Medical Specialty: Surgery
Sample Name: Laparoscopic Gastric Bypass

PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.

surgery, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric

The situation involves a description of a laparoscopic gastric bypass surgery, a major surgical procedure. This type of surgery is typically performed to treat morbid obesity and involves significant health improvements but also carries risks, making it a high-stakes situation. The surgery described includes detailed procedural steps and checks for complications, indicating the critical nature of the operation. Given the potential impact on the patient's health and the technical complexity of the procedure, it is considered high-stakes.


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

Medical Specialty: Surgery
Sample Name: Laparoscopic Cryoablation

PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:,  Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency.  The patient's baseline creatinine was around 1.6 to 1.7.  The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass.  Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time.  The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure.  The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed.  The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was given preoperative antibiotics.  The patient was bowel prepped.  The patient was placed in right side up, left side down, semiflank, with kidney rest up.  All the pressure points are very well padded using foam and towels.  The left knee was bent and the right knee was straight.  There was no tension on any of the joints.  All pressure points were well padded.  The patient was taped to the table using 2-inch wide tape all the way around.  A Foley catheter and OG tube were in place prior to prepping and draping the patient.  A periumbilical incision measuring about 6 cm was made.  The incision was carried through the subcutaneous tissue through the fascia using sharp dissection.  The peritoneum was open.  Abdomen was entered.  There were some adhesions on the right side of the abdomen, which were released using metz.  Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line.  A gel porter was placed.  Pneumoperitoneum was obtained.  All ports were placed under direct vision, and the right colon was reflected medially.  Duodenum was cauterized.  Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around.  Pictures were taken.  Superficial biopsies were taken of 2 renal lesions using 3 different probes.  The 2 lesions were frozen.  The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter.  So the R3.8 and R2.4 long probes were used.  Freezing/thawing, two cycles were done.  The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done.  The exact times or exact temperatures are on the chart.  There was a nice ice ball with each freezing and with passive sign.  The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed.  Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding.  From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes.  So the masses were visualized for a total of 30 minutes without any pneumoperitoneum.  Pneumoperitoneum was obtained again.  Fibrin glue was placed over it just for precautionary measure.  There was about a total of 100 mL of blood loss overall with the entire procedure.  Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ.  The kidney was kept in the left hand at all times.  Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen.  The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions.  At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially.  Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel.  Lap count was correct.  Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions.  No deeper biopsies were done to minimize the risk of bleeding.  The 12-mm ports were closed using 0-Vicryl and the middle incision.  The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle.  Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion.  After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition.
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DESCRIPTION: Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.

surgery, hand-assisted laparoscopic cryoablation, laparoscopic, cryoablation, bilateral renal mass, fibrin glue, laparoscopic cryoablation, renal insufficiency, renal lesions, renal biopsy, renal mass, insufficiency, renal, freezing/thawing, lesions

This medical scenario involves a surgical procedure, specifically a right hand-assisted laparoscopic cryoablation to treat renal lesions on a patient with bilateral renal masses and renal insufficiency. Surgical procedures, especially those involving vital organs like the kidneys, are generally considered high-stakes due to the potential risk of complications such as bleeding, infection, and possible renal failure. The patient has an underlying condition of renal insufficiency which adds to the complexity and risk of the procedure. The patient's age and health condition further elevate the stakes. The detailed postoperative and intraoperative information provided suggests a highly controlled and complex surgical environment, emphasizing the high-stakes nature of the procedure.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy & Liver Cyst Excision

PREOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,3.  Liver cyst.,PROCEDURES PERFORMED:,1.  Laparoscopic cholecystectomy.,2.  Excision of liver cyst.,ANESTHESIA:  ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1.  Gallbladder.,2.  Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:,  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.  Additionally, there was a notable liver cyst.  The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy.  The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods.  She had had multiple attacks in the past of these complaints.  She was discovered to have had right upper quadrant pain on examination.  Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis.  The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms.  She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE:  ,The patient was brought to the operative suite and placed in the supine position.  The patient received preoperative antibiotics with Kefzol.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient did undergo general endotracheal anesthesia.  Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel.  Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation.  The abdomen was insufflated to 15 mmHg.  After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder.  Decision to proceed with laparoscopic cystectomy was decided.  A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen.  Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin.  All ports were inserted with bladed 5 mm trocar then under direct visualization.  After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder.  Adhesions adjacent were taken down with a Maryland dissector.  Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly.  This helped to better delineate the cystic duct as well as the cystic artery.  Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one.  Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally.  Utilizing endoscissors, the cystic duct and cystic artery were ligated.  Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed.  Electrocautery was used to stop any bleeding encountered along the way.  The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen.  No evidence of stones were visualized.  Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port.  This was sent off as an specimen, a gallstone was identified within the gallbladder.  Next, utilizing copious amounts of irrigation, the abdomen was irrigated.  A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver.  This was also taken and sent off as specimen.  The abdomen was then copiously irrigated until clear irrigation was identified.  All laparoscopic ports were removed under direct visualization.  The abdomen was de-insufflated.  Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region.  All incisions were then closed with #4-0 undyed Vicryl.  Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures.  The areas were cleaned and dried.  Steri-Strips were placed.  On the incisions, sterile dressing was applied.  The patient tolerated the procedure well.  She was extubated following procedure.  She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.
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DESCRIPTION: Chronic cholecystitis, cholelithiasis, and liver cyst.  Laparoscopic cholecystectomy and excision of liver cyst.  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.

surgery, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic,

This surgical procedure involves laparoscopic cholecystectomy and liver cyst excision, which is generally considered routine elective surgery for dealing with chronic cholecystitis and cholelithiasis. Although complications could potentially arise considering it involves general anesthesia and intra-abdominal surgery, the reported procedure was without incident and described as well-tolerated by the patient. Therefore, while not devoid of risks, it is not considered highly critical or emergency surgery.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy & Appendectomy

PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS:  ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis.  She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her.  The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones.  After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  She was positively identified and the correct surgical site and procedure reviewed.  After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created.  The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg.  A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity.  Upper abdominal anatomy was normal.  Pelvic laparoscopy revealed bilaterally closed internal inguinal rings.  Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____.  There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region.  Using these, the gallbladder was grasped and retraced cephalad.  Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction.  A small ductotomy was created.  Reddick cholangiogram catheter was then placed within the duct and the balloon inflated.  Continuous fluoroscopy was used to instill contrast material.  This showed normal common bile duct which entered the duodenum without obstruction.  There was no evidence of common bile duct stones.  The cholangiogram catheter was removed.  The duct was doubly clipped and divided.  The artery was divided and cauterized.  The gallbladder was taken out of the gallbladder fossa.  It was then placed in Endocatch bag and left in the abdomen.  Attention was then paid to the appendix.  The appendix was identified and window was made in the mesoappendix at the base.  This was amputated with an Endo-GIA stapler.  The mesoappendix was divided with an Endo-GIA vascular stapler.  This was placed in another Endocatch bag.  The abdomen was then irrigated.  Hemostasis was satisfactory.  Both the appendix and gallbladder were removed and sent for pathology.  All trocars were removed.  The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures.  The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide.  The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture.  The skin was cleaned.  Mastisol, Steri-Strips and band-aids were applied.  The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.
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DESCRIPTION: Symptomatic cholelithiasis.  Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).  The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her.

surgery, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct

The situation involves a surgical procedure on an 18-year-old patient with sickle cell anemia who is experiencing symptomatic cholelithiasis. The procedure includes both a laparoscopic cholecystectomy and an appendectomy. While laparoscopic cholecystectomy is a common and generally low-risk procedure, the additional factor of the patient having sickle cell anemia — a condition that can complicate anesthesia and postoperative recovery — increases the stakes somewhat. Appendectomy in the absence of acute appendicitis is an elective procedure added due to the potential for future diagnostic challenges. Even though the situation is planned and controlled, and the patient is in stable condition post-operation, the surgery's complexity and the underlying chronic condition make it a moderately high-stakes medical situation.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 8

PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis.,PROCEDURE PERFORMED:  ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION:  ,To recovery room and to home.,FLUIDS:  ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis.  Final pathology is pending.,INDICATIONS FOR THE PROCEDURE:  ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.  He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL:  ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia.  The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities.  The anterior abdomen was then prepared and draped in a sterile fashion.  Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine.  The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade.  The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg.  The epigastric and right subcostal trocars were placed under direct vision.  The right upper quadrant was well visualized.  The gallbladder was noted to be significantly distended with surrounding dense adhesions.  The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector.  Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp.  The cystic duct was clipped x3 and then divided.  The cystic artery was dissected out in like fashion, clipped x3, and then divided.  The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis.  Prior to removal of the gallbladder, all irrigation fluid was clear.  No active bleeding or oozing was seen.  All clips were noted to be secured and intact and in place.  The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port.  The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology.  The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization.  The insufflation was allowed to escape.  The umbilical fascia was closed using interrupted #1 Vicryl sutures.  Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl.  Sterile dressings were applied.  The patient tolerated the procedure well.,
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DESCRIPTION: Chronic cholecystitis.   Laparoscopic cholecystectomy.  Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.

surgery, abdomen, bovie cautery, endotracheal anesthesia, laparoscopic cholecystectomy, cystic duct, chronic cholecystitis, abdominal, laparoscopic, cholecystectomy, cholecystitis, gallbladder,

The situation describes a laparoscopic cholecystectomy, which is a common surgical procedure to remove the gallbladder. It's typically performed to treat gallstones and associated complications such as chronic cholecystitis. The procedure ended without complications and the patient's condition was stable, indicating that the risks were well-managed. While any surgery carries inherent risks, laparoscopic cholecystectomy is often considered routine with low incidences of serious complications.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 6

PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.
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DESCRIPTION: Cholelithiasis; possible choledocholithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.

surgery, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct

The situation involves a laparoscopic cholecystectomy procedure, which is a common surgical operation performed to remove the gallbladder. Although it is generally considered to be a routine and low-risk surgery, the presence of potential choledocholithiasis (common bile duct stones) can complicate the procedure and increase the risk. Thus, while the stakes are not extremely high compared to more critical or life-threatening surgeries, there are significant considerations that need to be managed carefully, such as the potential complications from choledocholithiasis.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 10

PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:,  Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks.  The patient is also diabetic.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.  The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored.  There was no evidence of any peritoneal studding or masses.  The abdomen was otherwise within normal limits.  The gallbladder was easily visualized.  There was an intrahepatic gallbladder.  There was no evidence of any inflammatory change.,PROCEDURE:,  After informed written consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion.  Next, an infraumbilical incision was made with a #10 scalpel.  The skin was elevated with towel clips and a Veress needle was inserted.  The abdomen was then insufflated to 15 mmHg of pressure.  The Veress needle was removed and a #10 blade trocar was inserted without difficulty.  The laparoscope was then inserted through this #10 port and the abdomen was explored.  There was no evidence of any peritoneal studding.  The peritoneum was smooth.  The gallbladder was intrahepatic somewhat.  No evidence of any inflammatory change.  There were no other abnormalities noted in the abdomen.  Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty.  The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization.  The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder.  Using a curved dissector, the cystic duct was identified and freed up circumferentially.  Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct.  The cystic artery was transected in similar fashion.  Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip.  It was done without difficulty.  The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology.  Hemostasis was maintained using electrobovie cautery.  The liver bed was then copiously irrigated and aspirated.  All the fluid and air was then aspirated and then all ports were removed under direct visualization.  The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle.  The skin was closed with a running subcuticular #4-0 undyed Vicryl.  0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.
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DESCRIPTION: Laparoscopic cholecystectomy.  Biliary colic and biliary dyskinesia.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.

surgery, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder

The situation involves a laparoscopic cholecystectomy, which is a common surgical procedure to remove the gallbladder, typically due to gallstones or biliary dyskinesia. While laparoscopic surgery is less invasive than open surgery, it is still a surgical procedure requiring general anesthesia. The stakes involve potential complications related to surgery and anesthesia, but in this case, there were no reported intraoperative complications, and the patient tolerated the procedure well. The procedure is routine and the patient was stable post-operation, suggesting a low to moderate level of risk typical for surgical procedures of this nature.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 3

PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced.  The abdomen was prepped and draped and ports were placed.  The gallbladder was grasped and retracted.  The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained.  The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag.  The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak.  The ports were removed under direct vision with good hemostasis.  The Hasson was removed.  The abdomen was desufflated.  The gallbladder in its endo catch bag was removed.  The ports were closed.  The patient tolerated the procedure well.  Please see full hospital dictation.
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DESCRIPTION: Chronic cholecystitis without cholelithiasis.

surgery, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic

A laparoscopic cholecystectomy is a common surgical procedure for patients with chronic cholecystitis. While any surgery has inherent risks, this procedure is generally considered routine and has a low risk profile when performed by experienced surgeons. The description of the procedure indicates it was conducted without complications, and the patient tolerated it well. Therefore, the stakes are moderate but not extremely high in terms of typical surgical procedures.


Medical Specialty: Surgery
Sample Name: Laparoscopic Adrenalectomy

PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.
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DESCRIPTION: Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy.  Left adrenal mass, 5.5 cm and intraabdominal adhesions.

The situation involves the surgical removal of a 5.5 cm adrenal mass using laparoscopic adrenalectomy. This procedure, while routine for a skilled surgeon, involves general anesthesia, the potential for significant complications, and dealing with intraabdominal adhesions that could pose challenges during surgery. The patient's multiple pulmonary comorbidities elevate the risk further. Any surgical procedure, especially involving vital organs and major anesthesia, is considered high-stakes due to the inherent risks of surgery and the need for meticulous execution and monitoring for a successful outcome.


Medical Specialty: Surgery
Sample Name: Laparoscopic Appendectomy

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:,  Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE:  ,The patient was seen by me in the preoperative holding area.  The risks of the procedure were explained.  She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  General anesthesia was carried out without difficulty and a Foley catheter was inserted.  The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion.  A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum.  A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  The base of the cecum was acutely inflamed but not perforated.  I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty.  I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty.  I reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  One final inspection revealed no bleeding from the staple line.  We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture.  The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture.  Steri-strips and sterile dressings were applied.  No complications.  Minimal blood loss.  Specimen is the appendix.  Brought to the recovery room in stable condition.
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DESCRIPTION: Laparoscopic appendectomy.  Acute appendicitis.

surgery, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,

A laparoscopic appendectomy is a common surgical procedure to remove an inflamed appendix and is typically low-risk when performed by experienced surgeons. The operation described was successful without complications, minimal blood loss, and resulted in a stable postoperative condition of the patient. Although any surgical procedure carries some inherent risk, the standard nature of the surgery, coupled with the absence of complications here, indicates a relatively low-stakes scenario.


Medical Specialty: Surgery
Sample Name: Laminectomy & Foraminotomy Revision

PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.
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DESCRIPTION: Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.

The medical procedure described is a complex spinal surgery involving revisions of earlier surgeries, decompression, fusion, and the use of instrumentation to address multiple issues such as recurrent spinal stenosis, spondylolisthesis, and herniated nucleus pulposus. The stakes are high because this is a major surgery involving the spine, with potential risks including nerve damage, infection, blood loss, and a lengthy recovery time. The patient's condition is severe with disabling pain, has been unresponsive to conservative treatments, and requires a comprehensive surgical approach to address multiple spine issues. The high estimated blood loss and specific monitoring techniques (SSEP, EMG, and neurophysiological) also underscore the complexity and risks involved. These factors collectively suggest a high-stakes scenario in terms of potential impact on the patient's quality of life and the technical demands placed on the surgical team.


Medical Specialty: Surgery
Sample Name: Laparoscopic Appendectomy - 3

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Appendicitis.  Laparoscopic appendectomy.   CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.

surgery, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix,

A laparoscopic appendectomy is a common surgical procedure used to remove an inflamed appendix. While it is generally considered a routine and low-risk operation with a high success rate, it is still surgery, which inherently carries some degree of risk, particularly due to factors like anesthesia and potential complications. However, in this case, the procedure is described as having been completed successfully without complications, which suggests it was of typical risk for its kind. Furthermore, appendicitis, if treated in a timely manner, rarely results in high-stakes situations. Based on this, the situation can be considered moderately low-stakes.


Medical Specialty: Surgery
Sample Name: Kyphoplasty & Vertebroplasty

PREOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1.  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2.  Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:,  None.,SURGICAL INDICATIONS:,  The patient is an 80-year-old female who had previous history of compression fractures.  She had recently undergone an additional compression fracture of the T8 vertebrae.  She was in extreme pain.  This pain interfered with activities of daily living and was unimproved with conservative treatment modalities.  She is understanding the risks, benefits, and potential complications as well as all treatment alternatives.  The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table.  She was given sedative.  The thoracodorsal spine was then sterilely prepped and draped in the usual fashion.  Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae.  Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side.  This was directly over the posterior aspect of the pedicle on the left.  Once this was localized, the right side was localized as well.  Stab incisions were then created over the pedicles of T8 bilaterally.  Jamshidi needles were then placed percutaneously.  Their position was verified in both AP and lateral images.  They were advanced slowly under direct image intensification in biplanar fashion.  Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae.  The Jamshidi needles were then removed.  A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae.  This bone was then removed and sent to the lab.  The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images.  Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle.  This was advanced under direct image intensification in a biplanar fashion.  Once this was deemed satisfactory, it was impacted.  The inner trocar was removed and a guidewire was then placed.  An injection cannula was then placed over the guidewire into the body of T7.  In a similar fashion, T9 was dressed on the left side as well.  A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images.  The cement injection cannula was then placed over this entering the T9 vertebrae body.  Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae.  The balloons were inserted bilaterally.  The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg.  These were allowed to expand and reduce the fracture.  Once this was completed, the balloons were deflated and removed.  The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas.  This was done directly under image intensification.  Once this was completed, additional cement was injected into T9 as there was a larger vertebra.  The cement was allowed to cure.  The cannula was removed and final radiographs were obtained.  The stab incisions were then cleansed with water and antibiotic irrigation.  The wounds were then approximated with #4-0 Nylon in interrupted fashion.  Compression dressings were applied and fixed with tape.  She was aroused and moved to her inpatient bed.  She was moving all four extremities without deficit.  She had no significant pain.
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DESCRIPTION: Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.   Vertebroplasties at T7 and T9 with insertion of prosthetic device.   Fracture of the T8 vertebra and T9 vertebra.

surgery, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic,

This case involves an 80-year-old patient undergoing a kyphoplasty and vertebroplasty procedure, which are surgical interventions required due to fractures in the vertebrae causing extreme pain and interference with daily living. The condition is serious, and the surgeries aim to relieve pain and restore function. Although the procedure was without complications, vertebral surgeries are inherently high-stakes due to potential risks to the spinal cord and surrounding structures, potential for pain and limited movement if not treated properly, and the general vulnerability due to the patient's age.


Medical Specialty: Surgery
Sample Name: Knee Arthroscopy

PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.
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DESCRIPTION: Left knee arthroscopy with lateral capsular release.

surgery, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee,

The situation involves a surgical procedure, specifically a knee arthroscopy for a 14-year-old girl. While surgery inherently carries risks, this specific procedure, knee arthroscopy, is relatively common and typically not considered among the most high-risk surgeries. The surgery was performed without complications, and the postoperative plan involves typical recovery protocols such as immobilization and physical therapy. Given the information, the stakes of this situation are moderate, primarily due to the young age of the patient and the surgical nature of the treatment. However, since the procedure went smoothly with no complications, the stakes are relatively low within the context of surgical procedures.


Medical Specialty: Surgery
Sample Name: Knee Arthroplasty - Bilateral

PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee.  This operative note will discuss the right total knee arthroplasty.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:,  This is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  She has been unresponsive to conservative measures.  All risks, complications, anticipated benefits, and postoperative course were discussed.  The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table.  She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity.  The right lower extremity was then sterilely prepped and draped in the usual fashion.  An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg.  Longitudinal incision was made over the anterior aspect of the right knee.  Subcutaneous tissue was carefully dissected.  A medial parapatellar retinacular incision was made.  The patella was then everted and the above noted gross findings were appreciated.  A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  The appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  The trial femoral component was then positioned in place and noted to have good fit.  Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  The remnants of the anterior cruciate ligament and menisci were resected.  The tibial trial was positioned in place.  Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  The tibial holes were then drilled.  The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella.  The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  The knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  The femoral component was inserted with methylmethacrylate.  Any excessive methylmethacrylate and bony debris were removed from the joint.  Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  The methylmethacrylate was also used at the patella.  The prosthesis was positioned in place.  The patellar clamp held securely till the methylmethacrylate was firm.  After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  This component was removed and revised to a stemmed component with better alignment and position.  The previous component removed, the methylmethacrylate was removed.  Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  The trial tibial stemmed component was positioned in place.  Knee was placed through range of motion and the tracking was better.  Actual component was then obtained, methyl methacrylate was placed within the tibia.  The stemmed tibial component was impacted into place with good fit.  The Poly was then positioned in place.  Knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  The trial Poly was removed.  Wound was irrigated and the joint was inspected.  There was no debris.  Collateral ligaments and posterior cruciate ligaments remained intact.  Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  The tourniquet was deflated.  Hemostasis was satisfactory.  A drain was placed into the depths of the wound.  The medial retinacular incision was closed with one Ethibond suture in interrupted fashion.  The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion.  The skin was closed with surgical clips.  The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity.  At the completion of the procedure, distal pulses were intact.  Toes were pink, warm, with good capillary refill.  Distal neurovascular status was intact.  Postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  Prognosis is good in this 79-year-old female with a significant degenerative arthritis.
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DESCRIPTION: Bilateral knee degenerative arthritis.  Bilateral knee arthroplasty.  The Zimmer NexGen total knee system was utilized.

surgery, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,

This situation describes a surgical procedure for bilateral knee arthroplasty, which is generally complex and can be high-stakes due to the potential risks and complications associated with surgery, especially in a 79-year-old patient. Although it was noted that there were no complications during the procedure, and the outcome was satisfactory, the surgery involves significant medical intervention, anesthesia, and careful postoperative monitoring for recovery, which are typical high-stakes factors in orthopedic surgeries.


Medical Specialty: Surgery
Sample Name: Keller Bunionectomy

PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient.  An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position.  Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures.  The incision was medial to and parallel to the extensor hallucis longus tendon.  The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision.  The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp.  The surgical site was then flushed with saline.  The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion.  Site was dressed with a light compressive dressing.  The tourniquet was released.  Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:,  None.,INJECTABLES:,  Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:,  Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well.  Vital signs stable.  Vascular status intact to all digits.  Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).
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DESCRIPTION: Procedure note on Keller Bunionectomy

Procedure note on Keller Bunionectomy

surgery, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy,

The procedure described is a surgical operation, albeit a relatively minor one typically performed under local anesthesia. A Keller Bunionectomy is used to treat bunions, which is generally a low-risk and routine surgery for an experienced surgeon. The documentation indicates that the procedure was performed successfully with minimal complications such as low estimated blood loss and intact vascular status. The procedure involves the use of general surgical equipment and local anesthesia, indicating that it is not considered high-stakes under typical circumstances.


Medical Specialty: Surgery
Sample Name: Juxtarenal Abdominal Aortic Aneurysm Repair

PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.
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DESCRIPTION: Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.

surgery, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield, abdomen, prolene, arteries, juxtarenal, graft, aortic, endotracheal, renal, artery,

The procedure described is a juxtarenal abdominal aortic aneurysm repair, which is a complex and high-risk surgery. Juxtarenal aneurysms involve the section of the aorta just below the renal arteries, and repairing them requires meticulous surgical technique to avoid complications such as renal damage, bleeding, or ischemia. The use of a 14 mm Hemashield tube graft indicates significant aortic reconstruction. The risks involved in this surgical procedure, including the potential for loss of blood flow to critical organs, justify classifying this as a high-stakes situation.


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

Medical Specialty: Surgery
Sample Name: Ischial Ulcer Debridement

PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.
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DESCRIPTION: Debridement left ischial ulcer.

Debridement left ischial ulcer.

surgery, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer

The situation revolves around a surgical procedure for a patient with a complex medical history, including paraplegia and suspected osteomyelitis. The outcome of the procedure can significantly impact the patient's health, risk of infection, and quality of life. However, it's a planned surgical intervention with the potential for effective resolution of the immediate concern (the ulcer), rather than an emergency or life-threatening situation. The stakes are moderately high due to the implications of osteomyelitis and the need for successful debridement to facilitate healing, but they are not at the level of life-threatening acute surgical emergencies.


Medical Specialty: Surgery
Sample Name: Inguinal Herniorrhaphy & Circumcision

PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:,  Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair.  The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right.  The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced.  The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion.  An infraumbilical incision was made with a #15 Bard-Parker scalpel.  The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty.  Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg.  Next, the Veress was removed and #10 bladed trocar was inserted without difficulty.  The 30-degree camera laparoscope was then inserted and the abdomen was explored.  There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible.  Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus.  Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization.  A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization.  Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral.  The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty.  Dissection was carried out, freeing up the hernia sac from the peritoneum.  This was done without difficulty reducing the hernia in its entirety.  Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract.  The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples.  This was done without difficulty.  All three ports were removed under direct visualization.  No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle.  Skin was closed with running subcuticular #4-0 undyed Vicryl.  Steri-Strips and sterile dressings were applied.  Attention was next made to carrying out the circumcision.  The foreskin was retracted back over the penis head.  The desired amount of removing foreskin was marked out with a skin marker.  The foreskin was then put on tension using a clamp to protect the penis head.  A #15 blade scalpel was used to remove the foreskin and sending off as specimen.  This was done without difficulty.  Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially.  This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing.  The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.
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DESCRIPTION: Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.   Recurrent right inguinal hernia, as well as phimosis.

surgery, herniorrhaphy with mesh, laparoscopic, blunt dissector, inguinal herniorrhaphy, inguinal hernia, hernia, inguinal, peritoneum, circumcision, phimosis, foreskin

The procedure involves surgery, specifically a laparoscopic inguinal hernia repair and circumcision, on a 66-year-old patient with a recurrent hernia and phimosis. Surgeries inherently carry significant risks, including those related to anesthesia, and the complexity increases with laparoscopic techniques and the patient's age. While there were no complications reported, and the procedure was routine, surgical operations generally remain high-stakes due to the potential for serious complications, the requirement for precision in operation, and the patient's postoperative recovery and wellbeing.


Medical Specialty: Surgery
Sample Name: Inguinal Herniorrhaphy - 2

PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Care was taken not to injure the ilioinguinal nerve.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and sent to Pathology.  The stump was examined and no bleeding was noted.  The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring.  In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Bassini inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.

surgery, ilioinguinal nerve, adherent cremasteric muscle, bassini inguinal herniorrhaphy, external oblique aponeurosis, inguinal herniorrhaphy, metzenbaum scissors, external ring, blunt dissection, cord structures, bovie electrocautery, inguinal, electrocautery

The description details a surgical procedure known as Bassini inguinal herniorrhaphy, which is a repair for inguinal hernias. While surgical procedures involve inherent risks such as infection, bleeding, and complications from anesthesia, the procedure described seems to have been executed routinely without complications. Additionally, local anesthesia was utilized, which typically implies a less complex surgery compared to those with general anesthesia. The patient tolerated the procedure well and was in stable condition post-operation. These factors suggest the scenario is of moderate stakes rather than high stakes since the surgery, while serious, is commonly performed with a high success rate and minimal complications.


Medical Specialty: Surgery
Sample Name: Inguinal Herniorrhaphy - 1

PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF 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.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Direct inguinal hernia.  Rutkow direct inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.

surgery, cremasteric muscle, pubic tubercle, external oblique aponeurosis, inguinal herniorrhaphy, inguinal hernia, cord structures, penrose drain, bovie electrocautery, inguinal, herniorrhaphy, metzenbaum, bovie, electrocautery, cord, hernia

Inguinal herniorrhaphy, while a common surgical procedure, involves the use of general anesthesia and surgical intervention, which inherently carry certain risks such as infection, bleeding, or adverse reactions to anesthesia. However, it is generally a routine procedure with a high success rate and low complication rate when performed by experienced practitioners. The stakes involve ensuring patient safety and the proper execution of the surgery to effectively repair the hernia and prevent future complications. Therefore, while there are risks, they are relatively controlled in a surgical setting.