Medical Specialty: Surgery
Sample Name: Bilateral Upper Lid Blepharoplasty

PREOPERATIVE DIAGNOSIS:,  Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction.  The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.  All questions have been thoroughly answered, and the patient understands the surgery indicated.  She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation.  The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.  The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen.  The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction.  The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection.  Hemostasis was obtained with a bipolar cautery.  A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.  The defect in the orbital septum was identified, and herniated orbital fat was exposed.  The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit.  A similar procedure was performed exposing herniated portion of the nasal pocket.  Great care was taken to obtain perfect hemostasis with this maneuver.  A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion.  Careful hemostasis had been obtained on the upper lid areas.  The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact.  There was no diplopia, no ptosis, no ectropion.  Wounds were reexamined for hemostasis, and no hematomas were noted.  Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.
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DESCRIPTION: Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.

surgery, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis

Bilateral upper lid blepharoplasty, while a surgical procedure, is commonly performed and generally considered low to medium risk when conducted by experienced surgeons. It involves cosmetic correction and is elective rather than life-saving. There are inherent risks, such as infection or complications from anesthesia, but it is not an emergency or highly critical surgery.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Surgery
Sample Name: Belly Button Piercing

PROCEDURE:,  Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:,  The patient was prepped after informed consent was given of risk of infection and foreign body reaction.  The area was marked by the patient and then prepped.  The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through.  A small ball was placed over the end of the ring.  This terminated the procedure.,The patient tolerated the procedure well.  Postop instructions were given regarding maintenance.  Patient left the office in satisfactory condition.
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DESCRIPTION: Belly button piercing for insertion of belly button ring.

surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE

This procedure is a cosmetic one and not medically necessary, usually performed in non-high-stakes environments. The potential complications, such as infection or foreign body reaction, are generally low-risk and manageable. As the patient tolerated the procedure well and left in satisfactory condition, it further suggests the situation does not have significant urgency or consequence.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Bifrontal Cranioplasty

PREOPERATIVE DIAGNOSIS:,  Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for.  The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap.  He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty.  After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty.  He had previously undergone a CT scan.  Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed.  We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant.  He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis.  The scalp was prepped and draped in the usual sterile fashion.  A previous incision was reopened and the scalp flap was reflected forward.  We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap.  We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base.  We did explore laterally and saw a little bit of the mesh on the lateral orbit.  Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws.  We had achieved good hemostasis.  The wound was closed in multiple layers in usual fashion over a Blake drain.  At the end of the procedure, all sponge and needle counts were correct.  A sterile dressing was applied to the incision.  The patient was transported to the recovery room in good condition after having tolerated the procedure well.  I was personally present and scrubbed and performed/supervised all key portions.
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DESCRIPTION: Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.

surgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,

A bifrontal cranioplasty is a complex surgical procedure aimed at correcting a significant cranial defect, which in this case measures greater than 10 cm in the frontal region. The patient is a 66-year-old male with a history of chondrosarcoma that complicates the situation due to prior surgeries and modifications to the skull structure. The procedure involves significant risks inherent to major cranial surgery, including infection, bleeding, and the intricacies of working near the brain and critical blood vessels. Despite the estimated blood loss being nil in this instance, any cranial procedure could potentially become high-risk depending on various intraoperative factors. The patient having been without the bone flap for years adds complexity and potential difficulty to the surgery. These factors together indicate a higher-stakes situation primarily due to the procedure's nature and potential consequences if not executed perfectly.


Medical Specialty: Surgery
Sample Name: BCCa Excision - Lower Lid

PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.
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DESCRIPTION: Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.

surgery, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival,

This situation involves the surgical excision of a large basal cell carcinoma (BCC) on the lower eyelid, which is significant but also a common procedure with a high success rate when performed by skilled surgeons. The stakes are high because it involves delicate eye structures and cosmesis, but it's not life-threatening like some other carcinomas. Therefore, the procedure must be conducted with precision to avoid potential complications affecting vision or facial function, making it relatively high-stakes within a surgical context.


Medical Specialty: Surgery
Sample Name: Austin-Moore Bipolar Hemiarthroplasty

PREOPERATIVE DIAGNOSIS:,  Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table.  The right lower extremity was protectively padded.  The left leg was propped with multiple blankets.  The hip was then prepped and draped in the usual manner.  A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues.  Hemostasis was achieved utilizing electrocautery.  Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly.  The external rotators were identified after removal of the trochanteric bursa.  Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line.  They were then reflected distally.  The capsule was then opened in a T-fashion utilizing the cutting cautery.  Fraction hematoma exuded from the hip joint.  The cork screw was then impacted into the femoral head and it was removed from the acetabulum.  Bone fragments were removed from the neck and acetabulum.  The acetabulum was then inspected and noted to be free from debris.  The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur.  The T-handle broach was then passed down the canal.  The canal was then sequentially broached up to a medium broach.  The calcar was then plained with the hand plainer.  The trial components were positioned into place.  The medium component fit fairly well with the medium 28 mm femoral head.  Once the trial reduction was performed, the hip was taken through range of motion.  There was physiologic crystalling with longitudinal traction.  There was no tendency towards dislocation with flexion of the hip past 90 degrees.  The trial implants were then removed.  The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry.  The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit.  The implant was then impacted into place.  The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup.  The acetabulum was once again inspected, was free of debris.  The hip was reduced.  It was taken through full range of motion.  There was no tendency for dislocation.  The wound was copiously irrigated with gentamicin solution.  The capsule was then repaired with interrupted #1 Ethibond suture.  External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch.  The wound was once again copiously irrigated with gentamicin solution and suctioned dry.  Gluteus fascia was approximated with interrupted #1 Ethibond.  Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples.  A bulky dressing was applied to the wound.  The patient was then transferred to the hospital bed, an abductor pillow was positioned into place.  Circulatory status was intact to the extremity at completion of the case.
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DESCRIPTION: Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.  Displace subcapital fracture, left hip.

surgery, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,

Performing an Austin-Moore bipolar hemiarthroplasty to treat a displaced subcapital fracture of the hip is a significant surgical procedure. It requires precision to ensure the stability of the implant and to avoid complications such as dislocation or infection. While the procedure is standard for such fractures, the high demands for surgical skill, patient safety, and the implications of potential intraoperative or postoperative complications elevate the stakes. Therefore, while not the most extreme level of surgical urgency or risk, it is high-stakes relative to other medical situations.


Medical Specialty: Surgery
Sample Name: Ash Split Venous Port

ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture "wings.",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.
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DESCRIPTION: Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.

surgery, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter

The procedure described is a surgical intervention involving the placement of a venous port, which is typically used for patients requiring long-term intravenous access, often for chemotherapy, dialysis, or other intensive treatments. The procedure involves accessing the internal jugular vein and using fluoroscopic guidance to ensure proper placement, alongside necessary measures to prevent complications such as infections or pneumothorax. These factors make it a high-stakes procedure due to the potential risks involved and the critical nature of its function for ongoing patient treatment.


Medical Specialty: Surgery
Sample Name: Arthrotomy & Subscapularis Tendon Repair

TITLE OF OPERATION:  ,1.  Arthrotomy, removal humeral head implant, right shoulder.,2.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3.  Debridement glenohumeral joint.,4.  Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X.  However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis.  Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,3.  Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position.  A Foley catheter was placed in his bladder.  He was then placed in a beach chair position.  He was brought to the side of the table and the torso secured with towels and tape.  His head was then placed in the neutral position with no lateral bending or extension.  It was secured with paper tape over his forehead.  Care was taken to stay off his auricular cartilages and his orbits.  Right upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection.  Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep.  This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case.  Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally.  The patient had significant amount of scar already in this interval.  Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar.  This created a significant amount of bleeding.  As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus.  Care was taken to stay above the pectoralis minor and the conjoint tendon.  The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus.  Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component.  It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin.  The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity.  The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released.  The brachial plexus was identified as was the axillary nerve.  Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later.  This revealed sanguineous fluid inside the joint.  We did not feel it was infected based upon the fluid that came from the joint.  The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures.  The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously.  Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring.  This was done also very meticulously.  The upper one half of the latissimus dorsi tendon was also released.  Once this was completed, the humerus could be subluxed enough laterally that we could remove the head.  This was done with no difficulty.  Fortunately, the humeral component stayed intact.  There were some exudates beneath the humeral head, which were somewhat mucinous.  However, these do not really appear to be infected, however, we sent them to pathology for a frozen section.  This frozen section later returned as possible purulent material.  I discussed this personally with the pathologist at that point.  We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect.  As a result, all the mucinous exudates were carefully removed.  We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation.  At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain.  This came back as no organisms seen.  We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid.  The patient had significant amount of scar already.  The subscapularis itself was significantly scarred down to the anterior rim.  As a result, the adhesions along the anterior edge were released using a knife.  Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus.  Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis.  The subscapularis was then tagged with multiple number 2 Tycron sutures.  Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension.  As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus.  These all had excellent security in bone.  Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus.  Care was taken to remove fluid off the Morse taper.  The head was then impacted.  It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient.  Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus.  As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component.  The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion.  Also, it should be noted that the rotator cuff interval had to be released as part of the exposure.  We started the repair by closing the rotator cuff interval.  Anterior and posterior translation was then performed and was found to be very stable.  The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained.  This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon.  After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side.  Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation.  It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation.  The rotator cuff interval was closed with multiple number 2 Tycron sutures.  It was reinforced with 0 Vicryl sutures.  Two Hemovac drains were then placed inferiorly at the deltoid.  The deltopectoral interval was then closed with 0 Vicryl sutures.  A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections.  This was sewn into place with the drain pulled out superiorly.  Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered.  There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case.  This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement.  Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant.  This was being dictated for insurance purposes only and reflects no inherent difficulties with this case.  The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair.  This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker.  This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.
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DESCRIPTION: Arthrotomy, removal humeral head implant, right shoulder.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.  Debridement glenohumeral joint.  Biopsy and culturing the right shoulder.

surgery, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,

The situation involves a complex surgical procedure with significant risks and challenges. A revision surgery on the shoulder involving removal of a humeral head implant, repair of a torn subscapularis tendon, and additional interventions is inherently high-stakes due to the potential complications, such as nerve or artery damage, infection, and loss of function. The patient has a pacemaker, adding to the complexity due to the need for special precautions during surgery. The procedure's complexity is further increased by significant scar tissue, bleeding, and the need for intensive post-operative care. These factors elevate the stakes as they could have serious consequences for the patient's future health and functionality.


Medical Specialty: Surgery
Sample Name: Arthrotomy & Ostectomy & Capsular Mass Excision

PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Soft tissue mass, right knee.,2.  Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:,  This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee.  On aspiration, it was originally attempted to no avail.  There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present.  During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred.  The patient continued to complain of pain and dysfunction to his calf.  This was discussed with him at length.  He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy.  With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee.  It was noted to be tender.  It was marked preoperatively prior to an anesthetic.  Upon dissection, the patient was noted to have significant thickening of the posterior capsule.  The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle.  There was also noted to be prominence of the lateral femoral condyle ridge.  The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table.  After receiving IV sedation, he was placed prone.  Thigh tourniquet was placed.  He was prepped and draped in the usual sterile manner.  A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized.  The nerve was identified and carefully retracted throughout the case.  Both nerves were identified and carefully retracted throughout the case.  There was noted to be no neuroma present.  This was taken down until the gastroc was split.  There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised.  The lateral femoral condyle was then osteophied.  We then smoothed off with a rongeur.  After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve.  Tourniquet was deflated.  It was checked again.  There was no excessive swelling.  Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were warm _______ pulses distally at the end of the case.  The tourniquet as stated has been deflated prior to closure and hemostasis was controlled.  Expected surgical prognosis on this patient is guarded.
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DESCRIPTION: Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.  Soft tissue mass and osteophyte lateral femoral condyle, right knee.

surgery, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle,

The situation involves a surgical procedure to excise a capsular mass and perform an arthrotomy with ostectomy on a patient's right knee. The surgical procedure is complex, involving anesthesia, potential nerve involvement, and addressing both soft tissue mass and osteophyte. The stakes are elevated due to the patient's existing pain, potential risks described (such as recurrence, scar formation, and nerve palsy), and guarded prognosis. However, it's not a life-threatening emergency surgery, which positions it in the mid to high range of stakes.


Medical Specialty: Surgery
Sample Name: Arthroscopy - Shoulder

PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA:  ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION:  ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon.  There was some softening and loss of the articular cartilage over the glenoid.  The labrum was ________ attached permanently to the glenoid.  The biceps tendon was nonsubluxable.  Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side.  Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space.  There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:,  This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder.  MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position.  After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion.  The left extremity was prepped and draped in usual fashion.  The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect.  We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion.  A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder.  A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula.  The operative findings found intra-articularly were as described previously gross operative findings.  We did not see any evidence of acute pathology.  We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline.  The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal.  All this was done and hemostasis was achieved.  The rotator cuff was examined from the bursal side and showed no evidence of tears.  There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver.  We removed all of our instruments and suctioned the subacromial space dry.  A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling.  She was placed back on the gurney, extubated and taken to the PACU in stable condition.
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DESCRIPTION: Partial rotator cuff tear, left shoulder.  Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.

surgery, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,

The scenario describes a surgical procedure, specifically an arthroscopy of the shoulder with debridement and soft tissue decompression. While surgical procedures inherently carry a degree of risk, this type of arthroscopy is relatively common and routine, and is considered low to moderate in terms of risk compared to more invasive surgeries. The procedure reported no complications, the estimated blood loss was minimal, and the patient was reported to be stable post-operation, all of which contribute to assessing the stakes as moderate rather than high. However, because any surgical procedure involves anesthesia and potential complications, it cannot be considered extremely low-stakes.


Medical Specialty: Surgery
Sample Name: Arthroscopic SLAP lesion

PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic SLAP lesion.,2.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS:  ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  She had an injury to her right shoulder when she fell off a bike.  She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  This was an obvious avulsion into subchondral bone with bone exposed.  The anterior aspect had degenerative changes, but did not have evidence of avulsion.  The subscapular was noted to be intact.  On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially.  The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department.  She was safely placed in a modified beachchair position.  She was prepped and draped in the usual sterile manner.  The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion.  The edges were debrided both on the bony side as well as soft tissue side.  We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  Further debridement was carried out here.  A drill hole was made just on the articular surface superiorly for a knotless anchor.  A pull-through suture of #2 fiber wire was utilized with the ________.  This was pulled through.  It was tied to the leader suture of the knotless anchor.  This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  There was excellent fixation of the superior labrum.  It was noted to be solid and intact.  The anchor was placed safely in the bone.  There was no room for further knotless or other anchors.  After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff.  It was debrided.  Subchondral debridement was carried out to the tuberosity also.  Care was taken to go to the subchondral region but not beyond.  The bone was satisfactory.,Scope was then placed in the subacromial region.  Gross bursectomy was carried out with in the lateral portal.  This was done throughout as well as in the gutters anterolaterally and posteriorly.  Debridement was carried out further to the rotator cuff.  Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch.  There was an excellent reduction of the tear posteriorly and then anteriorly.  Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  This was done with a sliding stitch and then two half stitches.  There was excellent reduction of the tear.,Attention was then turned to the CA ligament.  It was released along with periosteum and the undersurface of the anterior acromion.  The CA ligament was not only released but resected.  There was noted to be no evidence of significant spurring with only a mostly type-I acromion.  Thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  A pain buster catheter was placed separately.  It was cut to length.  An interrupted #4-0 nylon was utilized for portal closure.  A 0.5% Marcaine was instilled subacromially.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient's arm was placed in a arm sling.  She was transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Rotator cuff tear, right shoulder.  Superior labrum anterior and posterior lesion (peel-back), right shoulder.  Arthroscopy with arthroscopic SLAP lesion.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.

surgery, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff

This scenario involves a detailed description of a surgical procedure for repairing a SLAP lesion and rotator cuff tear in a patient's shoulder. Surgical procedures generally carry inherent risks including infection, complications with anesthesia, and postoperative complications. These factors contribute to making the situation higher-stakes compared to non-surgical medical situations. However, this type of surgery is relatively routine and does not appear to be addressing life-threatening conditions, which slightly lowers its stakes in the broader medical context.


Medical Specialty: Surgery
Sample Name: Arthroscopic Rotator Cuff Repair - 2

PROCEDURES,1.  Arthroscopic rotator cuff repair.,2.  Arthroscopic subacromial decompression.,3.  Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given general anesthetic.  Once the patient was under general anesthetic, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  The patient was then carefully positioned into a beach-chair position.  We maintained the natural alignment of the head, neck, and thorax at all times.  The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery.  We injected the glenohumeral joint with sterile saline with a spinal needle.  This consisted of 60 cc of fluid.  We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint.  Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed.  We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition.  There was a superior labral tear (SLAP).  This was extensively debrided using a shaver through an anterior portal.  We also found a full thickness rotator cuff tear.  We then drained the glenohumeral joint.  We redirected our camera into the subacromial space.  An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver.  The bursa was extensively debrided.  We then abraded the bone over the footprint of where the rotator cuff is usually attached.  The corkscrew anchors were used to perform a rotator cuff repair.  Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed.  It was carefully positioned.  Pictures were taken.  We then drained the joint.  All instruments were removed.  The patient did receive IV antibiotic preoperatively.  All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump.  ABD, tape, and a sling were also applied.  A Cryo/Cuff was also placed over the shoulder.  The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax.  The patient was extubated and brought to the recovery room in stable condition.  I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.
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DESCRIPTION: Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.

surgery, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff,

The surgical procedure described involves repairing a rotator cuff, performing subacromial decompression, and debriding a labral tear. These are complex orthopedic surgeries requiring precision and expertise. While not typically life-threatening, the procedure is crucial for restoring shoulder function and preventing further injury or deterioration, impacting the patient's quality of life. Thus, this surgical procedure carries moderate stakes.


Medical Specialty: Surgery
Sample Name: Arthroscopy - Glenoid Labrum

PREOPERATIVE DIAGNOSIS:,  Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Massive rotator cuff tear, right shoulder.,2.  Near complete biceps tendon tear, right shoulder.,3.  Chondromalacia of glenohumeral joint, right shoulder.,4.  Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED:  ,1.  Arthroscopy of the arthroscopic glenoid labrum.,2.  Rotator cuff debridement shaving glenoid and humeral head.,3.  Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed.  He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention.  This was gradually done over a period of time.  No specific accident or injury could be seen or pointed.  He was refractory to conservative outpatient therapy.  After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion.  He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated.  His rotator interval was resolved as well as his subscapularis with tearing.  The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe.  Glenoid labrum had degenerative tear in the inferior surface.  Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position.  He was prepped and draped in the usual sterile manner.  The portals were created outside the end posteriorly and then anteriorly.  A full and complete diagnostic arthroscopy was carried out with the above-noted findings.  The shaver was placed anteriorly.  Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed.  Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out.  Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity.  No osteophytes were present.  Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring.  There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this.  We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly.  We took this back to the level of coracoid base.  We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn.  Because of this, further debridement was carried out.  Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge.  Care was taken to not to debride deeper than that.  This was done prior to the above.,All instrumentation was removed.  A Pain-Buster catheter was placed into a separate anterolateral portal cut to length.  Interrupted #4-0 nylon was utilized for portal closures.  Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling.  He was transferred to his cart and to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.
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DESCRIPTION: Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder.  Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.

surgery, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff,

The situation involves a detailed surgical procedure for a patient with a massive rotator cuff tear, a near complete biceps tendon tear, chondromalacia, and a glenoid labrum tear. The complexity and seriousness of the surgery, combined with the already deteriorated condition of the patient's shoulder, make it high-stakes. Additionally, unexpected surgical outcomes could significantly impact the patient's quality of life. This qualifies as high-stakes due to the potential for complications, the importance of successful recovery for the patient’s mobility, and the overall implications for the patient's daily functioning.


Medical Specialty: Surgery
Sample Name: Arthroscopic Rotator Cuff Repair

PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.
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DESCRIPTION: Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.

Arthroscopic rotator cuff repair is a routine, commonly performed surgical procedure aimed at relieving pain and restoring function due to a torn rotator cuff and shoulder impingement syndrome. Although it is a standard surgery with generally high success rates, like all surgeries, it involves certain risks and requires precision. However, it is not considered as high-risk or high-stakes as more complex or life-threatening surgeries (e.g., heart or brain surgery). The procedural description indicates that all standard protocols, including informed consent and surgical checks, were followed, reducing the stakes involved with the procedure. Given the routine nature and the controlled surgical environment, this situation involves moderate stakes.


Medical Specialty: Surgery
Sample Name: Arthroplasty

PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.
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DESCRIPTION: Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.

surgery, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion

The situation described involves a surgical procedure (arthroplasty) to address a hammertoe deformity and ulceration of the left fifth toe. While any surgical procedure carries some level of risk due to anesthesia, potential for infection, or complications, this does not appear to be an emergency or life-threatening situation. This type of surgery is commonly performed electively to relieve pain and improve function. The postoperative instructions seem standard, and there were no mentioned complications during the procedure. Hence, while it is a serious procedure requiring skill, it does not involve high-stakes outcomes like life-threatening situations or critical injuries.


Medical Specialty: Surgery
Sample Name: Arthroscopic Debridement & Labral Repair - Hip

PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.
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DESCRIPTION: Femoroacetabular impingement.  Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.

surgery, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum

The surgical procedure described involves complex operations on the hip, dealing with femoroacetabular impingement, which requires precision to prevent complications such as damage to the hip joint. The stakes are moderate to high because errors could lead to significant complications for the patient, affecting mobility and quality of life. However, such surgeries are commonly performed by skilled professionals, and the report indicates no complications, which adds confidence. The situation requires detailed attention but is not life-threatening.


Medical Specialty: Surgery
Sample Name: Appendectomy Laparoscopic - 1

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:,  This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain.  On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis.  However, the patient with additional history of loose stools for several days prior to event.  Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.  With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy.  She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach.  The appendix itself noted to have a significant inflammation about it.  There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:,  The patient was placed in supine position.  After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision.  Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg.  The Veress needle was then removed.  A 10 mm trocar was then introduced through this incision into the abdomen.  A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation.  Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation.  Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant.  This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix.  Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization.  Through this port, the dissector was utilized to create a small window in the mesoappendix.  Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix.  Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples.  Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure.  Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it.  The appendix was then removed from the 12 mm port site and taken off the surgical site.  The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated.  The base of the appendix was reevaluated and noted to be hemostatic.  Aspiration of warm saline irrigant then done and noted to be clear.  There was a small adhesion appreciated in the region of the surgical site.  This was taken down with blunt dissection without difficulty.  There was no evidence of other areas of disease.  Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact.  The instruments were removed from the patient and the port sites were then taken off under direct visualization.  The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2.  Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.
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DESCRIPTION: Laparoscopic appendectomy.  Acute suppurative appendicitis.  A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.

surgery, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis

The situation concerns a laparoscopic appendectomy, which is a surgical procedure used to treat acute appendicitis. Appendicitis can escalate to a life-threatening condition if the appendix bursts, causing peritonitis. The procedure itself was standard and concluded without complications, but given the risks associated with untreated appendicitis, such as perforation and infection, it is considered a high-stakes medical situation. The patient was stable and the surgery was routine, reducing the stakes slightly, but the potential for severe outcomes increases the overall stakes.


Medical Specialty: Surgery
Sample Name: Arthrodesis

PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia.  The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME:  ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:,  None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL:  ,The patient is a 5-year-4-month-old male who presents for evaluation of feet.  He has been having significant feet pain with significant planovalgus deformity.  The patient was noted to have flexible vertical talus.  It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening.  This was explained to the mother in detail.  This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time.  All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered.  The patient received Ancef preoperatively.  Bilateral nonsterile tourniquets were placed on each thigh.  A bump was placed underneath the left buttock.  Both the extremities were then prepped and draped in standard surgical fashion.  Attention was first turned towards the left side.  Intended incision was marked on the skin.  The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view.  The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg.  Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint.  The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally.  Once the foot was reduced a Steinman pin was used to hold it in position.  This position was first checked on the fluoroscopy.  The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction.  This was also checked with fluoroscopy.  The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half.  This was sutured using 2-0 Ethibond and that was also oversewn.  The wound was irrigated with normal saline.  The periosteal flap was sutured over the staple using 2-0 Vicryl.  Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl.  The area was injected with 6 mL of 0.25% Marcaine local anesthetic.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril.  Tourniquet was released after 53 minutes.  The exact same procedure was repeated on the right side with no changes or complications.  Tourniquet time on the right side was 45 minutes.  The patient tolerated the procedure well.  Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch.  The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request.  The patient is to be strict nonweightbearing for at least 6 weeks.  He is to follow up in the next 10 days for a check.  We will plan of changing to short-leg casts in about 4 weeks postop.
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DESCRIPTION: Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.

surgery, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, subtalar, achilles, anesthesia, planovalgus, foot, bilateral,

The situation involves a surgical procedure on a young child with congenital myotonic muscular dystrophy and bilateral planovalgus feet conditions. Surgery inherently involves moderate to high stakes due to the risks associated with general anesthesia, potential complications, and the need for postoperative care and recovery. As this procedure is being performed on a 5-year-old, it adds complexity and risk given the child's young age and the need for future surgeries. Nonetheless, the detailed procedural note indicates the surgery was completed without complications, lowering the immediate stakes. Overall, the stakes are higher than average due to the nature of the surgery and the age of the patient, but not extremely high due to the lack of complications and clear postoperative plan.


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Medical Specialty: Surgery
Sample Name: Appendectomy - 1

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions.  After having obtained an informed consent, he was placed in the operating room and under anesthesia.  Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  Antibiotics had been given prior to incision.  A McBurney incision was performed and it carried out through the peritoneal cavity.  Immediately there was  purulent material seen in the area.  Samples were taken for culture and sensitivity of aerobic and anaerobic sets.  The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  There was quite a bit of local peritonitis.  The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch.  The area was abundantly irrigated with normal saline and also the pelvis.  The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,
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DESCRIPTION: Acute appendicitis, gangrenous.  Appendectomy.

surgery, mcburney incision, abdominal, small bowel, acute appendicitis, appendectomy, gangrenous, appendix,

The situation concerns a surgical procedure for an urgent medical condition, acute appendicitis, that progressed to a gangrenous state. Appendectomy for acute, especially gangrenous appendicitis, is a high-stakes situation due to the risk of complications such as perforation, peritonitis, and sepsis if not treated promptly. The procedure was performed under urgent conditions, indicating the need for immediate surgical intervention to prevent potentially life-threatening complications. However, the procedure description indicates that it was performed successfully with minimal blood loss and the patient was in satisfactory condition afterward, lowering the immediate criticality post-surgery.


Medical Specialty: Surgery
Sample Name: Appendectomy - Laparoscopic

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic inflammatory disease.,2.  Periappendicitis.,PROCEDURE PERFORMED:,1.  Laparoscopic appendectomy.,2.  Peritoneal toilet and photos.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS FOR PROCEDURE: , The patient is a 31-year-old African-American female who presented with right lower quadrant abdominal pain presented with acute appendicitis.  She also had mild leukocytosis with bright blood cell count of 12,000.  The necessity for diagnostic laparoscopy was explained and possible appendectomy.  The patient is agreeable to proceed and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department.,The preoperative Foley, antibiotics, and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall.  A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation.  At this point, the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally.  A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view.  With the aid of a laparoscope, the pelvis was visualized.  The ovaries are brought in views and photos are taken.  There is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst.  Attention was then turned on the right lower quadrant.  The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears.  Attention was turned to the suprapubic area.  The 12 mm port was introduced under direct visualization and the mesoappendix was identified.  A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line.  Next, ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline.  Next, attention was turned to the right upper quadrant.  There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz-Hugh-Curtis syndrome also a prior pelvic inflammatory disease.  All free fluid is aspirated and patient's all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology.  Once the ports are removed the pneumoperitoneum is allowed to escape for patient's postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 Vicryl suture on a UR-6 needle.  Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and #4-0 Vicryl subcuticular closure is performed with undyed Vicryl.  Steri-Strips are applied along with sterile dressings.  The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum IV antibiotics in the General Medical Floor.  Routine postoperative care will be continued on this patient.
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DESCRIPTION: Laparoscopic appendectomy and peritoneal toilet and photos.  Pelvic inflammatory disease and periappendicitis.

surgery, acute appendicitis, periappendicitis, peritoneal toilet, pelvic inflammatory disease, abdominal wall, direct visualization, toilet, appendectomy, mesoappendix, laparoscopic, port, inflammatory

The scenario involves a surgical procedure - a laparoscopic appendectomy - which is a common intervention for acute appendicitis, a condition requiring timely treatment to prevent complications like rupture or sepsis. Additionally, the patient presented with complex issues such as pelvic inflammatory disease and periappendicitis, which add complexity to the case. The procedure notes indicate that there were no complications, minimal blood loss, and the patient was moved to postoperative care successfully. The emergent nature of appendicitis and possible complications from pelvic inflammatory disease make this scenario moderately high-stakes in the medical field, but since the procedure went without incident and the condition is routinely managed, it is not as high-stakes as more invasive or complex surgeries.


Medical Specialty: Surgery
Sample Name: Appendectomy

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis, nonperforated.,PROCEDURE PERFORMED:,  Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness.  Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia.  The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp.  The internal oblique fascia was similarly incised and its muscular fibers were similarly spread.  The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident.  Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound.  After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties.  The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix.  The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp.  The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline.  The mesoappendix and cecum were examined for hemostasis which was present.  The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was placed on the wound.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
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DESCRIPTION: Appendicitis, nonperforated.  Appendectomy.  A transverse right lower quadrant incision was made directly over the point of maximal tenderness.

surgery, peritoneal cavity, peritoneal fluid, abdominal cavity, abdominis muscle, transversalis fascia, peritoneum, internal oblique fascia, vicryl ties, appendectomy, appendicitis, appendix,

An appendectomy, though a common surgical procedure, involves general anesthesia and carries inherent surgical risks, including infection and complications from anesthesia. However, it is generally considered routine and not high-risk unless there are complications, such as perforated appendicitis, which are not present in this case. The procedure description indicates that the surgery went smoothly without any incidents, suggesting it was not high-stakes in this context.


Medical Specialty: Surgery
Sample Name: Aortobifemoral Bypass - 1

PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
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DESCRIPTION: Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.

surgery, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,

The situation involves an aortobifemoral bypass surgery, which is a complex and high-risk surgical procedure used to treat aortoiliac occlusive disease. The operation requires precision due to the critical nature of the affected arteries and the potential for complications such as bleeding or infection. Additionally, the patient has dementia, adding complexity to postoperative care and consent processes. These factors contribute to the high-stakes nature of the situation.