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--- resident:michael_gordon [2021/08/02 18:50] – [Distal Phalanx Amputation] jonathan
+++ resident:michael_gordon [2022/12/23 13:52] (current) – [Panniculectomy] haley.d
@@ Line 49: / Line 49: @@
 . blue towel wrapped around arm help by penetrating towel clamp\\
 .  long sheet over patient - held in place by 4 non penetrating towel clamps\\
+====Trigger Finger====
+<WRAP Group>
+<WRAP half column>
+Operative Report:\\
+Indication: This is a 69 year old male who previously presented to clinic with trigger fingers of the right long and ring fingers that was severe and caused the patient significant discomfort. Excision of A1 pulleys of the ring and long fingers was recommended. The risks of the procedure including pain, bleeding, infection, wound healing complications, injury to nearby structures, persistent pain, stiffness, need for hand therapy, and need for other procedures we explained to the patient. The patient was in agreement with the plan and provided informed consent. \\
+Report:
+The patient was marked in the pre-operative area, and then brought to OR #4. A timeout was performed, and the patient was placed under sedation anesthesia. Lidocaine was locally infiltrated into the surgical site, and the patient was prepped and draped in sterile fashion.
+A second timeout was performed confirming correct patient and surgical site, and the patient’s extremity was exsanguinated and tourniquet inflated to 250mmHg. First attention was turned to the ring finger. A longitudinal incision was made over the palmar aspect of the metacarpal head, directly over the A1 pulley. Litler scissors were used to carefully dissect down to the flexor tendon. The proximal end of the A1 pulley was identified and incised ulnarly and radially using Litlers to fully excise the A1 pulley and the proximal portion of A2. This was passed off the table. The finger was ranged and demonstrated no further triggering.
+Next, attention was turned to the long finger. A longitudinal incision was made over the palmar aspect of the metacarpal head, directly over the A1 pulley. Litler scissors were used to carefully dissect down to the flexor tendon. The proximal end of the A1 pulley was identified and incised ulnarly and radially using Litlers to fully excise the A1 pulley and the proximal portion of A2. The pulley was examined and appeared thickened. The underlying tendon demonstrated moderate fraying. The pulley was passed off the table, and the finger was ranged. The long finger did not stick, but demonstrated stiffer joint motion. Finally, both incisions were closed with 5-0 Nylon and dressed with Xeroform, wet gauze, dry gauze, Kerlix bandage, and an Ace wrap. All final instrument and sponge counts were correct.
+Tourniquet Time: 36 minutes
+Dr. Gordon was scrubbed in for the entirety of this procedure. \\
+</WRAP>
+</WRAP>
 ====Carpal Tunnel Release====
@@ Line 74: / Line 94: @@
 Technical Steps:\\
 -He will mark the incision.\\
--Uses Knife to cut until fat is seen, 2 ski hooks\\
+-Uses Knife to cut until fat is seen, 2 skin hooks\\
 -Bovie and smooth pickup to buzz vessels\\
 -then he uses ragnels and sens and you use litler scissors to dissect down to transverse carpal ligament.\\
@@ Line 118: / Line 138: @@
 . Right trapeziectomy with ligamentous reconstruction.\\
-After instillation of a supraclavicular block, the patient had his right hand and arm prepped and draped.  Preoperative skin markings were designed as a 3 cm oblique incision along the dorsal radial aspect of the base of the 1st metacarpal as well as a 1 cm transverse skin incision over the volar wrist crease directly over the FCR tendon.  The hand and arm were then exsanguinated with the Ace wrap, and the tourniquet on the upper arm was inflated to 250 mmHg.  Scalpel was then used to incise along the marked lines at the level of the dorsal aspect of the 1st metacarpal, going down through the skin into subcutaneous tissues.  After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was deepened until identification of superficial branches of the radial nerve could be visualized, which were then carefully retracted to the side, and dissection was performed around them.  The EPB and APL tendon sheaths were identified, and the capsule over the dorsal aspect of the trapezium was incised with a scalpel from the trapeziometacarpal joint to the scaphotrapezial joint.  Using the small Freer elevator and the small Joseph elevator, elevation of the periosteal layer on the trapezium was then performed, going both volarly and dorsally.  The trapezium was rocked carefully back and forth in an effort to free up as many of the attachments as possible and after achieving good mobility of the trapezium, the volar incision was made along the marked lines.  Again, after achieving hemostasis in the subcutaneous plane with use of electrocautery, the incision was carefully deepened down to identification of the FCR tendon.  The FCR tendon was then dissected distally, and the sheath overlying the tendon was divided going up into the palm.  The sheath was divided to the point where the FCR tendon could be removed out of the groove of the trapezium.  Returning then to the incision at the base of the 1st metacarpal dorsally, the trapezium was then further rocked back and forth until all ligamentous attachments had been divided, and the trapezium was removed.  There was severe disease at the trapeziometacarpal joint with lesser disease of the scaphoid and the trapezoid joints.  The bone was then sent to pathology for gross evaluation only.  The FCR tendon could be seen in the base of the wound at the base of the 1st metacarpal, and the FCR tendon was divided, leaving a tail of about 2 to 3 cm still attached to the base of the 2nd metacarpal.  A G2 Mitek drill bit was then used to drill into the central base of the 1st metacarpal, and then a G2 Mitek anchor with 2 additional sutures of 2-0 FiberWire was then placed into the base of the 1st metacarpal.  The thumb was then placed back on traction with 10 pounds, and the FCR tendon was brought from the distal connection to the base of the 2nd metacarpal over to the base of the 1st metacarpal, and then tied into position with horizontal mattress sutures of the 3 sutures in the G2 Mitek anchor.  The wound was then checked for hemostasis, and then closure of both incisions was accomplished with interrupted 5-0 nylon sutures in the skin.  Dressings consisting of Xeroform, wet gauze, dry gauze, Kerlix bandage, followed by application of a 4-inch plaster thumb spica wraparound splint to the patient's hand.  Tourniquet was then released after a total of 108 minutes of inflation time.
+After instillation of a supraclavicular block in the pre-operative area, the patient was brought to OR #4. A timeout was performed, and the patient was placed under general anesthesia. Pre-operative clindamycin was administered within 30 minutes of incision, and the patient was prepped and draped in sterile fashion.
+ Preoperative skin markings were designed as a 3 cm oblique incision along the dorsal radial aspect of the base of the 1st metacarpal. The hand and arm were then exsanguinated with the Ace wrap and finger tourniquet, and the tourniquet on the upper arm was inflated to 250 mmHg. The thumb was placed on 10 pounds of traction using a finger trap. Next, a scalpel was used to incise through the skin into subcutaneous tissues. After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was deepened using Litler scissors until EPB and APL tendon sheaths were identified, and the capsule over the dorsal aspect of the trapezium was incised with a scalpel from the trapeziometacarpal joint to the scaphotrapezial joint. Using the small Freer elevator and the small Joseph elevator, the trapezium was freed from its attachments taking care not to injure the neighboring carpal cartilage. The trapezium was rocked carefully back and forth until free, and was passed off the table en bloc. There was severe disease at the trapeziometacarpal joint with lesser disease of the scaphoid and the trapezoid joints.
+Next, the FCR tendon could be seen in the base of the wound, and the FCR tendon was sharply divided proximally, leaving a tail of about 2 to 3 cm still attached to the base of the 2nd metacarpal. A G2 Mitek drill bit was then used to drill into the central base of the 1st metacarpal, and then a G2 Mitek anchor with 2 additional sutures of 2-0 FiberWire was then placed into the base of the 1st metacarpal. The distal FCR tendon still attached to the 2nd metacarpal was then tied into position with horizontal mattress sutures of the 3 sutures in the G2 Mitek anchor. The wound was then checked for hemostasis, and the closure was accomplished with interrupted 5-0 nylon sutures in the skin. Dressings consisting of Xeroform, wet gauze, dry gauze, Kerlix bandage, followed by application of a 4-inch plaster thumb spica wraparound splint to the patient's hand. All final instrument and sponge counts were correct.
 </WRAP>
@@ Line 128: / Line 150: @@
 **DOES NOT USE C-ARM**
-Tourniquet: finger / forearm / arm\\
+Pre-operative block: Supraclavicular\\
-Drain: Type of drain and placement\\
+Tourniquet: upper arm, sterile\\
 Sutures: List all layers\\
 Dressing: What's preferred?\\
-Anatomy: Pertinent anatomy should be listed\\
+Anatomy: Dorsal sensory branch of radial nerve, EPB/APL (1st extensor compartment), FCR, trapezium and its articular surfaces\\
 Post-operative care: Include restrictions, splints, etc...\\
 Learning points/Pimp Questions:\\
+  * Will ask you to identify the articulations. The big saddle joint articulates with the metacarpal. Note the articulation with the second metacarpal as well. The others are of course the articulations with the trapezoid and the scaphoid.\\
 Special equipment: Bone anchor\\
 Sutures: 2-0 fiber wire for tendon reconstruction, 5-0 nylon for skin closure\\
 Notes: Removes trapezium whole. (ie. does not use rongeur unless a piece breaks)\\
-Will ask you to identify the articulations. The big saddle joint articulates with the metacarpal. Note the articulation with the second metacarpal as well. The others are of course the articulations with the trapezoid and the scaphoid.\\
 Sends trapezium for gross only pathology.\\
 {{url>https://www.youtube.com/embed/glldA0RXIDg}}
@@ Line 375: / Line 398: @@
 Operative Report:\\
-.  ORIF of left perilunate dislocation with repair of left scapholunate and lunotriquetral ligaments, bone anchors and K-wires
+.  ORIF of left perilunate dislocation with repair of left scapholunate and lunotriquetral ligaments, bone anchors and K-wires\\
 .  Left posterior interosseous nerve neurectomy\\
 \\
@@ Line 389: / Line 412: @@
 Photos\\
+{{:resident:256_2017_2676_fig3_html.png?600|}}
 Tourniquet: arm with finger traps (20 lbs weight)\\
@@ Line 397: / Line 421: @@
 Anatomy: Dorsal wrist (3rd dorsal extensor compartment and proximal carpus)\\
-Post-operative care: NWB to affected extremity; volar resting \\
+Post-operative care: NWB to affected extremity; volar based splint with MCPs free. \\
-Attending Pearls (Learning points/Pimp Questions):Know sequence of SLAC wrist\\
+Attending Pearls (Learning points/Pimp Questions):\\
+The posterior interosseous nerve can be found deep to 4th dorsal compartment. When exsanguinated, the vein can sometimes be easily visualized first.\\
+\\
+A chronic SL tear will lead do a DISI deformity where the scaphoid is flex and the lunate is extended.\\
+\\
+The sequence of a SLAC wrist occurs in a predictable pattern:\\
+Stage I: Arthritis between scaphoid and radial styloid\\
+Stage II: Arthritis between scaphoid and entire scaphoid facet of the radius\\
+Stage III: Arthritis between capitate and lunate\\
+\\
 </WRAP>
@@ Line 422: / Line 455: @@
 Photos\\
+{{:resident:screen_shot_2021-08-02_at_5.24.50_pm.png?600|}}
 Tourniquet: finger\\
@@ Line 428: / Line 462: @@
 Dressing: Xeroform, wet gauze, dry gauze, 2inch kling with Alumafoam splint for the DIP joint, Ace everything over that\\
-Anatomy: Extensor anatomy\\
+Anatomy:
+The proximal interphalangeal (PIP) joint and distal interphalangeal (DIP) joint configurations are quite similar.\\
+\\
+The condylar heads are biconvex but slightly asymmetric, being about twice as wide volarly as dorsally.\\
+\\
+The reciprocal bases of the distal segment are biconcave, having a central ridge.\\
+\\
+The volar plate extends from the neck of the phalanx to the volar base of the more distal phalanx, preventing joint hyperextension.\\
+\\
+Radial and ulnar collateral ligaments provide additional joint stability. The “true” collateral ligaments have bony attachments at both ends, whereas the accessory collateral ligaments extend from the condylar head to the volar plate.\\
+\\
+The axis of rotation and radius of curvature for a given interphalangeal joint are fairly constant. Consequently, the true collateral ligaments are effectively isometric, whereas the accessory collateral ligaments resist lateral translation when the joint is extended.\\
+\\
+As a result of the ligamentous and bony architecture, the PIP and DIP joints normally function as highly constrained hinge joints.\\
+\\
+The extensor tendon crosses the DIP joint dorsally as the terminal tendon, inserting slightly distal to the dorsal base of the distal phalanx.\\
+\\
+The germinal matrix of the nail bed is close to the terminal tendon insertion (average of 1.3 mm distal).\\
+\\
+The flexor digitorum profundus (FDP) tendon inserts broadly on the volar aspect of the distal phalanx, extending from the base to the midshaft.\\
+\\
+Over the PIP joint, the extensor apparatus splits into thirds. Contributions from the extensor tendon, the interosseous tendons, and lumbricals form the central slip, which inserts onto the dorsal base of the middle phalanx. The lateral bands travel past the PIP joint along the lateral margins and then combine to form the terminal tendon distally.\\
+\\
+The flexor digitorum superficialis (FDS) tendon splits to insert on the volar lateral margins of the proximal shaft of the middle phalanx.\\
-Post-operative care: NWB finger; no motion\\
+Post-operative care: For DIP joint arthrodesis, protection with a simple aluminum splint is sufficient. PIP motion is encouraged. Splinting may be unnecessary if a fusion screw is used. Radiographs are taken at 6 weeks postoperatively. Buried pins may be removed once the fusion is radiographically solid (at least 8 weeks postoperatively).\\
+Attending Pearls (Learning points/Pimp Questions): \\
+The fusion position varies with the digit and joint involved. Invariably, the decision is a compromise between appearance and function. The ideal posture should replicate the normal digital cascade.\\
+\\
+In general, the DIP joints and thumb interphalangeal joint should be fused in 0 to 10 degrees of flexion.\\
+\\
+For the PIP joint, some authors recommend a uniform 40-degree flexion position for all digits, whereas others recommend 40 degrees for the index finger, progressing ulnarward in 5-degree increments to 55 degrees in the small finger. Many prefer a slightly more extended position for the index PIP that will still allow functional tip-to-tip pinch.\\
+\\
+The recommended fusion angle of the MCP joints is a cascade from 25 degrees of flexion in the index digit, progressing ulnarward in 5-degree increments to 40 degrees in the small finger.15\\
+\\
+The recommended fusion angle of the MCP joint of the thumb is 10 to 15 degrees of flexion and just resting at the radial border of the index finger mid-distal phalanx.\\
-Attending Pearls (Learning points/Pimp Questions): Know the angles for arthrodesis in each digit for DIP 2nd and 3rd digit fused in extension
+{{:resident:screen_shot_2021-08-02_at_5.25.55_pm.png?600|}}
-th and 5th digit fused in 10-20° flexion\\
 </WRAP>
@@ Line 454: / Line 522: @@
 Photos\\
-Tourniquet: arm\\
+Tourniquet: upper arm\\
 Drain: none\\
 Sutures: 5-0 nylon sutures (interrupted for skin)\\
@@ Line 460: / Line 528: @@
 Anatomy: Flexor tendon anatomy and anatomy of the pulleys\\
+The ring finger involved in 75% of cases. During grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients and therefore ring finger exposed to greater average force than other fingers during the pull-away motion.
-Post-operative care: NWB; minimal ROM\\
+Post-operative care: NWB; ROM at 6 weeks\\
-Attending Pearls (Learning points/Pimp Questions): Understand the anatomy of the pulleys\\
+Attending Pearls (Learning points/Pimp Questions):
+{{:resident:ch38_table_text_01.jpeg?600|}}
+Mallet fingers are the extensor equivalent, but it is the central slip instead of the tendon itself that is attaching to the distal phalanx.
+\\
 </WRAP>
@@ Line 639: / Line 712: @@
 </WRAP>
 </WRAP>
+====Breast Reduction====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Reduction Mammaplasty\\
+\\
+The patient was taken to the operating room, and positioned on the surgical table. After a timeout confirming the correct patient and surgical procedure was conducted, general anesthesia was started. The patient was prepped and draped in standard fashion. \\
+A 38 mm cookie cutter was used to mark out the nipple areola complexes bilaterally. Next an approximately 10cm wide inferior pedicle on both breasts was marked and de-epithelialized using a knife.  The pedicles were then dissected down to the chest wall using electrocautery, taking care not to undermine the pedicle. Once the pedicles were established, the remainder of the wise-pattern incisions were incised using a knife. Electrocautery was used to establish superior breast flaps of about 2cm thickness. The excess medial and lateral breast skin and breast parenchyma were passed off the table. All left and right breast specimens were sent separately to pathology. The breasts were then temporarily closed with 2-0 Vicryl, and the patient was sat up to assess symmetry and cosmesis. The right breast was slightly larger than the left, and the left breast had remaining axillary standing cone deformity. The areas requiring additional resection were marked, and the patient was returned to supine position. Electrocautery was then used to excise additional lateral breast tissue from the left breast and remove additional breast tissue from the right breast. Again, the breasts were temporarily closed with 2-0 Vicryl, and the patient was sat up. At this point, the breasts had good size symmetry and shape. The amount of resected specimens were 311 grams on the left breast and 467 grams on the right breast. The patient was returned to supine, and temporary sutures were removed. The breasts were copiously hemostased using electrocautery. 3-0 PDS was then used to anchor superficial fascia to chest wall to reinforce the lateral breast shape bilaterally. A round Blake 15F drain was placed in each breast pocket and secured with 3-0 Nylon. The breasts were then closed with 2-0 Vicryl and 4-0 Monocryl. \\
+At this point, the new NAC location was marked 6cm above the inferior incision with the 38mm cookie cutter bilaterally. This area of skin was removed using scissors and hemostased with electrocautery. The NAC was then inset with 5-0 Vicryl and 5-0 Fast-absorbing gut. The incisions were then dressed with Benzoin, steri-strips, and Tegaderms. The nipples were dressed with steri-strips, Telfa, sponge, and Tegaderm. \\
+All final sponge and instrument counts were correct. The patient was extubated, placed in a surgical bra, and transferred to recovery without issue. \\
+Dr. Gordon was present for the entirety of this procedure. \\
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Two 15-French Blake drains\\
+Sutures: 2-0 Vicryl, 4-0 Mono, 3-0 PDS, 5-0 Vicryl, 5-0 fast-gut\\
+Dressing:  Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision sites. Scrub sponge cut into 38mm NAC with 38mm Telfa between NAC and sponge. Cut hole in center of both for nip.  Biopatch and Tegaderm dressings were placed on the drains.\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Learning points/Pimp Questions:\\
+</WRAP>
+</WRAP>
 ==== Lipoma Resection ====