Medical Specialty: Surgery
Sample Name: Inguinal Herniorrhaphy

PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 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 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 went to  Pathology.  The ends of the suture were then cut and the stump retracted back into the abdomen.,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 3-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped and draped with benzoin, and Steri-Strips were applied.  A dressing consisting of a 2 x 2 and OpSite was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
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DESCRIPTION: 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, inguinal canal, cremasteric muscle, pubic tubercl, inguinal herniorrhaphy, blunt dissection, penrose drain, bovie electrocautery, cord structures, inguinal, electrocautery, cord

The situation described is a common surgical procedure known as inguinal herniorrhaphy, which is typically performed to repair hernias in the groin area. While any surgical procedure carries inherent risks, an inguinal hernia repair is generally considered routine and low-risk when performed on otherwise healthy patients. The description mentions that the procedure was conducted without incident, and the patient was stable post-operation. This suggests that the stakes are not exceptionally high compared to more complex or life-threatening surgeries.


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Medical Specialty: Surgery
Sample Name: Inguinal Hernia Repair - 2

PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left direct and indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia with Prolene mesh.,ANESTHESIA: , IV sedation with local.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to Recovery in stable condition.,SPECIMEN: , Hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac.,BRIEF HISTORY:  ,This is a 53-year-old male who presented to Dr. Y's office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months.  The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,INTRAOPERATIVE FINDINGS: , The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac.  The patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms.,PROCEDURE: , After informed consent, risks and benefits of the procedure were explained to the patient, the patient was brought to the operative suite, prepped and draped in the normal sterile fashion.  The left inguinal ligament was identified from the pubic tubercle to the ASIS.  Two fingerbreadths above the pubic tubercle, a transverse incision was made.  First, the skin was anesthetized with 1% lidocaine and then an incision was made with a #15 blade scalpel, approximately 6 cm in length.  Dissection was then carried down with electro Bovie cautery through Scarpa's fascia maintaining hemostasis.  Once the external oblique was identified, external oblique was incised in the length of its fibers with a #15 blade scalpel.  Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring.  Next, the external oblique was grasped with Ochsner on both sides.  The cord, cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it.  Next, the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down, grasped with two hemostats.  A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored.  There was some turbid fluid within the hernia sac, which was sent down for cultures.  Gram stain was negative for organisms.  Next, the hernia sac was to be ligated at its base and transected.  A peon was used at the base.  Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen.  An #0 Vicryl stick suture was used with #0 Vicryl loop suture to suture ligate the hernia sac at its base.,Next, attention was made to placing a Prolene mesh to cover the floor.  The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures.  Attention was made to salvaging the ilioinguinal nerve, which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact.  Attention was next made after suturing the mesh with the #2-0 Polydek suture.  The external oblique was then closed over the roof with a running #0 Vicryl suture, taking care not to strangulate the cord and to recreate the external ring.  After injecting the external oblique and cord structures with Marcaine for anesthetic, the Scarpa's fascia was approximated with interrupted #3-0 Vicryl sutures.  The skin was closed with a running subcuticular #4-0 undyed Vicryl suture.  Steri-Strip with sterile dressings were applied.,The patient tolerated the procedure well and was transferred to Recovery in stable condition.
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DESCRIPTION: Left direct and indirect inguinal hernia.  Repair of left inguinal hernia with Prolene mesh.  The patient was found to have a left inguinal hernia increasing over the past several months.  The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.

surgery, left inguinal hernia, prolene mesh, hernia sac, gram stain, inguinal hernia repair, inguinal hernial repair, metzenbaum scissors, cord structures, inguinal hernia, sac, inguinal, hernia, metzenbaum, prolene, vicryl, cord, suture, oblique, mesh,

The situation describes a surgical procedure for repairing a left inguinal hernia using Prolene mesh. Inguinal hernia repair is a common surgical procedure, typically not considered extremely high-stakes compared to other operations. However, there are still inherent risks associated with any surgical procedure, such as infection, recurrence of the hernia, and complications related to anesthesia. The patient in this case has a history of multiple abdominal surgeries, which might increase the risk of complications. Despite this, the preoperative and intraoperative details indicate that the procedure was completed successfully with no complications, and the patient was stable postoperatively. Therefore, while surgery inherently carries higher stakes than non-invasive procedures, the described situation does not present unusually high stakes beyond what is typical for this type of surgery.

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Medical Specialty: Surgery
Sample Name: Inguinal Hernia Repair - 4

PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.
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DESCRIPTION: Right inguinal hernia.    Right direct inguinal hernia repair with PHS mesh system.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.

surgery, groin, phs mesh, inguinal hernia repair, direct inguinal hernia, preperitoneal space, external oblique, cord structures, inguinal hernia, inguinal, hernia, external, oblique, mesh,

Inguinal hernia repair is a common surgical procedure with a high success rate. The surgery is important and does carry risks inherent to surgeries requiring anesthesia, but it is generally considered routine and the stakes are relatively typical for surgical procedures. Given the provided description, the procedure went without complication and followed standard practices.


Medical Specialty: Surgery
Sample Name: Inguinal Hernia Repair

PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernia, bilateral hydroceles.,POSTOPERATIVE DIAGNOSES:,  Bilateral inguinal hernia, bilateral hydroceles.,PROCEDURES: , Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given.,ANESTHESIA: , General inhalational anesthetic.,ABNORMAL FINDINGS:,  Same as above.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,FLUIDS RECEIVED: , 400 mL of Crystalloid.,DRAINS: , No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR PROCEDURE:  ,The patient is a 7-year-old boy with the history of fairly sizeable right inguinal hernia and hydrocele, was found to have a second smaller one on evaluation with ultrasound and physical exam.  Plan is for repair of both.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  Once he was anesthetized, he was then placed in a supine position and sterilely prepped and draped.  A right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis.  The external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors.  Using a curved mosquito clamp, we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal.  The cord structures were then dissected off the sac and then the sac itself was divided in the midline, twisted upon itself and suture ligated up at the peritoneal reflection with 3-0 Vicryl suture.  This was done twice.  The distal end where a large hydrocele noted, was gently milked into the lower aspect of the incision.  The hydrocele sac was then opened and drained and then the testis was delivered into the field.  The sac was then opened completely around the testis.  The appendix testis was cauterized.  We wrapped the sac around the back of the testis and tacked into place using the Lord maneuver using 4-0 Vicryl as a figure-of-eight suture.  Once this was done, the testis was then placed back into the scrotum in the proper orientation.  Ilioinguinal nerve block and wound instillation was then done with 10 mL of 0.25% Marcaine.  A similar procedure was done on the left side, also finding a small hernia, which was divided and ligated with the 3-0 Vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a Lord maneuver after opening the sac completely.  Again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3-0 Vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure.  Scarpa fascia was closed with 4-0 chromic suture on each side and the skin was closed with 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on both incisions.  IV Toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure.  The patient tolerated the procedure and was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally.

surgery, bilateral hydrocele repair, bilateral inguinal hernia, external oblique fascia, ilioinguinal nerve block, bilateral hydroceles, external oblique, oblique fascia, cord structures, hydrocele sac, lord maneuver, nerve block, bilateral inguinal, ilioinguinal nerve, inguinal hernia, hernia, inguinal, hydrocele, bilateral, sac,

The described medical procedure is a surgical operation on a 7-year-old boy to repair bilateral inguinal hernias and hydroceles. While the procedure itself is fairly routine in pediatric surgery and involves common practices like the use of anesthesia and careful surgical techniques, it is still a surgical intervention with inherent risks, especially for a young child. The stakes are heightened because the patient is a child, and any complications could have significant consequences. Additionally, anesthesia and surgical interventions always carry some level of risk, even if it is relatively low. However, the detailed description of the procedure indicates that it went smoothly, with minimal blood loss and no drains required, which suggests a successful surgery with low immediate complication risk. Therefore, it's characterized as a moderate-stakes medical situation.


Medical Specialty: Surgery
Sample Name: Iliac Crest Bone Graft - Maxilla & Mandible

PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.
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DESCRIPTION: Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.  Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.

surgery, autologous iliac crest bone graft, to, mandible, mandibular atrophy, maxillary atrophy, facial deformity, masticatory dysfunction, iliac crest bone graft, mental foramina, iliac crest, bone, autologous, maxillary, mandibular, maxilla

The procedure described is an autologous iliac crest bone graft to the maxilla and mandible under general anesthesia, which involves significant surgical intervention. High-stakes factors include the use of general anesthesia, the complexity of the procedure, potential complications (e.g., blood loss, infection, nerve damage), and the necessity to restore critical functions like mastication and facial structure. However, the description indicates the procedure went as planned, with the surgical team taking standard precautions and managing blood loss effectively. Nevertheless, the procedure involves significant risk due to both the complexity and the body's physiological response to surgery.


Medical Specialty: Surgery
Sample Name: I&D - Perirectal Abscess

PREOPERATIVE DIAGNOSIS:,  Perirectal abscess.,POSTOPERATIVE DIAGNOSIS:,  Perirectal abscess.,PROCEDURE: , Incision and drainage (I&D) of perirectal abscess.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room after obtaining an informed consent.  A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.,Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope.  I found some small internal hemorrhoids and no fistulous tracts.,Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained.  All necrotic tissue was debrided.  The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area.  The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.,Estimated blood loss was minimal.  The patient tolerated the procedure well and was sent for recovery in satisfactory condition.
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DESCRIPTION: Perirectal abscess.  Incision and drainage (I&D) of perirectal abscess.

surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal,

The described situation involves a surgical procedure for treating a perirectal abscess, which is a standard but still serious surgery. The successful drainage of an abscess can immediately relieve significant pain and prevent the spread of infection, potentially avoiding severe complications. While the procedure is routine for a trained surgeon, any surgical intervention carries inherent risks such as infection, bleeding, or complications from anesthesia. Therefore, it is relatively high-stakes, particularly considering the importance of correctly performing the procedure to ensure effective recovery and prevent recurrence.


Medical Specialty: Surgery
Sample Name: I&D & Wound Closure - Scalp Lacerations

PREOPERATIVE DIAGNOSIS: , Scalp lacerations.,POSTOPERATIVE DIAGNOSIS: , Scalp lacerations.,OPERATION PERFORMED: , Incision and drainage (I&D) with primary wound closure of scalp lacerations.,ANESTHESIA:,  GET.,EBL: , Minimal.,COMPLICATIONS: , None.,DRAINS: , None.,DISPOSITION: , Vital signs stable and taken to the recovery room in a satisfactory condition.,INDICATION FOR PROCEDURE:  ,The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident.  The patient was taken to the operating room for an I&D of the lacerations with wound closure.,PROCEDURE IN DETAIL:  ,After appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5.  Before the neck instrumentation was performed, the patient's lacerations to her scalp were I&D'ed and closed.  It was noted that the head was significantly contaminated with blood as well as mangled.  It was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair.  This was shaved appropriately with shavers.  Once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide.  Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline.  No significant debris was appreciated.  Once this was done, staples were used to oppose the dermal edges together.  The patient was subsequently dressed sterilely using bacitracin ointment, Xeroform, 4x4s, and tape.  The neck procedure was subsequently performed.
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DESCRIPTION: Incision and drainage (I&D) with primary wound closure of scalp lacerations.  The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident.  The patient was taken to the operating room for an I&D of the lacerations with wound closure.

surgery, drainage, incision, primary wound closure, lacerations, wound closure, scalp lacerations, scalp, i&d,

The situation involves a surgical procedure on a middle-aged female who sustained significant scalp lacerations from a motor vehicle accident. While the surgery itself—incision and drainage followed by wound closure—was completed without complications and the patient's condition was stable post-operation, the stakes are elevated due to the nature of the injury resulting from an accident and the necessity for surgical intervention. Surgeons must ensure proper wound management to prevent infection and promote healing. However, given the successful procedure and lack of complications, the stakes, while still considerable, are not at the highest level.


Medical Specialty: Surgery
Sample Name: I&D & Foreign Body Removal

PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.
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DESCRIPTION: Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.

surgery, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot

The surgical procedure described involves the removal of a foreign body from a child's foot and managing an ongoing infection. While it is a surgical intervention, it is relatively common and low-risk compared to other surgical procedures. There are no immediate life-threatening conditions mentioned, and the procedure was reported to be well-tolerated with stable vital signs post-operation. The stakes are higher than a routine check-up due to the involvement of general anesthesia and the necessity for surgical intervention, but it is not considered a high-stakes complex surgery.


Medical Specialty: Surgery
Sample Name: Iliac Artery Catheter & Stent Placement, Arteriography, Angioplasty

PREOPERATIVE DIAGNOSIS: , External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,POSTOPERATIVE DIAGNOSIS:,  External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,PROCEDURES:,1.  Placement of right external iliac artery catheter via left femoral approach.,2.  Arteriography of the right iliac arteries.,3.  Primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon.,3.  Open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.,ANESTHESIA: , Local with intravenous sedation.,INDICATION FOR PROCEDURE:,  He is a 67-year-old white male who is well known to me.  He had severe peripheral vascular disease and recently underwent a kidney transplant.  He has had some troubles with increasing serum creatinine and hypertension.  Duplex suggests a high-grade iliac stenosis just proximal to his transplant kidney.  He is brought to the operating room for arteriography and potential treatment of this.,DESCRIPTION OF PROCEDURE: , The patient was brought to operating room #14.  A condom catheter was put in place.  Preoperative antibiotics were administered.  The patient's left arm was prepped and draped in the usual sterile fashion.  An incision was made over his brachial artery after anesthetizing the skin.  His brachial artery was dissected free and looped with vessel loops.  Under direct vision, it was punctured with an 18-gauge needle and a short 3J guidewire and 6-French sheath put in place.  A 3J guidewire was then introduced after the administration of intravenous heparin and advanced into the descending thoracic aorta.  This was then advanced down into the right common iliac artery.  The catheter was placed over this and arteriography performed.  After adjusting the image intensifier to unfold the origin of the renal artery from the iliac system.  We were able to demonstrate an approximately 60-70% stenosis of the external iliac artery.  Immediately preceding the origin of the artery for the transplant kidney, which appeared to be widely patent.  We elected to try and treat this.  With catheter support a magic torque guidewire was advanced through the stenosis and into the common femoral artery.  An 8 mm diameter x 3 cm length angioplasty balloon was positioned across the stenosis and inflated.  This inflation was held for one minute.  This was then deflated and a catheter positioned again in the proximal common iliac artery.  For this application, we used a guide catheter that would allow us to inject contrast without losing our wire purchase.  This showed an improvement in the stenosis, but a residual stenosis of at least 30% and we elected to stent this.  An 8 mm diameter x 3 cm length stent was chosen and placed just proximal to the origin of the renal artery.  After this was completed, the stent introduction balloon was removed and the catheter replaced.  Repeat angiography showed a widely patent segment with no evidence of any residual stenosis.  There was no evidence of any dissection or damage to the renal artery.  We interpreted this as satisfactory procedure.  Guidewires and sheaths were removed.  The brachial artery was repaired with two interrupted sutures of 7-0 Prolene.  The wound was irrigated and the subcutaneous tissue closed with a running suture of Vicryl.  The skin was reapproximated with a running intracuticular suture of Monocryl.  Steri-Strips and sterile occlusive dressing were applied and the patient was taken to the recovery room in stable condition.  Estimated blood loss for the procedure was less than 50 mL.  Total contrast employed was 37.5 mL.  Total fluoroscopy time was 12 minutes and 43 seconds.
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DESCRIPTION: Placement of right external iliac artery catheter via left femoral approach, arteriography of the right iliac arteries, primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon, open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.

surgery, external iliac artery catheter, catheter via left femoral, external iliac artery stenosis, impaired renal function, common iliac artery, iliac artery catheter, external iliac artery, iliac artery, femoral approach, iliac arteries, transplanted kidney, renovascular hypertension, widely patent, residual stenosis, stent placement, angioplasty balloon, brachial artery, renal artery, iliac, angioplasty, artery, guidewire, arteriography, kidney, renal, catheter, stenosis

The situation involves a surgical procedure addressing a serious medical condition, specifically external iliac artery stenosis affecting a recently transplanted kidney. The patient's existing condition of renovascular hypertension and impaired renal function, combined with the need for precise intervention (angioplasty and stent placement) to maintain adequate blood flow to the transplanted kidney, elevates the stakes. Complications or failure of the procedure could lead to significant health deterioration, making this a high-stakes medical situation.


Medical Specialty: Surgery
Sample Name: Hysterectomy & Salpingoophorectomy

PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,
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DESCRIPTION: Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.

The medical procedure described involves a total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis for a patient with stage IV endometriosis. Surgery involves significant risk, especially given the patient's complex preoperative condition with severe adhesions and prior surgeries. High blood loss and the need for careful dissection to avoid injury to surrounding organs like the bowel and ureters further increase the stakes. While the procedure was completed without complications, the nature of abdominal surgery, combined with the potential for complications during recovery, suggests that this is a high-stakes situation in a medical context.


Medical Specialty: Surgery
Sample Name: Hysterectomy (TAH - BSO)

PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:,  Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:,  General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy.  She was counseled to undergo staging laparotomy.,FINDINGS:,  Examination under anesthesia revealed a small uterus with no nodularity.  During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease.  Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal.  There was no evidence of residual neoplasm after removal of the uterus.  The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided.  The peritoneum was entered without difficulty and washings were obtained.  The abdomen was explored with findings as noted.  A Bookwalter retractor was placed and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament.  The round ligaments were isolated, divided, and ligated.  The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters.  The infundibulopelvic ligaments were isolated, divided, and doubly ligated.  The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated.  Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated.  When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries.  Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches.  The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy.  Metzenbaum scissors were used to incise lymphatic tissues.  Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially.  The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally.  Ligaclips were applied where necessary.  After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes.  Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised.  The pelvis was again irrigated and excellent hemostasis was noted.  The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture.  Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed.  Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch.  The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.

surgery, tah, bso, lymphadenectomy, endometrial, total abdominal hysterectomy, bilateral salpingo oophorectomy, tubes and ovaries, salpingo oophorectomy, lymph nodes, endometrial cancer, abdominal, hysterectomy, oophorectomy, hemostasis, retractors, washings, laparotomy, ligated, pelvic, uterus, nodes,

The situation described involves a complex surgical procedure (hysterectomy with staging for endometrial cancer) which is inherently high-stakes. Surgery always carries risks, such as complications from anesthesia, bleeding, or infection. Moreover, the procedure is being performed to treat and stage cancer, determining the extent of the disease and guiding further treatment, which is critical to the patient's prognosis. The successful execution significantly impacts the patient's well-being and future management of her cancer, making this a high-stakes scenario.


Medical Specialty: Surgery
Sample Name: Hysterectomy - Laparoscopic Supracervical

PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.
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DESCRIPTION: Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea.

surgery, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar

The situation described is a surgical procedure called a laparoscopic supracervical hysterectomy, which involves the removal of the uterus while leaving the cervix intact. This is a significant operation, requiring general anesthesia and laparoscopic techniques, and it involves several potential risks and complications. The stakes of such a procedure are high because it is a surgery that can affect the patient's health, recovery time, and quality of life, although it was performed without complications in this case. Additionally, surgeries typically carry inherent risks such as bleeding, infection, or injuries to adjacent organs, which contribute to the high-stakes nature. Therefore, the procedure, while routine for many practitioners, remains high-stakes for the patient involved.


Medical Specialty: Surgery
Sample Name: Hypospadias Repair

PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS:  ,10 mL.,FLUIDS RECEIVED:,  300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee.  Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  The dorsal hood was retracted and cleansed.  He was then sterilely prepped and draped.  Stay suture of #4-0 Prolene was then placed in the glans.  His urethra was calibrated to 10-French bougie-a-boule.  We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum.  Byers flaps were also marked.  Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis.  On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage.  Once this was done, an electrocautery was used for hemostasis were then used.  A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee.  We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture.  Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight.  We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate.  We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings.  Using the curved iris scissors, we then elevated the wings even further.  Again, electrocautery was used for hemostasis.  An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture.  There were two areas of coverage with the tissue flap relocation from the glanular wings.  The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl.  Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl.  Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline.  The extra dorsal hood tissue of preputial skin was then excised.  An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline.  The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself.  At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing.  Telfa and the surgical eye tape was then used for the final dressing.  IV Toradol was given.  The patient tolerated the procedure well and was in stable condition upon transfer to recovery room.
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DESCRIPTION: Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.

surgery, tissue flap relocation, urethroplasty plate incision, penile shaft skin, chordee release, zaontz catheter, penile shaft, hypospadias repair, flap relocation, coronal cuff, urethral plate, tissue flap, hypospadias, flap, chordee,

The situation involves a surgical procedure on a 6-month-old patient, which inherently carries risks related to anesthesia, the complexity of the surgery, and potential complications. Surgical procedures on infants are high-stakes due to the increased vulnerability of the patient and the precision required to avoid complications that could impact future development. However, the procedure described is a planned, routine repair for hypospadias—an abnormality in the urethra—and it appears to have been executed without complications, as the patient was stable post-operation. This context suggests the procedure, while serious, is standard practice in pediatric surgery, which slightly lowers the stakes compared to emergency or highly complex surgeries.


Medical Specialty: Surgery
Sample Name: Hemivulvectomy

PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Wide Local Excision of the Vulva.  Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.

surgery, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,

This is a high-stakes situation because it involves recurrent vulvar melanoma, a serious and potentially life-threatening condition. Surgery, especially radical procedures like hemivulvectomy, carries significant risks including complications and impacts on quality of life. The patient's medical history of melanoma makes this situation even more critical due to the potential for metastasis and other complications. Furthermore, this is a specialized surgical intervention requiring precise execution to ensure the removal of cancerous tissue while attempting to preserve as much healthy tissue as possible.


Medical Specialty: Surgery
Sample Name: Hernia Repair

PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia.,ANESTHESIA:,  General; 0.25% Marcaine at trocar sites.,NAME OF OPERATION:,  Laparoscopic left inguinal hernia repair.,PROCEDURE: , A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly.  The rectus muscle was retracted laterally.  Balloon dissector was passed below the muscle and above the peritoneum.  Insufflation and deinsufflation were done with the balloon removed.  The structural balloon was placed in the preperitoneal space and insufflated to 10 mmHg carbon dioxide.  The other trocars were placed in the lower midline times two.  The hernia sac was easily identified and was well defined.  It was dissected off the cord anteromedially.  It was an indirect sac.  It was taken back down and reduced into the peritoneal cavity.  Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place.  After this was completed, there was good hemostasis.  The cord, structures, and vas were left intact.  The trocars were removed.  The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin.  Steri-Strips were applied.  The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Laparoscopic left inguinal hernia repair.

surgery, rectus fascia, hernia, laparoscopic left inguinal hernia, inguinal hernia repair, hernia repair, laparoscopic, rectus, fascia, repair, balloon, inguinal,

A laparoscopic left inguinal hernia repair is a common and relatively low-risk surgical procedure. Although surgery always carries some degree of risk, this procedure is typically straightforward and performed under general anesthesia. The post-operative report indicates that the patient tolerated the procedure well, suggesting that the stakes in this scenario are not especially high. However, as it involves surgery under general anesthesia, it still carries some inherent risk.


Medical Specialty: Surgery
Sample Name: Hydrocelectomy.

PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum, approximately 8 cm.  Laboratory data included a hematocrit of 43.5, hemoglobin of 15.0, and white count 4700.  Creatinine 1.3, sodium 141, and potassium 4.0.  Calcium 8.6.  Chest x-ray was unremarkable.  EKG was normal.,PROCEDURE: , The patient was satisfactorily given general anesthesia, prepped and draped in supine position, and left scrotal incision was made, carried down to the tunica vaginalis forming the hydrocele.  This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord.  In the fashion, the hydrocele was excised and fluid drained.,Cord was infiltrated with 5 mL of 0.25% Marcaine.  The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3-0 Vicryl sutures for hemostasis.  The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3-0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia.,The left scrotal incision was closed, first closing the Dartos fascia with interrupted 3-0 Vicryl sutures.  Skin was closed with an interrupted running 4-0 chromic suture.  A sterile dressing was applied.  The patient was sent to the recovery room in good condition, upon awakening from general anesthesia.  Plan is to discharge the patient and see him back in the office in a week or 2 in followup.  Further plans will depend upon how he does.
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DESCRIPTION: Left hydrocelectomy.   This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum.

surgery, hydrocele, erectile dysfunction, spermatic cord, tunica vaginalis, vicryl sutures, dartos fascia, hydrocelectomy, psa, testicle, scrotum, scrotal,

The situation involves a surgical procedure called hydrocelectomy, which is the removal of a hydrocele. While surgery always carries some risk, hydrocelectomy is generally a routine and low-risk procedure, especially since the patient was sent to recovery in good condition and is planned for discharge soon after. The stakes are moderate due to the need for general anesthesia and the patient's age and existing health issues, but not extremely high due to the nature of the surgery.


Medical Specialty: Surgery
Sample Name: Hemilaminotomy & Foraminotomy

PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.
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DESCRIPTION: Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.

surgery, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,

The situation described involves a surgical procedure, which inherently carries certain risks and is critical to patient outcomes. Surgery usually involves high-stakes decision-making due to potential complications, the need for precision, and the overall impact on patient health. However, the procedure did not involve any reported complications, and the patient was stable post-operation, which can moderate the stakes somewhat. The estimated blood loss was minimal, also indicating a well-managed situation. Nonetheless, given the nature of surgery and the requirement for skilled execution, this scenario remains 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: Hemodialysis Fistula Construction

PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty.  The right arm, axilla, and chest wall were prepped and draped in sterile fashion.  Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent.  The draining veins are the deep brachial veins.  The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture.  A nice length of vein was obtained to the distal one third of the arm.  This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein.  A transverse skin incision was made over the superior aspect of the old fistula vein.  This vein was carefully dissected out and encircled with vascular tapes.  The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula.  The patient was sensible, was then systemically heparinized.  The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter.  The brachial vein end was spatulated.  Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion.  After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled.  The anastomosis was completed.  A nice thrill could be palpated over the outflow brachial vein.  Hemostasis was noted.  A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture.  The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin.  Sterile dressings were applied.  The patient was then x-ray'd and taken to Recovery in satisfactory condition.  Estimated blood loss 50 mL, drains 8 mm Blake.  Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.
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DESCRIPTION: Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.  End-stage renal disease with failing AV dialysis fistula.

surgery, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial,

The situation detailed involves surgical construction of a hemodialysis fistula, a critical procedure for patients with end-stage renal disease. These patients rely on dialysis for survival, and the procedure was necessary due to the failure of a previous fistula. Surgical procedures inherently carry risks, such as bleeding or infection, but this description notes a successful operation with no apparent complications. Despite being successful, the stakes are high because the patient's condition necessitates reliable dialysis access to sustain life.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 9

PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.
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DESCRIPTION: Left heart catheterization, left ventriculography, selective coronary angiography.

The situation involves a cardiac catheterization procedure, which is an invasive medical procedure with significant risks, including conscious sedation risks, death, cerebrovascular accident, dye reaction, emergency surgery, vascular access injury or infection, and complications from catheter-based interventions. While the patient tolerated the procedure without complications, the stakes remain high due to the potential for serious adverse events and the critical nature of the patient's cardiac condition.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 10

PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.
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DESCRIPTION: Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.

surgery, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography

This procedure description involves a complex and delicate series of interventions on the heart’s vasculature, including dealing with total occlusion of the right coronary artery and potential complications like dissection or perforation. The successful outcome and stable condition of the patient indicate careful management of high-stakes variables. Such cardiac procedures, given the critical nature of the cardiac system and the potential for catastrophic outcomes if complications aren’t managed, are inherently high-stakes.


Medical Specialty: Surgery
Sample Name: Heart Catheterization & Ventriculogram

PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.
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DESCRIPTION: Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.

The procedure described involves heart catheterization and various diagnostic assessments essential in the context of evaluating a patient with severe mitral stenosis and moderate aortic insufficiency for potential valve repair or replacement. These are serious cardiovascular issues that, if left unaddressed, could result in significant health risks, including heart failure. The procedure is critical in assessing the patient's condition to plan lifesaving interventions. Therefore, the stakes are high due to the potential impact on the patient's health and the invasive nature of the procedure.


Medical Specialty: Surgery
Sample Name: Heart Catheterization

PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,
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DESCRIPTION: Right and left heart catheterization, coronary angiography, left ventriculography.

surgery, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions

The situation involves a heart catheterization procedure, which is a critical and invasive procedure aimed at diagnosing and treating heart conditions. The procedures carried out are typically high-stakes because they involve direct intervention in the cardiovascular system, can lead to immediate complications, and require precise execution. In this specific case, while the immediate outcome was successful with no complications, the context of cardiac assessments like these inherently carries high stakes given the potential for significant impacts on the patient's health and the nature of the potential diagnoses (like severe mitral regurgitation and left ventricular dilatation). Therefore, the importance of the situation for patient outcomes makes it high-stakes.