Sample Report: Shock Wave Lithotripsy

DIAGNOSIS: Left renal calculi.

PROCEDURE PERFORMED: Left extracorporeal shock wave lithotripsy.

DESCRIPTION OF PROCEDURE: After the patient was placed in the supine position and in the F2 focus of the MSL 5000 lithotriptor, shock wave lithotripsy was started at 17 kV and went up to 23, where a total of 3000 shocks were given to the stone with fragmentation of this left renal calculi. No complications were encountered. The patient was sent to the recovery room in stable and satisfactory condition.

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Sample Report: Pubovaginal Sling

PROCEDURE PERFORMED: Pubovaginal sling.

DETAILS OF PROCEDURE: In lithotomy position, the patient was prepped and draped in sterile fashion. A 16-French Foley catheter was placed initially into the bladder. An Allis clamp was placed on the vaginal mucosa. The bladder neck was then identified and marked using a sterile marking pencil. The vaginal mucosa was then infiltrated using 1% Xylocaine with epinephrine to help aid in hydrodissection. Following this, Malis scissors were then used to dissect the vaginal flap, which was in the shape of an inverted U. Dissection was performed laterally to the pelvic sidewalls and in the retropubic space bilaterally. Following this, a transverse incision was made in the suprapubic region down to the level of the rectus fascia. Stamey needles were then placed on either side of the bladder neck.

Following this, the fascia lata graft was then prepared using a mattress suture of 0 Prolene on either side. Having marked the midline, the 0 Prolene suture was then placed through either eye of the Stamey needles, and the sutures were brought out through the abdominal wall. Cystoscopy was then performed, which was within normal limits. A 4-French open-ended catheter was placed up each ureteric orifice and easily passed, and normal efflux of urine could be seen from each ureteral orifice. The midline of the fascia lata flap was then attached to the underlying vaginal wall in the midline using 4-0 Vicryl. A running suture of 2-0 chromic was used to approximate the vaginal incisions. The sutures of 0 Prolene were then tied across each other along the anterior rectus fascia and allowed good suspension of the bladder neck. The subcutaneous tissue in the abdominal incision was then approximated using interrupted sutures of 3-0 chromic. The skin edges were approximated using a running suture of 4-0 Vicryl. The patient tolerated the procedure well.

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Sample Report: Lymphadenectomy & Prostatovesiculectomy

DIAGNOSIS: Carcinoma of the prostate.

DESCRIPTION OF PROCEDURE: In the supine position, after endotracheal anesthesia, the abdomen and genitalia were prepped and draped in the usual fashion. A midline incision was made from the symphysis pubis towards the umbilicus for about 5 inches, deepened through the subcutaneous tissues down to the fascial layer, which was incised. Retropubic exposure was accomplished, exposing the iliopsoas fossa, and this was retracted with the Bookwalter retractor to expose and allow the lymphadenectomy.

The lymphadenectomy was done in limited fashion by mobilizing the fibroareolar tissue on both sides (anterior medial and inferior to the iliac vein into the obturator fossa off the obturator nerve vessels) using medium or large hemoclips as appropriate. Frozen section revealed these to be negative. The procedure was continued by mobilizing the endopelvic fascia and incising it posteriorly to anteriorly. At the anterior portion, we incised the puboprostatic ligaments. Triple ligation of the dorsal vein complex was accomplished. Dividing between the second and third cephalad sutures, we identified the urethroprostatic angle, at which point the lateral exposure was accomplished by dividing the fascia again to drop the neurovascular bundle posterolaterally.

The posterior urethra was now incised. The catheter was removed. Dissection of the prostate off the rectum was done through Denonvilliers fascia. Proximally we were able to mobilize the lateral aspects of the pedicles between hemoclips. Seminal vesicles were exposed through incision of Denonvilliers fascia again and division of pedicles between hemoclips. The pedicles to the seminal vesicles and ejaculatory ducts were divided between Ligaclips. A portion of this ejaculatory duct was removed with the seminal vesicles, and the bladder neck was mobilized against some mild traction of the Foley, sparing about a 1-cm section of prostatic urethra. This was everted with 3-0 chromic sutures on the seromuscular layer and anastomosed to the urethra using the Greenfield suture guide. Irrigation revealed no leaks or bleeding after thorough irrigation of the pelvis. All counts were correct.

Insertion of the J-P drain was accomplished through a separate stab incision on the right side and secured using 3-0 nylon. Closure was done with a running Dexon, with subcutaneous tissues anastomosed with 3-0 Dexon and a subcuticular 3-0 Dexon suture. Steri-Strips and OpSite dressing was applied. The patient tolerated the procedure well with no complications encountered and was sent to the recovery room in stable and satisfactory condition.

IMPRESSION: Carcinoma of the prostate.

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Sample Report: Limited Colonoscopy

INDICATIONS: Heme-positive stool with anemia of unclear origin.

PROCEDURE PERFORMED: Limited colonoscopy.

PREMEDICATION: Demerol 50 mg IV, Versed 3 mg IV, and glucagon 1 mg IV.

DESCRIPTION OF PROCEDURE: The video colonoscope was only able to be passed to approximately 40 cm. Because of intense spasm in the midst of innumerable diverticula along with some stool, it was felt that the scope could not be safely advanced further. The procedure was therefor terminated, despite trying to advance the scope in both left and right lateral decubitus positions.

IMPRESSION: Severe narrowing/spasm of the midsigmoid colon in the midst of diverticulosis, otherwise unremarkable distal 40 cm.

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Sample Report: Laparoscopic Nissen Fundoplication

PREOPERATIVE DIAGNOSIS: Refractory gastroesophageal reflux disease.

POSTOPERATIVE DIAGNOSIS: Refractory gastroesophageal reflux disease.

PROCEDURE PERFORMED: Laparoscopic Nissen fundoplication.

ANESTHESIA: General.

DESCRIPTION OF PROCEDURE: With the patient in the supine position with his legs in the stirrups, initially an abdominal puncture was made for a Veress needle. After inflating the abdomen, a 10-mm port was placed approximately 5 cm above the umbilicus. Under direct vision, additional ports were placed in the right and left subcostal areas in the upper midline to facilitate dissection.

The liver was distracted superiorly using liver retractor, and this exposed the esophageal hiatus. There was a moderate-sized paraesophageal hernia, which was reduced. The crura were then dissected until the esophagus was freed from the crura circumferentially. Care was taken to preserve the vagus nerve trunk.

Once the crural area was well dissected, attention was turned to the fundus, which was mobilized by taking down the short gastric using a Harmonic scalpel. One of the short gastrics had some brisk bleeding which was controlled readily, again, with the Harmonic scalpel. Approximately 75 cc of blood was lost during the course of controlling that small short gastric bleeder. Once the fundus was completely freed, the crural repair was accomplished with interrupted sutures of 0 Ethibond placed with an EndoStitch device. The wrap was then passed posterior to the esophagus and held in place while a 50-French bougie was passed. With the bougie in place, the fundoplication was accomplished using interrupted sutures of 2-0 Ethibond, taking care to get the sutures through the medial and lateral portions of the fundus for the plication as well as the anterior surface of the esophagus. The most superior sutures were placed between the esophageal crura and the apex of the wrap.

Being satisfied with the wrap, the area of dissection was irrigated. Hemostasis was assured, and the ports were then removed under direct vision. The port sites were closed with 0 Vicryl interrupted for the fascia and 3-0 Vicryl subcuticular, with benzoin and Steri-Strips for the skin. The patient tolerated the procedure well.

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Sample Report: Laparoscopic Cholecystectomy

PREOPERATIVE DIAGNOSES

1. Cholelithiasis.

2. History of paroxysmal atrial tachycardia.

POSTOPERATIVE DIAGNOSES

1. Cholelithiasis.

2. History of paroxysmal atrial tachycardia.

PROCEDURES PERFORMED

1. Laparoscopic cholecystectomy.

2. Hasson cannula insertion.

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in the supine position. After placement of pneumatic compression devices, a Foley catheter, and orogastric tube, the patient had undergone satisfactory induction of general endotracheal anesthesia. The abdomen was prepped and draped using a Betadine preparation and sterile drapes. The patient had had a previous TAH/BSO and had a very long vertical midline incision. A cutdown was, therefore, performed at the infraumbilical position. Significant scar tissue was entered. The peritoneum was entered between hemostats, and finger dissection freed any intraabdominal adhesions. Then 0 Vicryl was placed for tacking sutures, and a Hasson cannula was inserted. A pneumoperitoneum was created without difficulty.

At this point, the 10-mm, 0-degree laparoscope was inserted. Two 5-mm trocars were placed under direct vision, one in the right anterior axillary line and one in the right midclavicular line. A second Veress port was placed in the left midline subxiphoid position. Gallbladder grasping forceps were used to grasp Hartmann pouch and the fundus of the gallbladder. A Maryland dissector was used to identify the gallbladder-cystic junction. No palpable stones were noted. The cystic duct appeared to be quite small. This was then doubly clipped and singly clipped proximally, and the cystic artery was similarly dealt with. The gallbladder was removed from the liver bed with electrocautery dissection. No spillage of bile or blood was appreciated.

The camera was applied to the subxiphoid port. The gallbladder was grasped with forceps and delivered through the umbilical wound without any contamination. The trocars were removed under direct vision, without evidence of bleeding.

The umbilicus was closed with interrupted sutures of 0 Vicryl. The skin was closed with 4-0 Vicryl in a similar fashion.

All sponge and needle counts were correct. The patient tolerated the procedure well and left the operating room in satisfactory condition.

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Sample Report: Hemicolectomy & Transverse Colorectal Anastomosis

PREOPERATIVE DIAGNOSIS: Refractory inflammatory bowel disease.

POSTOPERATIVE DIAGNOSIS: Refractory inflammatory bowel disease

PROCEDURE PERFORMED: Left hemicolectomy with transverse colorectal anastomosis.

FINDINGS: A few small plaques on the transverse colon (one excised for biopsy).

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was introduced. Her abdomen was prepped and draped in the usual sterile fashion with the patient in the modified lithotomy position. The previous midline scar was excised. The midline vertical scar was excised using a 10-blade scalpel. The subcutaneous tissues were divided with electrocautery. The fascia was also opened with electrocautery. The peritoneum was carefully grasped and entered. The incision was opened up along its length that extended from about 3 cm supraumbilical down to a few centimeters from the pubis. Gross peritoneal exploration was done. In the cul-de-sac, there was some fluid, which was submitted for cytology. There were a few plaques on the transverse colon. The liver was normal. I could not really evaluate the previous Nissen fundoplication from the lower abdominal incision. The colon looked normal. There was surgical absence of appendix.

The left colon was then dissected from the retroperitoneum. There was a fair amount of scar tissue, and this dissection took some time. The ureter was identified and was kept well out of the field of dissection. The greater omentum was dissected off the transverse colon to mobilize the splenic flexure. Resection was done by dividing the colon at the distal aspect of the transverse colon. I could see that there was essentially a branching blood vessel, probably the original middle colic artery, right at the area of the bowel I divided. I did take the left branch of the middle colic vessel and resect the mesentery. Vessels were ligated with clamps. This was done to where the rectum had been mobilized. The previous anastomosis was intact and widely patent.

A TA-55 stapler was applied across the rectum, about 3 cm below the previous anastomosis. Once the mesentery was divided, the TA stapler was fired. Attempts were made to save the superior hemorrhoidal vessels. The specimen was submitted to pathology. The transverse colon was then prepared for anastomosis. The staple line was excised, and a sizer was used to confirm that a 31-mm sizer fit easily within the lumen, secured with a pursestring suture. The remaining stapler was then passed up through the anus in the usual fashion and the spike advanced to the TA-55 staple line. This was fired, creating an anastomosis in the usual fashion. This was reinforced in a few areas using 3-0 silk popoffs. The TA-55 staple line outside of the anastomosis was also reinforced using interrupted 3-0 Lembert sutures. The anastomosis was then tested by placing it underwater and insufflating through the anus. This confirmed that the anastomosis was patent, and there was no evidence of bubbles or a leak. The water was evacuated. The mesenteric defect was then closed to prevent internal hernias. The small bowel was run from the ligament of Treitz to the cecum, and there were no abnormalities noted.

Attention was then turned towards closure. The fascia was reapproximated using a running 0 Vicryl suture. The skin edges were then approximated using skin clips. A sterile dressing was applied. The patient was extubated and an epidural catheter was placed. The patient was taken to the recovery room in stable condition.

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Sample Report: Hemicolectomy & Pancreaticoduodenectomy

PROCEDURES PERFORMED

1. Partial colectomy with anastomosis (right hemicolectomy).

2. Pancreaticoduodenectomy (Whipple procedure).

DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite and was administered a general intubation anesthetic. Foley catheter was placed to gravity drainage. The abdomen was prepped with Betadine and sterilely draped.

A midline incision was made with a scalpel and electrocautery through the subcutaneous fat and then through the rectus fascia. The peritoneal cavity was entered above the level of the umbilicus. The lower abdomen and pelvis were obliterated, with adhesions involving the omentum. These omental adhesions involved the entire lower abdomen and pelvis. Dissection was carried out with electrocautery and Metzenbaum scissors to free up the omentum and to free up multiple loops of small bowel which were adherent to each other. There were noted to be sutures from a previous surgery in what appeared to be the sigmoid colon. The patient also had sutures in the distal small bowel, about 6 to 8 cm from the ileocecal valve, also consistent with what appeared to be some type of small bowel resection.

The ascending colon was mobilized with sharp dissection, and palpation revealed a soft mass within the proximal ascending colon. Dissection was carried around the hepatic flexure, incising the peritoneum, separating it into pedicles, which were clipped and then divided. Dissection was carried around and through the gastrocolic tissue. Again, this tissue was either divided between large Weck clips or between clamps, and the tissue was tied with 2-0 silk. It was at this point that a mass was noted in the head of the pancreas that measured about 3 cm x 4 cm. The remainder of the pancreas was smooth with only one or two other areas of slight induration, one in the body and one in the tail.

There were enlarged lymph nodes around the common bile duct. These were soft. One of these was removed and sent for frozen section. Meanwhile, dissection was carried out to complete mobilization of the terminal small bowel and the ascending colon over to the mid transverse colon. The omentum was divided up to the midpoint of the transverse colon. The vessels along the right side of the middle colic artery and vein were sacrificed after the bowel had been divided between a bowel clamp and a Kocher. The dissection extended to the origin of the right colic and ileocolic vessels, and these vessels were divided between clamps and tied with 0 silk. There were small palpable nodes evident in the proximal mesocolon. These nodes were included as much as possible. The duodenum was dissected away from the mesocolon to allow for proximal ligation of the respective vessels. The distal small bowel was divided between a Kocher clamp and a bowel clamp. This was just proximal to the area of the previous anastomosis. The remaining mesentery of the terminal ileum and cecum was divided between clamps and tied with 2-0 silk.

The bowel was then prepared for an end-to-end anastomosis. This was carried out in two layers with the outer layer of interrupted seromuscular 3-0 silk and an inner layer of continuous interlocking 3-0 chromic. The mesenteric defect was closed with interrupted 3-0 silk. By this time I received word that the lymph node removed from the common bile duct area did not show any evidence of malignancy. Both right and left lobes of the liver were unremarkable to palpation. The gallbladder was moderately distended. The stomach was unremarkable. There was no evidence of any tumor studding the peritoneum. There was no free fluid within the peritoneal cavity. At this point, I went out and spoke with the patient's family and apprised them of the situation involving the pancreas. After discussion, it was decided to proceed at this time with the pancreaticoduodenectomy for the suspected neoplasm at the head of the pancreas.

The midline incision was extended up to the xiphoid. The self-retaining Bookwalter retractor was used, and the mobilization of the duodenum was completed to the inferior vena cava. The ligament of Treitz was mobilized by incising the peritoneum there. Gastroepiploic vessels were divided near their origin at the region of the head of the pancreas, and the head of the pancreas and duodenum were mobilized. The dissection was carried along the middle colic vein to the identified superior mesenteric vein, which then led into the identification of the portal vein. Blunt dissection was carried out easily over the portal vein behind the neck of the pancreas. The neck of the pancreas was totally normal. Dissection was then carried out in the lesser curvature area of the stomach over the duodenum to identify the gastroduodenal vessel. This was identified as being separate from the hepatic artery. The gastroduodenal vessel was encircled with a vessel loop. The opening was made in the lesser sac, and dissection was carried out over the superior aspect of the pancreas to allow for passage of a large Kelly clamp behind the neck of the pancreas. Again, a vessel loop was wrapped around the neck of the pancreas. Dissection was then carried out over the common bile duct, separated from the hepatic artery and the portal vein. The common bile duct appeared to be about 8 mm to 9 mm in diameter. It was encircled again with a vessel loop. At this point another enlarged node was located just above the neck of the pancreas near the celiac access. This lymph node was not hard, but it was enlarged and appeared to be slightly discolored. At this point there was no evidence of any extension of the tumor beyond the region of the head of the pancreas. It was elected then to proceed with the pancreaticoduodenectomy.

The pancreas was divided over its neck, with the TA-55 stapler applied across the proximal portion. The severed neck of the pancreas had bleeding, which was controlled easily with several 3-0 silk sutures. The pancreatic duct was found to lie in the posterior portion of the gland, and it measured perhaps 3 mm to 4 mm. Dissection was carried along the lateral aspect, right along the portal vein. The pancreaticoduodenal arteries were divided between clamps. The tissue along here was separated into small pedicles, and these were divided between clamps and tied with 2-0 silk. In this fashion, the head of the pancreas and the uncinate process were removed and dissection carried up towards the gastroduodenal vessel, which was then divided between clamps and tied with 2-0 silk. The distal common bile duct was also subsequently divided, and this allowed resection of the head of the pancreas along with the uncinate process.

The duodenum was divided between clamps just distal to the pylorus, and the small bowel at the duodenojejunal junction was divided as well, with a TA-55 stapler being applied distally, and then the bowel transected. The resected specimen, then, was the head of the pancreas, duodenum and distal common bile duct. Later inspection revealed that the preserved pylorus and 3 cm of duodenum appeared a bit dusky, and so I elected to resect the distal half of the stomach as well. The antrectomy was carried out by dividing the gastric vessels and ligating them with 0 silk.

The pancreaticojejunostomy anastomosis was carried out. This was an end-to-side fashion. The outer layer of the pancreaticojejunostomy was interrupted 3-0 silk. The inner layer was mucosa to mucosa with interrupted 4-0 silk, and the anterior outer layer was interrupted 3-0 silk in two layers. Approximately 8 cm distal to this anastomosis, the site was selected for the choledochojejunostomy. Before this was accomplished, the gallbladder was resected. The gallbladder was taken down from the fundus to the cystic duct in the usual fashion with electrocautery and also in some areas tissue divided between clamps, tied, and divided with 2-0 silk. Weck clips were also used in these areas. The dissection was carried down to identify the cystic artery, which was ligated with 2-0 silk and divided. The cystic duct was dissected down and then divided and ligated with 2-0 silk. The choledochojejunostomy was an end-to-side anastomosis. This was carried out in essentially one layer with interrupted 3-0 Vicryl, although 3-0 silk was used on either side of the anastomosis. The loop of jejunum was then brought around so that a gastrojejunostomy could be performed. This again was an end-to-side anastomosis. The midpoint of the stomach was divided between a ball clamp, which was applied along the greater curvature for about 4 cm, and then the medial half of the stomach was closed with a TA-90 stapler, 4.8 staple height. Again the anastomosis was carried out in two layers. An outer layer was interrupted 3-0 seromuscular silk, and the inner layer was continuous interlocking 3-0 chromic. All three anastomoses were accomplished with excellent blood supply to the respective organs and without any tension.

Irrigation of the abdominal cavity was carried out. Inspection revealed good hemostasis. Some of the omentum over the transverse colon appeared to be dusky, so this was resected. Next, two Jackson-Pratt drains were brought through the abdominal wall, one on the right side and one on the left side. One was placed near the area of the choledochojejunostomy, and the other one was located near the pancreaticojejunostomy. These were secured to the skin using 2-0 nylon. After an accurate sponge, instrument, and needle count was conducted, the abdomen was closed with continuous 1-0 Panacryl. The skin was approximated with skin staples. The patient was subsequently transferred to a cart and taken to recovery in good condition.

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Sample Report: Exploratory Laparotomy & Splenectomy

PREOPERATIVE DIAGNOSIS: Blunt abdominal trauma.

POSTOPERATIVE DIAGNOSIS: Splenic laceration and hemoperitoneum.

PROCEDURE PERFORMED: Exploratory laparotomy and splenectomy.

FINDINGS

1. Hemoperitoneum, about 1000 cc.

2. Splenic laceration, grade 3.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where a Foley bladder catheter was placed using a sterile technique. The patient had two large-bore IVs and was given high-rate boluses of IV fluids and blood. The abdomen and upper thighs were prepped from the nipples to the knees. The patient was sterilely draped. The anesthetist then put the patient to sleep, and the incision was made nearly simultaneously. The blood pressure did remain stable with the administration of blood.

The subcutaneous tissues were opened sharply to the fascia, which was also opened sharply. The peritoneum was grasped and carefully opened. The incision was opened along its length, which extended from the xiphoid to the infraumbilical region. A large amount of hemoperitoneum, mainly in the left hemiabdomen, was evacuated. Packs were placed in all four quadrants, starting with left upper quadrant and then the right upper quadrant. There was a large gush of blood in the right upper quadrant, somewhat concerning for a liver injury. Once all four quadrants were packed and the patient remained stable, the packs were removed initially from the lower quadrants, revealing no injuries but adhesions and scarring around the cecum. Then packs were removed from around the liver, and careful inspection of the right and left lobes of the liver revealed no injury to the liver. The packs were gradually removed from the left upper quadrant, and it was found that the spleen was indeed lacerated in the lower half, fairly significantly. This was definitely the source of the bleeding. The peritoneal attachments were quickly divided bluntly. The hilum was isolated. The splenic vessels were divided between straight clamps, and the spleen was removed. Packs were held over the area until hemodynamic stability could again be confirmed. The blood vessels were then controlled with suture ligatures of 0 Vicryl. Short gastric vessels were also ligated. A pack was placed, and again the rest of the abdomen was explored. The adhesions in the right lower quadrant were divided so that the omentum could be freed up. Once this was done, the small bowel was run from the ligament of Treitz to the cecum, and no injury was noted. The entire colon was inspected, and again no injury was noted. The left upper quadrant was again inspected, and another 3-0 silk suture ligature was used to complete the hemostasis. Hemostasis was good. An NG tube was positioned in good location. All of the packs were removed.

The fascia was closed with running 0 Vicryl suture. Given the large amount of laps used, abdominal films were taken, which revealed no evidence of retained lap sponges. Subcutaneous tissues were irrigated, and the skin was closed with staples. The patient tolerated the procedure and was transported to the ICU postoperatively in good condition.

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Sample Report: Esophagogastroduodenoscopy

PREOPERATIVE DIAGNOSES

1. Foreign body of the esophagus.

2. Dysphagia

POSTOPERATIVE DIAGNOSES

1. Foreign body of the esophagus.

2. Dysphagia

3. Esophagitis and Schatzki ring of the distal esophagus with stricture.

PROCEDURE PERFORMED: Esophagogastroduodenoscopy with random biopsies and esophageal dilatation.

DESCRIPTION OF PROCEDURE: After satisfactory IV analgesia with Versed and Sublimaze and topical anesthesia with viscous Xylocaine and Hurricaine spray, the procedure was performed without incident. The GIF video endoscope was inserted under direct vision. The patient was found to have a meat bolus in the distal esophagus. The patient was found to have a Schatzki ring and diffuse inflammation. The bolus was displaced into the stomach. The stomach itself had an inflamed gastric mucosa with linear streaking and superficial erosions in the antrum and prepyloric region. The first segment of the duodenum also had inflammation. The remainder was normal. The patient had no evidence of ulcerative, neoplastic, or polypoid lesions. I randomly biopsied the antral and prepyloric areas to exclude Helicobacter pylori and randomly biopsied the EG junction. I then did an esophageal dilatation using the balloon, without incident. I visualized the EG junction, and it seemed that the ring had been fractured, but I did not see any significant bleeding. The patient tolerated all of these procedures well and was returned to the recovery room in stable condition.

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Sample Report: Cystoscopy & Ureteroscopy

DIAGNOSIS: Left distal ureteral calculus.

PROCEDURES PERFORMED

1. Cystoscopy.

2. Left ureteroscopy.

3. Insertion of a double-J stent.

DESCRIPTION OF PROCEDURE: After spinal anesthesia, the abdomen and genitalia were prepped and draped in the usual fashion. Endoscopic evaluation failed to reveal any abnormalities of the bladder. Bimanual pelvic examination revealed a very small cystic change in the apex. Retrograde pyelogram revealed the distal ureteral calculus to be on the edge of the distal ureter. Endoscopically this was most likely a phlebolith as it was not intramural and intramucosal. The distal ureteral stricture was dilated to 15 French with a 4-cm balloon at 17 atmospheres. A double-J stent was inserted and secured in place to prepare for left ESWL of the patient's 1-cm stone in the lower pole of the left kidney. The patient tolerated the procedure well and was sent to the recovery room in stable condition.

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Sample Report: Cystoscopy & Transurethral Resection

DIAGNOSIS: Benign prostatic hypertrophy.

PROCEDURE PERFORMED: Cystoscopy and transurethral resection of the prostate with vaporization.

DESCRIPTION OF PROCEDURE: In the dorsal lithotomy position after spinal anesthesia, the abdomen and genitalia were prepped and draped in the usual fashion. Endoscopic evaluation demonstrated that the patient had no significant urethral abnormalities. The prostate revealed two visual fields of significant intravesical components with median lobe type of hypertrophy and 3+ trabeculation of the bladder muscle without significant other pathology. Resection was carried out using the Iglesias rectoscope element with continued monitoring, continued Sorbitol irrigation, and video monitoring. Resection was done to the median lobe components to the circular capsule of fibers of the bladder neck floor, lateral lobes, anterior tissue and apically, circumferentially removing all of the obstructive tissue down to the level of the verumontanum. Irrigation was done and all chips were removed. Fulguration was done with a VaporTrode electrode and VaporTrode ball at a setting of 250 watts for complete hemostasis. At the end of the procedure, no injuries to the bladder, trigone, ureteral orifices, prostatic fossa, external sphincter, verumontanum, or urethra were noted. The patient tolerated the procedure well and was taken to the recovery room in stable and satisfactory condition.

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Sample Report: Colonoscopy with Polypectomy

PREPROCEDURE DIAGNOSIS: Unexplained gastrointestinal bleeding.

POSTPROCEDURE DIAGNOSES

1. Two small sessile polyps in the sigmoid colon. Hot biopsy ablation performed.

2. Internal hemorrhoids.

PROCEDURE PERFORMED: Colonoscopy with polypectomy using hot biopsy forceps.

DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was placed in the left lateral position. Medications were given to achieve and maintain optimal sedation. The video colonoscope was introduced through the anal opening into the rectum and was advanced up to the cecum. The appendiceal opening and ileocecal valve were identified. The colonoscope was withdrawn. The only significant findings were two small sessile polyps in the sigmoid colon. These were removed using hot biopsy forceps. Internal hemorrhoids were noted. The rest of the exam was unremarkable. The colonoscope was withdrawn. The patient was transferred to the recovery room in stable condition.

IMPRESSION: No significant pathology that can explain gastrointestinal bleeding.

PLAN: Transfuse two units of packed red blood cells since the hematocrit is 25; maintain the hematocrit and consider further gastrointestinal evaluation if the gastrointestinal bleeding persists.

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Sample Report: Abdominal Aortogram: Coral Reef Aorta

HISTORY OF PRESENT ILLNESS: This 65-year-old white female presented with a history of debilitating nausea, vomiting, and abdominal cramping following the ingestion of food.

FINDINGS: There is a filling defect in the abdominal aorta, with significant narrowing of the lumen seen on anteroposterior view of the abdominal aorta. It appears to be at the level of the renal artery origin. This is also seen on the lateral view. The superior mesenteric artery origin is markedly narrowed, and there is occlusion of the celiac origin.

DIAGNOSIS: Coral reef aorta, with mesenteric insufficiency.

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Sample Report: CT Scan: Suspected Asbestosis

INDICATIONS: Patient with history of asbestos exposure.

FINDINGS: CT exam to the chest was performed at 8-mm sections and filmed at mediastinal and lung windows, with 2-mm thin sections at the base of the left lung.

Multiple calcified pleural plaques are seen bilaterally, with bilateral pleural thickening. A 2.5 x 2.5-cm mass is noted along the posterior surface of the left lower lobe of the lung. Linear and stippled calcifications appear in the anterior aspect. Bronchovascular bundles within the vicinity of the mass appear to converge on the region.

IMPRESSION: The findings are consistent with asbestos exposure. The 2.5-cm mass at the left base is indicative of rounded atelectasis or a malignancy.

RECOMMENDATION: Recommend pulmonary consultation for consideration of percutaneous needle biopsy.

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Sample Report: Death Summary: Cor Pulmonale

HISTORY: The patient, a 40-year-old male, was admitted through the emergency department after a syncopal episode at his place of employment. He has a history of emphysema and increasing dyspnea on exertion. He reported having intermittent night sweats and episodes of overwhelming fatigue over the past several weeks.

PHYSICAL EXAMINATION: At the time he was seen after admission, his temperature was normal at 98.6, respirations were 27 per minute, and pulse was 98 and regular. Blood pressure was 100/70. Jugular venous pressure was raised to 5 cm above the sternal angle, with prominence of the A waves. A right parasternal heave was present, and there was a loudpulmonic second heart sound. An ejection systolic murmur was heard in the pulmonary area. Pitting edema was present in the lower extremities.

X-RAY AND LABORATORY FINDINGS: Chest x-ray revealed an enlarged right ventricle, with prominent pulmonary conus. There was no obvious lung infiltrate. Pulmonary function tests revealed decreased diffusing lung capacity. There was no evidence of pulmonary embolism on ventilation/perfusion scan. Cross-sectional echocardiogram and Doppler studies revealed a significantly enlarged right atrium and ventricle with a dilated pulmonary artery and severe pericardial effusion.

Left and right cardiac catheterization revealed pulmonary hypertension with reduced cardiac output. There was also mild impairment of the left ventricle.

HOSPITAL COURSE: The patient suddenly became severely hypotensive and was transferred to theCCU for stabilization and monitoring. He received prednisolone, IV cyclophosphamide, captopril, furosemide, and plasmapheresis. He developed deep venous thrombosis for which he received warfarin.

Initially there appeared to be a somewhat overall improvement in his condition; however, on the second day in CCU he experienced cardiac arrest and, despite aggressive efforts, he was unable to be revived.

CAUSE OF DEATH: Cor pulmonale.

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Sample Report: Discharge Summary: Posttraumatic Aortic Pseudoaneurysm

REASON FOR ADMISSION: Posttraumatic chest discomfort.

HISTORY OF PRESENT ILLNESS: The patient is a middle-aged male who enjoyed good health until approximately 3 weeks ago when he was kicked in the area of his right chest by his horse. Following that, he experienced unremitting chest discomfort.

PHYSICAL EXAMINATIONS: His physical examination was within normal limits except for discomfort over the right chest area. See his chart for details of physical findings.

LABORATORY DATA: Laboratory values were all within normal limits.

STUDIES: Chest x-ray revealed a well-defined middle mediastinal mass. On the lateral view, the mass appeared to overlap the aorta. Rib fractures were noted on the right side. CT scan revealed a focal outpouching of the aorta with surrounding thrombus, consistent with an aortic pseudoaneurysm, most likely posttraumatic.

HOSPITAL COURSE: The patient was advised of the findings and that immediate surgical intervention was necessary to avoid possible rupture and even death. 

Aneurysmectomy was performed without complication, and he has done remarkably well following surgery. The patient is discharged on postoperative day 5. He is to rest at home and will be seen in my office in 2 days.

DISCHARGE MEDICATION: Tylenol Extra Strength as needed for discomfort.

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Sample Report: Electrophysiological (EPS) Study

PROCEDURES PERFORMED

1. Comprehensive electrophysiological study.

2. With left atrial recording.

3. Venous access x2.

4. Electrocardiogram x6.

5. Conscious sedation x1 hour.

6. Pulse oximetry.

COMPLICATIONS: None.

INDICATIONS:

1. Coronary artery disease.

2. Congestive heart failure.

3. Ventricular tachycardia.

4. Palpitations.

ANESTHESIA: ASA classification class III. Conscious sedation provided by surgeon. Over a period of 1 hour, a total of 2 mg of IV Versed and 25 mcg of IV fentanyl was given. The patient was under continuous electrocardiographic, hemodynamic, pulse oximetric and clinical evaluation. His level of consciousness was assessed throughout the procedure. At the end of the procedure, he was alert and oriented with no obvious complication from the sedation.

DETAILS OF PROCEDURE: After appropriate informed consent was obtained, the patient was taken to the clinical laboratory in the fasting state. Both groins were prepared in the usual sterile fashion. Local anesthetic was applied to the skin. One 6-French and one 7-French sheath were placed in the right femoral vein. Through these sheaths, a deflectable quadripolar and a deflectable octapolar catheter were advanced to the cardiac chambers. The quadripolar catheter was placed initially in the right ventricular (RV) apex. The octapolar catheter was placed in the coronary sinus. Ventricular pacing was performed. There was no VA conduction at 600 msec. The octapolar catheter was then placed in the atrioventricular (AV) junction. The quadripolar catheter was then placed in the right atrium. Basic intervals were measured. Rapid atrial pacing was performed. The AV node Wenckebach cycle length was 360 msec.

Ventricular stimulation was performed with the quadripolar catheter in the right ventricular apex. The right ventricular apex effective refractory period was 400/240. Ventricular stimulation was performed. Multiple episodes of nonsustained monomorphic ventricular tachycardia, which terminated spontaneously, were documented. The catheters were removed. Hemostasis was achieved. No immediate complications were noted.

FINDINGS:

1. Sinus cycle length 1095 msec; PR interval 183 msec; QRS interval 110 msec; QT interval 439 msec; AH interval 81 msec; HV interval 56 msec. The AV node antegrade Wenckebach was 316 msec. There was no VA conduction at 600 msec.

2. Inducible monomorphic ventricular tachycardia.

3. Significant sinus node dysfunction.

RECOMMENDATIONS: Implantation of a dual-chamber implantable cardioverter-defibrillator.

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Sample Report: EPS Study, Left Atrial Recording, Mapping, and Repeat Simulation

PROCEDURES PERFORMED: Comprehensive electrophysiologic testing, left atrial recording, and repeat stimulation on isoproterenol.

MEDICATIONS: Versed 3 mg, fentanyl 100 mcg, and isoproterenol 5 mcg bolus x2.

INDICATIONS: Palpitations and near syncope and wide-complex tachycardia during exercise testing.

ASA CLASS: II

SEDATION: Conscious sedation was performed for a total of 60 minutes using Versed and fentanyl as described above. Continuous oximetric airway and heart rate monitoring as well as intermittent noninvasive blood pressure monitoring were performed throughout. At the end of the procedure, the patient was awakened from conscious sedation and returned to his room in good condition.

DETAILS OF PROCEDURE: After informed consent was obtained, the right and left femoral areas were prepped and draped in the usual sterile fashion. Then 15 mL of 1% Xylocaine was used for local anesthesia. Using a modified Seldinger technique, 6- and 7-French sheaths were inserted in the right femoral vein. Three 6-French sheaths were inserted in the left femoral vein. Under fluoroscopic guidance, a deflectable quadripolar catheter was placed in the high right atrium, deflectable octapolar was placed in the His bundle, deflectable quadripolar placed in the right ventricular apex, and deflectable decapolar was placed in the coronary sinus. Program stimulation was performed, see results below. Repeat testing was performed with isoproterenol, see results below.

At the end of the procedure, catheters were withdrawn, sheaths removed, and pressure was held tightly until hemostasis was obtained.

FINDINGS:

1. Baseline showed sinus rhythm with sinus cycle length 656, PR interval 234, QRS interval 120, AH interval 98, and HV interval 63.

2. Carotid sinus massage produced no sinus slowing.

3. Antegrade Wenckebach was 470, retrograde there was no PA conduction. AV node-ERP 600/400. Dual AV nodal physiology was not present.

4. There was no block below the His with atrial overdrive pacing.

5. There was no evidence for an accessory pathway.

6. Right ventricular apex ERP 600/240 and 400/230. Repeat testing was performed with isoproterenol with single and double premature atrial contractions as well as burst atrial pacing. Program stimulation was performed in the ventricle with up to quadruple extrastimuli at 3 drive cycle lengths in 2 right ventricular locations without production of arrhythmia.

IMPRESSION:

1. Normal sinus node.

2. Normal atrioventricular node without dual physiology.

3. Moderate His-Purkinje system disease.

4. No inducible ventricular tachycardia.

RECOMMENDATIONS:

1. Would increase Cardizem to 240 mg daily for better blood pressure control.

2. Would check outpatient event monitoring.

3. Would initiate aspirin therapy.

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Sample Report: EPS Study, Left Ventricular Recording, Mapping, and Central Venogram

PROCEDURE: Comprehensive electrophysiologic study with left ventricular recording, mapping of the left ventricle, central venogram.

INDICATION: Congestive heart failure.

MEDICATIONS: Versed 3 mg, fentanyl 50 mcg, and Isovue as directed.

COMPLICATIONS: None.

DETAILS OF PROCEDURE: After informed consent was obtained, the patient was brought into the electrophysiologic laboratory. The patient was prepped and draped in the usual sterile fashion. Over the course of 1 hour, he was given 3 mg of Versed and 50 mcg of fentanyl. He was on continuous pulse oximetry, noninvasive blood pressure measurements, and continuous electrocardiography. His ASA classification is III. He tolerated the procedure well, was awake, alert, and oriented. Repeated measures of respiratory rate and effort, level of sedation and consciousness were maintained throughout the study, as well as hemodynamics.

Using lidocaine, skin overlying the left femoral vessel was locally anesthetized and two 6-French sheaths were placed through the right femoral vein. Deflectable quadripolar catheter was placed in the high right atrium, demonstrating underlying atrial arrhythmia. The patient has underlying complete heart block with a permanent pacemaker and HV interval could not be obtained but the catheters were then moved to the right ventricular apex, and a second catheter was used to engage the coronary sinus. With the coronary sinus engaged, mapping was performed after physically finding the os of various lateral veins. A very posterior lateral branch was found that went to the lateral aspect of the inferolateral wall out to the apex, and a high lateral branch was also found. Intraventricular pacing between left atrial wires and right ventricular wires was used to map activation times, QRS durations, and intraventricular conduction times to assist in placement of biventricular pacing tomorrow. Finally, induction of ventricular arrhythmias was performed and then a long J wire was advanced to the central circulation. A catheter was advanced to the superior vena cava and used to engage the left subclavian vein. This was advanced over the J wire, and the venogram was performed.

FINDINGS:

1. The left subclavian vein was widely patent.

2. A high left ventricular pacing site provides longer intraventricular conduction times and narrower QRS complexes with biventricular pacing versus the large inferolateral vein.

3. Easily inducible ventricular tachycardia seen.

IMPRESSION: Successful mapping of the left ventricle of biventricular pacing, inducible ventricular arrhythmias.

RECOMMENDATIONS: Implantable cardioverter-defibrillator tomorrow.

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