Differences

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--- resident:david_khechoyan [2021/07/19 17:13] – taylor
+++ resident:david_khechoyan [2022/12/22 07:22] (current) – taylor
@@ Line 15: / Line 15: @@
 General Tips:\\
-\\
+Dr. Khechoyan likes to prep the patient himself. He is methodical about muscle dissection and a believer in anatomic subunits.\\
+Will place mayfield himself.\\
+Has a particular way of draping the head drape. Will likely drape himself.\\
+Pleasant days where he will do a lot of teaching and you will do a lot of first assist.\\
 ====Pediatric Plastic Surgery and Craniofacial Plastic Surgery - Post Operative Home Care Instructions====
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 At the end of the operation, all sponge and needle counts were correct. The patient tolerated the operation well. The patient's care was then turned over to the Anesthesia team. The patient emerged from the anesthetic uneventfully and was transported to the recovery room in stable condition.
+Resident:\\
+Marking instructions: Fisher repair. Marks alar rim stopping at the mid alar point. Next marks nasal-cheek junction and stops at subalare. These two points make a line and allow placement of the nasal sill mark. This is an intersection with a bowtie semicircular line with the columellar midline and side points. Transposes these marks to the lateral side. Draws cupid bow points. Now you can measure the total lip height (TLH usually around 8), and greater lip height (GLH usually around 6). Subtract these and rose thompson effect to get the lesser lip height (LLH). Note that this is the base of the triangle. Make the backcut perpindecular to the GLH line.\\
 ====Cleft Lip Instructions Patient Family====
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 </WRAP>
+====Sagittal strip craniectomy with biparietal morcellation====
+<WRAP group>
+<WRAP half column>
+The patient and the patient's family were met in the pre-operative area.
+The surgical site was marked with the surgeon's initials.
+The risks, benefits, details, and alternatives of the operation were discussed in detail. All questions were answered. The informed consent for surgery was signed by parent/guardian.
+The patient was brought into the operating room and laid supine on the operating room table. General anesthesia was induced by the Anesthesiology provider. A pre-operative intravenous dose of antibiotics was administered.
+A time-out was performed during which we identified the operation and the operative site. All team members introduced themselves. All issues and concerns were discussed and resolved before proceeding with the operation.
+The eyes were protected with Tegaderm tapes.
+A bicoronal sinusoidal incision was designed from ear to ear and infiltrated with local anesthetic; local anesthetic, 0.25% bupivacaine with 1:200,000 epinephrine, was infiltrated into the proposed surgical site(s), with appropriate weight-based dosing. The hair around the incision was minimally shaved.
+The surgical site was prepared and draped in a sterile fashion.
+The incision was made with a 15-blade and monopolar cautery down through the galea; wide, bidirectional sub-galeal undermining and scalp mobilization was performed to expose the cranium from frontal to occipital bones. The sagittal suture was noted to be fused; the metopic, bilateral coronal and lamboid sutures were noted to be open.
+Three pairs of parasagittal burr holes were made along the planned parasagittal cuts from the anterior fontanelle to the lambda.
+A 3-cm strip craniectomy centered over the fused sagittal suture was then performed from anterior fontanelle to the lambda, after burr holes were made and the dissection proceeded across the midline and bone was removed across the midline with Kerrison rongeurs; there were no dural tears, and the patient remained hemodynamically stable.
+As bilateral frontal cranioplasty and remodeling, a caudally-based barrel stave (approximately 2 cm in width) straddling the open RIGHT coronal suture was cut with a craniotome, dissected off the dura, out-fractured as a green-stick fracture with a Tonsil clamp, and contoured into the appropriate more rounded shape with a Tessier elevator.
+Then, a caudally-based barrel stave (approximately 2 cm in width) straddling the open LEFT coronal suture was cut with a craniotome, dissected off the dura, out-fractured as a green-stick fracture with a Tonsil clamp, and contoured into the appropriate more rounded shape with a Tessier elevator.
+Then, bilateral, extensive parietal morcellation cuts were designed and then cut with a craniotome in a brick-type pattern, spanning an expanse of 6.5 to 7.0 cm from parasagittal edge of the sagittal craniectomy to the superior temporal crest, with two bone graft (flaps) caudally and three bone graft (flaps) toward the midline. These extensive bone grafts were retained with their attachment to dura and secured in placed with a Surgicel. This was done on the right side first, and then the left side.
+A 7-French flat Jackson-Pratt drain was placed through the RIGHT occiput.
+Copious irrigation was applied with at least 1 liter of normal saline; hemostasis was noted. The scalp was then closed in layers, with 3-0 Vicryl for the galea layer, followed by a running 4-0 Monocryl suture on the surface; bacitracin was applied to the incision.
+Please note that Modifier 22 applies to all components of this operation as significantly increased operative time and technical effort were required to safely achieve all steps of this operation. This was primarily because of thicker bone in the bilateral parietal and frontal regions, which rendered every part of the operation more challenging, including, but not limited to, making burr holes, craniotomy cuts, and reshaping of the barrel staves, among other steps. These circumstances and findings justifies the application of Modifier 22.
+At the end of the operation, all sponge and needle counts were confirmed to be correct.
+The patient tolerated the operation well.
+The patient's care was then turned over to the Anesthesia team.
+The patient emerged from the anesthetic uneventfully and was transported to the recovery room in stable condition.
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+***
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