactory condition.
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Port Placement
Date of Surgery:
Pre-op Diagnosis: Post-op Diagnosis: Procedure:
1) centrally inserted tunnelled catheter with subcutaneous resevoir - i.e. port
2) intraoperative fluoroscopy
3) intraoperative ultrasound
Surgeon(s): Dan Tran, MD.Anesthesia: Findings: normal anatomy
Complication: none
PROCEDURE: History and Physical examination was reviewed. The patient was given preoperative IV antibiotics, brought back to the operating room. The patient was placed supine on the operating room table. Time out was performed to confirm the patient and case to be performed. All was in agreement. The patient was prepped and draped using standard prep (DuraPrep etc). The patient was first placed in Trendelenburg position. Seldinger technique with help of intraoperative ultrasonography was used to access the patient's left internal jugular vein. The guide wire into the patient's central venous system. It is threaded down the needle and passed down the superior vena cava into the atrium. This was done under the supervision of intraoperative fluoroscopy. Once the wire was placed successfully, the insertion needle was removed. Local anesthetic was then used to perform a field block in the area below the left clavicle.
Next a #10 scalpel was used to create a subcutaneous pocket. The knife was used to make a skin incision roughly about 3.5 centimeters. Dissection to undermine the subcutaneous tissue was created using the electrocautery. Once the pocket was large enough to fit the port, then the catheter itself was tunneled underneath the skin. It is tunneled from the subcutaneous pocket region toward the needle insertion site.
Next the dilator and sheath complex was placed over the wire. Then it was inserted again using a Seldinger technique. Under fluoroscopic guidance to identify and assure it is in proper position, once it is then the guide wire was removed. Next the dilator was removed leaving the sheath in the central vein. Next the catheter was then slid into the sheath, passed beyond, passed further down into the central venous system where the tip of the catheter was allowed to rest at the atrium superior vena cava complex. The opposite end of the wire was trimmed so that it would be able to fit onto the port at the subcutaneous pocket site. Finally, when this was achieved, again with the help of fluoroscopy, I tested the port by flushing and pulling back on it and there was good blood flow without any obstruction. The wound was then irrigated. The port was anchored into the pectoral fascia using 3-0 Prolene suture. All skin incisions were then closed using absorbable stitch.
The patient overall tolerated the procedure well, was transferred to the recovery room in stable and satisfactory condition. A post-port placement x-ray will be obtained to evaluate for position as well as to evaluate for any complications.
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Port Removal
Date of Surgery:
Pre-op Diagnosis: Post-op Diagnosis: Procedure: Removal of Port
Surgeon(s): Dan Tran, MD.Anesthesia: MacFindings: normal anatomy
Complication: none
INDICATIONS
This patient has previous need for a port for long-term IV access. The patient has now completed, the need and would like to have this removed.
PROCEDURE
The patient was seen in the preop holding area. The patient was given preop intravenous antibiotics and then subsequently brought back to the OR and placed supine on the OR table. Time out was performed to identify the patient and case to be done. The patient was prepped using DuraPrep solution. Finally, local anesthetic which is a combination of lidocaine and Marcaine was used to perform field block.
A #15 scalpel was used to make a skin incision on top of the old incision above the port. Dissection down to the port was performed using electrocautery. The two anchoring stitches were removed using Metzenbaum scissors. At this point the port was free and it was then slid out along with the catheter in whole and intact. The wound was then irrigated. The 3-0 Vicryl suture was used to perform hemostasis and the wound was closed using absorbable stitch.
The patient overall tolerated the procedure well, transferred to recovery room in stable and satisfactory condition.
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sebaceous cyst
Date of Surgery:
Pre-op Diagnosis: Epidermal Inclusion CystPost-op Diagnosis: Same as Preoperative Diagnosis. Procedure: Complete excision of epidermal inclusion cystIndication: pain, discomfort, enlargement
Surgeon(s): Dan Tran, MD.Anesthesia: Findings: Epidermal inclusion cyst
Description of Procedure:
Location:
Type: Sharp with scalpel
Length: 6 cm
Width: 1 cm
Depth: subcutaneous, down to but does not penetrate fascia
Size - about 5 cm
Patient with enlarging epidermal inclusion cyst. IV abx was begun in the preop holding area. The patient was seen in preop holding area. Site was marked with the patient's consent
.
Patient brought back to OR. Time out was performed. Number 10 scalpel was used for the skin incision. Size as above. excisionall debridement was performed to remove chronic, enlarging cyst. The debridement was carried to healthy tissue. Wound Cavity Washout out with copious saline.
Wound closed with
The entire cyst removed and send to pathlogy
Pt tolerated procedure and was transferred to recovery in stable and satisfactory condition
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Skin Cancer
Date of Surgery
Preop Dx - skin cancer
Postop Dx - same
Procedure
1)- wide excision of skin cancer
2) tissue transfer and mobilization technique to create adequate laxity for wound closure
3) - layered closure of the entire length of the incision. Please see the dimension described below for the length of the incision.
Surgeon - Dr. Dan Tran
Complication - None
Specimen - skin cancer
Blood Loss - Minimal
Location:
Length:
Width:
Depth: subcutaneous, down to but does not penetrate fascia
Patient is a - who was diagnosed with skin cancer located
The patient was seen in the preop holding area where the lesion was identified and marked with the patient consent.
The patient was then brought back to the OR placed supine on the OR table. Standard prep and drape was performed.
A combination of lidocaine and Marcaine was used to create a field block around the area of intended incision.
The scalpel used to make an elliptical incision with the length with a depth as above. Full-thickness excision of the skin cancer was removed and sent for pathology.
Hemostasis was obtained when needed using electrocautery.
Because of the with require for complete excision of the skin cancer, tissue transfer technique and mobilization was performed
For the entire length of the incision so that there would be proper laxity for closure of the wound.
The skin was closed entire length with layered closure using absorbable stitches. These with 3 0 Vicryl, followed by 4 Monocryl sutures
This was followed by 3 0 Prolene suture
After the closure was completed, the wound was clean and the patient's wound was dressed.
The patient tolerated the procedure well and was transferred to the recovery room in stable and satisfactory condition.
SAMPLE Consult
Chief Complaint: nausea/vomiting, constipation
HPI: 81-year-old female with no known past medical history presents emergency department with nausea vomiting abdominal pain for the past 4 days. No bowel movements past 4 days. Patient history obtained by the patient's sister who is at bedside. Per the patient she has not had a bowel movement over the past 4 days however the patient has not been eating over the past 4 days as well. Patient prior to that having intermittent episodes of diarrhea. Patient is mildly nauseous at this time but has not vomited today. Patient is passing gas. No abdominal surgeries. George Lai patient.
No fevers, chills, hematochezia, constipation, urinary frequency, urgency, burning, or pain with urination. The patient is passing gas, denies back pain. No chest pain or shortness of breath. The patient also denies numbness, headache, paresthesia, weakness, dizziness, vertigo, or changes in vision.
Onset: Subacute
Location/Radiation: Generalized abdomen
Duration: 4 days
Character: Nausea vomiting diarrhea, constipation
Aggravating Factors: Nothing
Relieving Factors: Nothing
Timing: Constant
Severity: Mild
Past Medical History: patient denies any medical problem
Past Surgical History: patient states no hx of any surgery
Family History: positive for hypertension
Medications: None
Allergies: no food allergies, the drug allergies stated in nursing document
SHx: Lives here in town, denies drug use.
ROS:
all pertinent positives and negatives are stated in HPI, all other systems reviewed and are negative.
HEENT: no headache, no blurry vision
CVS: no syncope, no shortness of breath, no chest pain
GI: + generalized abdominal pain, +nausea/vomiting +constipation, no abdominal to back pain
GU: no urinary urgency, frequency, pelvic pain, or burning/pain with urination.
Ortho: no bone pain, no muscle pain
Skin: no rash or skin lesions
Neuro: no seizure, no stiffness, no weakness
Endo: no polyuria or polydipsia
HEMA: no anemia
Allergy/imm: No urticarial, no season allergy.
General: no weakness, no fever, no chills
Resp: no SOB, no distress
PHYSICAL EXAM
GENERAL APPEARANCE: Patient is alert, awake, resting, speaking in complete sentences and in no acute distress.
HEENT: PERRLA, EOMI.
NECK: Supple.
LUNGS: Clear to auscultation bilaterally. Normal breath sounds. No Wheezing. No Rales or Rhonchi.
HEART: Auscultation: RRR. Normal heart sounds. No gallops or murmurs.
Palpation: Normal peripheral pulses.
ABDOMEN: No palpable tenderness, no palpable spleen or liver tenderness. Normal bowel sounds. No guarding, no rebound. (-) Rosvings, (-) McBurney’s point tenderness, (-) Murphy’s Sign.
EXTREMITIES: Strength 5/5 in all 4 extremities with full range of motion. Patient ambulatory. Good muscle tone.
NEURO: No sensory or motor exam deficit. GCS 15. Patient is speaking in complete sentences, no slurring, normal articulation. No facial muscle weakness noted. Patient is ambulatory without gait abnormalities.
VASCULAR: Bilateral radial pulses are equal and normal.
SKIN: Warm, pink, and dry. No pathological skin rashes.
PSYCH: normal mentation. Awake and alert, not suicidal or homicidal.
MEDICAL DECISION/PROCEDURES/ER COURSE:
ER COURSE:
Patient was placed in the examination room and evaluated by me immediately.
Patient was checked periodically to assure stability and response to treatment.
All clinical findings, any available ancillary testing results, and course of management was discussed with patient & family involved with the care of the patient whom agreed to.
EKG is reviewed and interpreted by myself.
The rhythm is regular, sinus, rate 99, Axis is normal, QRS complex is narrow. There is no sign of acute ischemia, infarction, or pericarditis. This patient has T-wave inversions in V2. When compared to prior EKGs in 2013 the patient appears to have an unchanged EKG.
81-year-old female presents emergency department with nausea vomiting diarrhea constipation intermittently over the past 4 days. No new medical problems. Sent in by her George Lai patient's primary care physician. Ordered CBC CMP troponin EKG chest x-ray blood cultures x2, urine cultures and lactic acid x2, CT abdomen pelvis with contrast, 4 mg IV Zofran. Chest x-ray per Radiology shows less visible right mid lung linear atelectasis or scarring. No acute cardiopulmonary changes. Patient noted to have mildly elevated leukocytosis. Hemoglobin hematocrit appear to be stable. BUN is elevated 82 creatinine is elevated 2.1. No baseline to suggest chronic kidney disease. GFR is low.Upon conversation with the patient's sister the patient appears to have had history of poor kidney function the past. In the setting of the patient's low GFR ordered a CT abdomen pelvis without contrast. CT abdomen pelvis per radiology suggest the patient has a small bowel obstruction. The level of the proximal ileum. Patient is status post cholecystectomy. Mild colonic diverticulitis there is pneumobilia related to prior patellectomy her sphincterectomy. Patient while in the emergency department has had no vomiting. Patient has been no acute distress however the patient should be admitted to the hospital for evaluation of small-bowel obstruction. Will place NG tube. Patient's labs are otherwise unremarkable. Pt admitted to med surg, I spoke the patient’s pcp George Lai who will admit the patient to med surg. Pt admitted in guarded condition
CLINICAL IMPRESSION:
1. Small bowel obstruction
2. chronic kidney disease