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--- resident:michael_gordon [2022/09/21 17:51] – [Carpal Tunnel Release] haley.d
+++ resident:michael_gordon [2022/12/23 13:52] (current) – [Panniculectomy] haley.d
@@ Line 56: / Line 56: @@
 Operative Report:\\
-Indication:\\
+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. \\
-	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.
+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.
-	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\\
+Tourniquet Time: 36 minutes
 Dr. Gordon was scrubbed in for the entirety of this procedure. \\
@@ Line 714: / 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 ====