Plastics

Operative Report:
1. Right First Dorsal Compartment Release

A sterile forearm tourniquet was placed and the arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.

We began with the right first dorsal compartment release. A 2 cm transverse incision was made just proximal to the radial styloid over the first compartment.  Bipolar electrocautery was used for hemostasis and using blunt dissection with scissors the subcutaneous tissue was dissected longitudinally with care to avoid any injury to neurovascular structures. Extension was then further carried down to the extensor sheaths.  Using a scalpel, an incision was made over the tendon sheath over the distal part of the radial styloid.  Then the tendon sheath was further bluntly dissected to release any underlying structures or tendons underneath the tendon sheath.  The tendon sheath was then opened up proximally and distally, fully releasing the first dorsal compartment. There were no sub-sheaths located within the first compartment.    The wound was then irrigated and hemostasis was excellent. The wounds were closed using a 4-0 nylon locking horizontal mattresses were placed in interrupted fashion and a sterile dressing including a plaster volar splint was placed using a Xeroform, 4 x 8 gauze, Webril, bias wrap.  

Photos

Tourniquet: Sterile forearm tourniquet
Drain: None
Sutures: 4-0 nylon locking horizontal mattress
Dressing: Plaster volar splint was placed using a Xeroform, 4 x 8 gauze, Webril, bias wrap

Anatomy: Makes a transverse incision over the 1st dorsal compartment

Post-operative care:
Volar plaster splint used to rest thumb

Attending Pearls (Learning points/Pimp Questions):
Makes a transverse incision over the 1st dorsal compartment
When releasing the tendon sheath should you cut on the volar or dorsal side? Dorsal to prevent volar subluxation that can result in tendon clicking.
There can be multiple sub-sheaths and it is essential to release them all.

Operative Report 1.ORIF left scaphoid nonunion with autograft harvested from volar distal radius cortex and headless cannulated 3.0mm Synthes screw

The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.

The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.

A volar approach to the wrist was made over the flexor carpi radialis with extension radially at the proximal wrist crease to avoid the palmar cutaneous nerve. The sheath overlying the flexor carpi radialis (FCR) was incised and the tendon was retracted ulnarly. The deep sheath was then incised and the tendons were retracted ulnarly. The joint capsule over the scaphoid was palpated and the position was confirmed by fluoroscopy. The joint capsule/ligaments were incised to reveal the scaphoid non-union. The fracture was opened with the freer and dental pick. Two 0.062 in k-wires were placed as joysticks in the proximal and distal scaphoid fragments. The nonunion was excised using the dental pick, rongeur and osteotome to fresh bone edges.

Attention was turned to the volar distal radius. Pronator quadratus was elevated. A 0.045“ K wire was used to outline the graft in the volar cortex of the distal radius metaphysis. An osteotome was then used to excise the bone graft. Curette was then used to obtain more cancellous autograft. The graft was set aside. Cancellous bone chips were packed into the donor defect site and the pronator quadratus was repaired with 4-0 vicryl sutures.

Attention was returned to the scaphoid. Copious irrigation was performed to ensure that all edges of the proximal and distal aspect of the scaphoid as well as the cancellous portion of the scaphoid was completely debrided. The scaphoid was reduced using the k-wire joysticks, opening the humpback deformity. A guidewire for the 3.0mm Synthes cannulated headless screw was then placed from distal through the distal portion of the scaphoid, across the defect, into the proximal end. Fluoroscopy was used to confirm placement. A Kocher clamp was used to hold the joysticks in reduction. The guidwire was then withdrawn into the distal portion. The autograft from the distal radius was then packed into portion of the scaphoid nonunion, starting with the cancellous bone and then wedging in the corticocancellous graft. This was packed with a combination of a Freer as well as a tamp and gentle mallet.

The guidewire was then advanced to the proximal scaphoid. Position of the guidewire was confirmed with fluoroscopy, and then a second de-rotational guidewire was placed. The guidewire was measured and was overdrilled and a 22mm 3.0mm Synthes headless compression screw was placed over the guidewire. This was carefully advanced and some compression was applied, taking care to not extrude the graft. Fluoroscopy confirmed good placement of the screw down the axis of the scaphoid and the guidewires and joy-stick k-wires removed.

The joint capsule was closed with 3-0 vicryl sutures. At this point the tourniquet was let down and hemostasis was obtained. The incision was irrigated. The skin was closed with 4-0 nylon horizontal mattress sutures. The incision was dressed with xeroforom, 4×8 gauze and cast padding followed by a thumb spica splint.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: - discharge to home with some pain medication; elevate; NWB L arm.
- F/U hand clinic 10-14 days for suture removal and thumb spica cast placement.
- Cast x 6 weeks and then remove for re-evaluation.

Learning points/Pimp Questions:

The patient was taken to the operating suite and was placed supine on the operating table. Then the surgical site identification was performed and the left index, middle and ring fingers were correctly identified as the correct sites. Everybody in the operating room including nurses, anesthesiologist, as well as surgeon and surgical assistant agreed with both patient identification and site identification.

After adequate anesthetic was given by the anesthesiology team, 4 cc of 1:1 mixture of 1% lidocaine and 0.25% bupivacaine was injected subcutaneously above the A1 pulley of the three identified digits. The left upper extremity was then prepped and draped in the standard sterile manner. A sterile tourniquet was applied on the forearm. Esmarch was used to exsanguinate the arm and the tourniquet was inflated to 250 mmHg.

A 2cm incision was placed in-line with the distal palmar flexion crease over the A1 pulley of the left index finger and a combination of sharp and blunt dissection was performed down to the A1 pulley. The radial and ulnar neurovascular bundles were protected during the duration of the procedure. Then the A1 pulley of the left index finger was divided sharply with a Beaver blade. Full release was achieved in this manner. The flexor tendons were inspected and visualized to be gliding smoothly without bunching or clicking.

This approach was repeated to release the A1 pulleys of the middle and ring finger as well, again with careful dissection down to the A1 pulley, protection of the nerves on either side, and division of the complete A1 pulley. Then the three surgical incisions were copiously irrigated with normal saline and the tourrniquet was released. Then the surgical incisions was closed with interrupted horizontal stitches of 4/0 nylons. Finally, a soft sterile dressing was applied. All counts verified at the end of the case.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report
1. Open decompression of right ulnar nerve at elbow, in situ (right cubital tunnel release)

The patient was transported to Operating Room #4 and remained supine on the gurney with a hand table. A pre-anesthesia time-out was performed. The patient was administered general anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The surgical field was prepped and draped in the usual sterile fashion with a sterile tourniquet on the proximal upper arm. A final time-out was performed.

The planned incision was marked between the medial epicondyle and olecranon, extending 4 cm proximal and 4 cm distal. The limb was exsanguinated with an Esmarch bandage and the tourniquet was inflated to 250 mmHg. The incision was made sharply with a 15 blade scalpel. Dissection was carried down to the subcutaneous tissue and any superficial veins were addressed with bipolar cautery. The medial antebrachial cutaneous nerve was identified and protected. The ulnar nerve was identified just lateral to the medial epicondyle. The intermuscular septum was entered and retracted and the ulnar nerve was dissected free proximally by dividing the septum and the arcade of Struthers. The septum was excised.

The dissection was then turned distally The fibroaponeurotic coverings and cubital tunnel retinaculum were divided. The dissection proceeded through the fascia of the two heads of the flexor carpi ulnaris muscle. The area was palpated and we confirmed that the ulnar nerve was free from compression with minimal traction. Range of motion of the elbow indicated no subluxation of the nerve over the medial epicondyle. The tourniquet was deflated and hemostasis was obtained. The arm and hand appeared well perfused.The incision was irrigated with normal saline.

10 ml of 0.25% bupivicaine was injected at the incision site. The skin was closed with buried interrupted deep dermal 3-0 Monocryl suture and a running subcuticular 4-0 Monocryl. The wound was dressed with Xeroform and a bulky soft tissue dressing of gauze, Webril, and bias.

The patient was awaken from anesthesia and transferred to PACU in good condition.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Soft bulky dressing on the elbow to remain in place until follow up. Discharge home. Follow up in Hand Clinic for incision check/dressing removal; gradual increase back to normal activity/weight bearing.

Learning points/Pimp Questions:

Operative Report

The patient's right wrist was marked preoperatively. The patient was brought to the operating room. She remained on the stretcher. Her right upper extremity was placed on a hand table. A surgical pause was performed in accordance with hospital regulations. Preoperative antibiotics were given. Anesthesia was administered in the usual fashion. The right upper extremity was prepped and draped in the usual sterile fashion and a sterile tourniquet was placed on the upper arm.

The side and site were confirmed and procedure once again. The arm was elevated and exsanguinated using the Esmarch bandage and the tourniquet was inflated at 250 mmHg. The dorsal incision in line with Lister's tubercle extended distally to 2.5 cm over the wrist. This was incised with a 15 blade.

Careful dissection was performed down avoiding the veins and the nerves to the extensor retinaculum. This was incised over the third compartment and the EPL tendon was retracted. Once released, we then made a capsular incision longitudinally over the proximal scaphoid. This was incised with a 15 blade and tenotomy scissors were used to complete it, taking care to not injure the carpal bones or SLIL beneath. The wrist joint did not show any signs of acute trauma and it did show what appeared to be a chronic nonunion of the proximal pole. The proximal piece was in mostly 1 piece and the fracture site was identified and inspected. The intraoperative fluoroscopy was used to examine this. The alignment was appropriate. A dental pick was used to remove the fibrous tissue from either end of the scaphoid fracture. Due to the chronic nature of this, we did elect to do a bone graft for this fracture and we used an osteotome to carefully elevate Lister's tubercle at its base. A curette was used to remove cancellous bone grafting bone graft from the distal radius and this was placed in a cup. We turned our attention back to the scaphoid where we placed the bone graft into the defect. We then flexed the wrist and chose a 0.8 mm K-wire and this was advanced through the proximal piece down through the central axis of the scaphoid. Intraoperative fluoroscopy in multiple views confirmed placement of this wire. We measured at about 22 to 23 mm and then we advanced the K-wire distally into the trapezium. We selected an 18 mm screw. We had used the 1.6 mm cannulated drill to drill over the wire through the proximal piece and partially into the distal scaphoid. The screw 18 mm in length was then advanced over the wire across the fracture site and into the scaphoid. We achieved compression as noted on the fluoroscopy as well as clinically. We used the fluoroscopy to confirm adequate placement of the screw.
The wire was released. The head was confirmed to be buried underneath the cartilage cap of the scaphoid proximal pole. Confirmed the bone graft was still in place and then we took representative final images. We irrigated the wrist joint and then closed the capsule using a 5-0 PDS suture. We then irrigated once again and repaired with the interrupted 5-0 PDS at again the extensor retinaculum the EPL was not transposed and remained at its native spot. There was plenty of room with the extensor retinacular repair and we then used a 4-0 Monocryl for deep dermal and running skin closure of the incision. Xeroform, 4 x 8s, Webril and a thumb spica splint were placed for the patient.

Tourniquet: finger / forearm / arm
Drain: Yes/No
Sutures:
Dressing:

Resident Notes:
Approach dorsally for proximal pole injuries.
3-4 approach through extensor compartments.
Before boring, advance the wire through the trapezium.
Two screws are better than one if you can fit them.
Consider a de-torsion wire before placing the screw.
Avoid injuring the SLIL ligament – a pimp question.
Repair the capsule, repair lister's tubercle if you take bone craft, +/- transposing EPL.

Post-operative care: Ibuprofen/APAP/Oxy
Transition to thumb spica cast in 2 weeks
Cast for 3 months

Operative Report:
The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
 
The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.
 
The laceration was extended with two oblique incisions in order to gain more proximal access to the ulnar nerve and more distal access to the flexor tendons as they were entering the carpal tunnel. The wound was explored and the flexor tendons to the index finger was intact as well as the median nerve. The more ulnar sided structures had obvious injuries. Flexor carpi radialis has a 5% partial laceration. Flexor digitorum superficialis (FDS) of the long finger was lacerated, but the flexor digitorum profundus (FDP) was intact. The ring and small fingers had both FDS and FDP lacerated. The ulnar nerve was lacerated distal to takeoff of the dorsal sensory branch. Flexor carpi ulnaris was lacerated. The wrist and fingers were flexed in order to provide a tensionless repair of the tendons, nerves and artery.
 
The injuries were repaired from the radial to ulnar. The proximal muscle belly and tendon of FDS of the long finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair.
 
The microscope was brought into the room and the distal and proximal ulnar neurovascular bundles were identified and the artery and nerve ends were bluntly dissected. The distal and proximal ends of the ulnar artery were clamed and the repaired with 9-0 nylon sutures in a 0-180 fashion repair. At this point, 2 hours had past and the tourniquet was released. The clamps were removed and there was pulsatile flow through the artery. Next, we turned our attention to the ulnar nerve. The nerve was lacerated distal to the branching of the dorsal sensory branch. Both the ulnar nerve and dorsal sensory branch were identified and bluntly dissected under the microscope. The ulnar nerve was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap. Next, the dorsal sensory branch was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap.
 
Finally, the microscope was removed and flexor carpi ulnaris proximal and distal tendons were identified and the ends bluntly dissected free. Flexor carpi ulnaris was repaired with a 3-0 supramid using a modified kessler 4 strand repair followed by a figure of 8 repair with a 4-0 fiberwire. The incision was closed with 4-0 nylon simple interrupted sutures. Xeroform, 8×8 were applied followed by a dorsal extension blocking splint with the wrist and the fingers in flexion.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:
Note about wrist flexors. Since the cross the elbow, the elbow should be immobilized as well in 90 degrees when you make the splint.
FDS flexors go through the carpal tunnel like spiderman.

Operative Report:
1. Trapeziectomy with ligament reconstruction and tendon interposition
2. Partial trapezoid excision

Consent: possible injury to the nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion and all questions were answered to the patient's satisfaction prior to completing the consent.

Operative Procedure: The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.

The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. A Wagner longitudinal incision at the junction of the glabrous skin was made over the carpometacarpal joint, curving at the proximal wrist and stopping at the crossing of the flexor carpi radialis tendon. The incision was completed down to the subcutaneous tissue. The dorsal radial sensory nerve and its branches were identified and protected. The extensor pollicis brevis tendon and abductor pollicis longus tendon were identified and retracted radially. The joint space between the first metacarpal and the trapezium was identified using the c-arm and a subperiosteal longitudinal capsulotomy was made over the joint. Full-thickness flaps were raised using mixture of blunt and sharp dissection with scissors. The capsular incision extended for visualization of the base of the first metacarpal and full trapezium and part of the scapho-trapezial-trapezoid joint. Position was confirmed using a mini C-arm. Care was taken to preserve the capsule to facilitate later reattachment. The trapezium was then dissected circumferentially. A K-wire pin was then driven into the trapezium to use as a joystick handle to further help with retraction and movement to further facilitate fully dissecting free the trapezium. The FCR tendon at the base of the CMC joint was identified and care was taken to avoid injury to the tendon. The trapezium was removed piecemeal using the rongeur with careful attention not to injure the FCR tendon lying in the volar groove of the bone. The trapezoid was evaluated and appeared denuded of cartilage. An osteotomy was made to remove the articulating surface with scaphoid.

The flexor carpi radialis position was marked about 10 cm from the proximal wrist crease. A 2 cm transverse incision was made and using the scissors with blunt dissection through the subcutaneous tissues, the FCR tendon was visualized. Using a freer, dissection was carried over the FCR tendon superficially and deep to it, freeing it up as much as possible from the forearm incision as well as from the Wagner incision moving proximally along the FCR. The musculotendinous junction was identified, and the tendon was lifted into the incision using a right-angle clamp. The FCR was then transected. Then at the base of the FCR tendon, the FCR was pulled distally into the trapezial bed. The proximal forearm incision was closed with a 4-0 nylon suture.

Using a burr drill bit, the volar aspect of the base of the thumb metacarpal was burred down to cortical bone. Then a position onto the more dorsal aspect of the thumb base, the position for the Mitek anchor suture was chosen and predrilled. Then two #2-0 mini-Mitek anchor were placed into the thumb metacarpal base. The FCR tendon was then pulled into its new anatomic position, and the suture of the Mitek anchor was then passed through the FCR tendon and tied. The remaining FCR tendon was then rolled up into an anchovy using 3-0 vicryl sutures.

The capsule edges were re-approximated with 3-0 vicryl sutures. The tourniquet was deflated and hemostasis was obtained and the incision irrigated. The incision was closed with 4-0 nylon simple and horizontal mattress sutures. The incision was dressed with xeroform, 4×8 gauze and a thumb spica splint was applied.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

There are many ways to perform the suspension of the 1st metacarpal, although there is no clear data to show that it is truly vital. The most important part is the thumb spica for 6 weeks-3 months for it to heal.

When to perform APL/EPB tenodesis? To prevent hyperextension of the MCP joint.

Operative Report:
  The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. An 8 cm incision was made over the flexor carpi radialis flexor tendon. The incision was continued down to the FCR sheath and the bipolar was used to achieve hemostasis of small vessels. The FCR sheath was incised and the FCR tendon retracted. The radial artery was identified and retracted radially. The antebrachial fascia was incised. Next, the pronator quadratus fascia was sharply incised in an “L” shape and elevated from radial to ulnar. The fracture line was identified and the periosteum elevated.
 
The fracture was freed with the dental pick and the freer elevator. The fracture still had some mobility.  Once all the fragments were free, the mini fluoroscopy was brought in and the fracture reduced with traction and dorsal pressure; we confirmed the reduction with multiple views. The regular Acumed volar distal radius plate was chosen as the best size match. The plate was secured with proximal (vs. distal) k-wires and fluoroscopy was used to confirm placement; the distal radial screw was placed using a locking screw.
 
We then turned our attention to the shaft and placed the oblong screw, keeping this a bit loose, and removed the K wires. The radial styloid fragment was then reduced further, and another K wire was used to hold the ulnar two fragments. We then placed the ulnar distal locking screw followed by the remaining distal row, and then the distal most radial styloid screw.
 
We reduced the fragments to achieve more volar tilt and tightened the shaft screw, and then placed two more shaft screws.  Final fluoroscopy images were taken confirming reduction and plate placement.
 
The pronator quadratus fascia was closed with 4-0 vicryl, achieving almost complete plate coverage.  The skin was closed with 4-0 nylon locking horizontal mattress sutures. Xeroform was placed over the incision and a volar resting splint was placed with the MCP joints free.

The incision was irrigated and then closed with 4-0 nylon locking horizontal mattress sutures. The incision was dressed with xeroform and a soft dressing of 4×4 gauze, webril and a volar resting splint. The tourniquet was released and normal perfusion returned to the hand.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:
The patient was taken to the the operating room and secured and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
 
Local anesthesia of 6 ccs of 50:50 1% lidocaine and 0.25% marcaine was injected into the volar wrist in line with the 3rd webspace. A tourniquet was placed sterilely and the forearm and hand were exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.
 
A 2 cm incision was made over the volar wrist in line with the 3rd webspace. The fat overlying the superficial palmar fascia was excised with the scapel. Retractors were used to visualize the superficial palmar fascia and we encountered origins of the thenar musculature. The superficial palmar fascia was excised ulnar to the muscle insertions. At the level of the transverse carpal ligament, we also encountered hypothernar musculature origins. Retractors were placed deeper into the incision and the transverse carpal ligament (TCL) was excised with the beaver blade to reveal the median nerve. Ragnell scissors were used to spread above the TCL distally and a freer elevator was used to free the nerve off the TCL. Then the TCL was cut until a small fat pad was visualized and the nerve was released. Next we turned our attention to the proximal aspect of the TCL. We again spread with the ragnell scissors above the TCL and freed the nerve from the TCL with the freer. The TCL was cut with the ragnell scissors and then slid through the antebrachial fascia to release the median nerve.The tourniquet was deflated to reveal the median nerve with constriction and hyperemia.

Technical Steps Will do Lalonde approach in clinic. Only change is to include epi in the local instead of a tourniquet.
1. Inject local
2. Prep and place tourniquet sterilly on forarm if in OR.
3. Rolled blue towels under wrist.
4. Mark approximately 2 cm incision and incise with 15 blade.
5. Go through subcuatneous tissue with 15 blade.
6. Dissect with Ragnell scissors. She will retract with 2 Ragnells and a sharp Sen.
7. Once TCL exposed, sharply incise with beaver blade or 15 blade.
8. Go distally until you reach the distal fat.
9. Incise proximally with beaver blade or 15 blade and then spread above and below with ragnell scissors (not to wide as you only need a tunnel for your scissors). This is so you can ensure the next step is done under direct vision.
10. Slide ragnell scissors proximally. This is a translation of the scissor. The scissor tips are curved and the tip goes straight proximally while your hand is off to the side and you translate it forward.
11. Ensure complete release with the freer.
12. Close with 4-0 nylon. She prefers locked horizontal mattress sutures.

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Postoperative Care Soft dressing
APAP/Ibuprofen
No Narcotics

Learning points/Pimp Questions: Has been known to ask brachial plexus questions to interns and medical students during carpal tunnel release. Make sure you can draw it out and especially explain where the median nerve comes from.

Operative Report:
The patient was identified in the preoperative care area where informed consent was reviewed with the patients. The surgical site was marked, all of their questions were answered and concerns were addressed. The patient was brought back to the operating room by the anesthesia staff. All pressure points were well padded. A surgical time-out was performed per protocol, and appropriate perioperative antibiotics were administered prior to the start of the procedure. General anesthesia was then obtained. A nonsterile tourniquet was placed on the right upper extremity, which was then prepped and draped in a standard sterile fashion.

An incision was made over the right fifth metacarpal in a longitudinal incision. Bipolar electrocautery was used to cauterize any of the small subcutaneous vessels. Using a Littler scissors, dissection was carried down to the fascia, taking care to protect and move to the side the extensor tendons and sensory nerves. An incision was made over the dorsal periosteum of the fifth metacarpal, and the freer was used to elevate the periosteum and expose the fracture. This was performed proximally and distally on the fifth metacarpal to give us enough room for reduction and plating of the fracture. The bone callus was debrided using a rongeur. The fracture was able to be reduced, and a reduction clamp was placed to hold it. The reduction was confirmed using the mini fluoroscopy and and a Synthes 1.5 mm T-shaped plate was chosen. The most distal ulnar screw hole was cut off to better conform to the metacarpal head, creating an L-shaped plate. The size and shape was confirmed to be appropriate.

An olive threaded K wire was used to secure one end of the plate, and the second hole on the other end was drilled and then the appropriate length was determined for bicortical screw, which was placed with good purchase. A second distal screw was placed, angling appropriately in the head of the metacarpal. Orthogonal views were taken to confirm length and placement. Then two proximal shaft screws were placed, and then the olive wire was removed and a third proximal screw was placed.

A fourth proximal screw was then placed through the plate, followed by a third distal screw. Because of the shape of the fracture, a 1.5mm single dorsal radial lag screw by technique was then placed to further support the construct, and the two middle holes in the plate were left open.

The incision was irrigated. Using a 4-0 Vicryl, the periosteum was closed in interrupted fashion. A 4-0 Monocryl was used for deep dermal sutures in an interrupted fashion and then using a 4-0 Monocryl, the skin was closed with a running subcuticular stitch. Steristrips were applied. 10 mL of 0.25% Marcaine was instilled into the incision. A volar resting splint was applied. The tourniquet was released and normal perfusion returned to the hand and fingers.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Postoperative Plan:
- He will be discharged home when he meets PACU criteria.
- Follow up in Hand Clinic as scheduled
- 24 Hours of Keflex post-op
- NWB RUE

Learning points/Pimp Questions:

Operative Report:
1. Abdominally-based random pattern skin flap, 10 cm by 10 cm, for coverage of right dorsal hand shearing degloving injury. \\  
Care of the patient was assumed from Dr. Ipaktchi and the Ortho Hand team following revision amputation of the right index finger and fillet of finger flap to resurface the dorsal aspects of the long finger and remaining index finger. The wound now measured 10 cm by 8 cm to the dorsal hand with some exposure of the bases of the proximal phalanges of the index and long fingers.
 
We began by templating the defect onto a piece of Esmarch bandage as a random-pattern inferiorly-based “omega” flap. The template was transferred to the abdomen at the right lower quadrant and the proposed flap marked out for an inferiorly-based random pattern flap. The template was oriented so as to facilitate a relaxed position of the hand onto the abdomen. The length of the flap was increased by 2 cm so as to reach the superior margin of the flap to the radial aspect of the hand defect without undue tension. 4 cm lateral limbs were marked at the base to facilitate closure of the donor site.
 
The superior, medial, and lateral flap margins were incised with a 10-blade scalpel. Dissection was carried through the subcutaneous tissues using Bovie electrocautery. The flap was raised from superior to inferior. Laterally where the tissue was thinner, dissection was carried above the external oblique fascia. Medially where the tissue was thicker, dissection was carried below the superficial fascial system, leaving some fat down on the abdominal wall. Adequate hemostasis was obtained.
 
After first ensuring that the flap was of adequate width and length to resurface the right dorsal hand, we began closure of the donor site. The subcutaneous tissue was undermined for several centimeters in each direction for mobilization. The superior corners of the defect were closed with 3-0 Vicryl for the SFS and simple interrupted 3-0 Nylon sutures for approximately 5 cm each. The inferolateral edges were brought together and closed for approximately 4 cm using 3-0 Nylon suture. This left a triangular-shaped defect centrally at the donor site measuring 4 cm by 4 cm.
 
The flap was then inset to the dorsal hand using simple interrupted 3-0 Nylon suture, with the lateral, superior, and medial edges of the flap well approximated to the proximal, radial, and distal aspects of the dorsal hand, respectively.
 
The incision sites were dressed with bacitracin ointment. The triangular-shaped defect was dressed with wet-to-dry 4×4 gauze. The raw surface of the flap at the base was dressed with wet-to-dry 4×4 gauze. A split ABD pad was placed over the abdomen and under the hand. The hand was wrapped in Burn gauze and Kerlix.
 
The forearm and upper arm abrasions were dressed with bacitracin ointment, Xeroform, and Kerlix.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care:
- Return to ward. Pediatrics primary.
- Non-weight bearing RUE.
- Ancef x 24 hours post-operatively.
- Abdominal binder at all times to keep hand in place.
- Okay to gently range at elbow and shoulder, keeping hand in place.
- NO flap checks necessary.
- Plan for dressing change in OR with Dr. Ipaktchi on Monday, 7/20/20. Otherwise no dressing changes. Okay to re-inforce with 4×4 gauze or ABD pads, gently tucking at inferior aspect, if needed.
- Ultimately will follow up with Hand/Plastics as outpatient with plan for flap division at 3-4 weeks.
- Plastics to continue to follow.

Learning points/Pimp Questions:

Operative Report:
1. Total Submuscular Tissue Expander Placement

In the preoperative area, consent was acquired, and the patient's midline and bilateral inframammary folds were marked in the upright position. The patient was then brought to the operating room and placed in supine position. A time out was performed confirming correct patient, procedure, and site, and the patient received 2g of Ancef prior to induction of general anesthesia. The patient was then prepped and draped in the usual sterile fashion. A bilateral skin-sparing mastectomy and left sentinel lymph node biopsy was completed by Dr. Jaiswal; please see her separate operative note for details on the portion of the procedure.

Following completion of the mastectomy, the reconstruction portion of the case commenced. A left subpectoral pocket was created. The pectoralis major muscle was released and the inferior and lateral portion of the pocket was raised beneath the serratus anterior muscle creating a inferolateral muscle flap and rectus abdominus fascia elevated inferiorly.

This was repeated on the right side, with the same pectoralis and serratus anterior and rectus fascia flaps were elevated.

The pockets were copiously irrigated with normal saline and hemostasis was ensured. The base diameter was measured intra-operatively and confirmed to accommodate a 12 cm base width tissue expander bilaterally. A 15 french round blake drain was placed at this time and secured, exiting inferolaterally in each side.

The pockets were again irrigated with normal saline, and hemostasis again confirmed. They were then copiously irrigated with antibiotic containing normal saline. The skin and subpectoral pocket were cleansed with diluted betadine and gloves were changed. Using a minimal-touch technique, the above tissue expanders were placed into the subpectoral submuscular pockets. They were secured in place with 2-0 PDS suture through 4 of the 6 tabs. The pectoralis and serratus flaps were subsequently approximated using interrupted 3-0 vicryl sutures.

The skin at the incisions of the NSM were closed with 3-0 monocryl interrupted deep dermal sutures and a subcuticular running suture of 4-0 monocryl. The skin incisions were then covered in surgical skin glue. The patient tolerated the procedure well and without complication. She was transferred to the postoperative care unit if stable condition. All needle and sponge counts were correct at the end of the case.

Photos

Tourniquet: finger / forearm / arm
Drain: 15 french round blake drain x2
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:
The patient was marked in the preoperative holding area. The new position of the nipple areolar complex was marked and correlated to the level of the inframammary fold along the breast meridians and a Wise pattern was delineated. The patient was then transported to the operating room and placed in supine position. All bony prominences were padded. SCD boots were placed. Perioperative antibiotics were given. General endotracheal anesthesia was administered. A proper timeout was taken, in which all present parties were in agreement. The patient was prepped and draped in the usual sterile fashion.

The markings were then re-delineated. The nipple-areolar complex was inscribed with a 42 mm cookie cutter and a scalpel was used to incise around the epidermis of the nipple-areolar complex. The inferior pedicle was also delineated and incised, and the inferior pedicle was de epithelialized. The remaining incisions were then created, on the medial and lateral breast a dermoglandular wedge excisions were created, taking care not to narrow the base of the inferior pedicle. The nipple-areolar complex was maintained on a dermoglandular inferior pedicle of its tissue. The chest wall attachments were maintained to the pedicle, in order to include the intercostal and chest wall perforating vessels. The perfusion of the nipple-areolar complex was assessed, based on arterial and venous bleeding from the cut edges. The upper breast skin flaps were undermined to the pectoral surface. These upper skin flaps were contoured by excision of additional fat and parenchyma to better contour the breast. These skin flaps were about 2 cm thick and well perfused. This was repeated for the contralateral breast. Preliminary weight of the breast tissue excised and sent to pathology for final weights, The left breast was 300 gm and the right breast weighed 522 gm. The surgical field was then irrigated with an antibiotic solution. Hemostasis was achieved using electrocautery Bovie. The skin was temporarily closed with staples and the patient was then placed in sitting position to assess breast symmetry. The breast symmetry was good. The incisions were reopened. The field was inspected for hemostasis and irrigated with a sterile saline. The inferior pedicle and nipple-areolar complex were inspected for bleeding and tissue viability and appeared to be viable. The pedicle was oriented and had tacking sutures placed with 3-0 PDS to better align the nipple areolar complex to the proposed markings of the new areola on either side. The skin was realigned with staples. A half buried mattress was placed at the T-Junction of each breast using a 2-0 Nylon. Deep dermal sutures were placed using a 3-0 monocryl in simple interrupted fashion.The inferior incision was closed with a running 3-0 V-Loc. 3-0 Monocryl was used on the vertical limb. The patient was sat up again to assess nipple-areolar complex placement. A cookie cutter was used to delineate the site of the new nipple-areolar complex. Nipple position was in correct anatomical position and was anatomically pleasing, with approximately 6cm from nipple to IMF and 4cm from bottom of areola to IMF. 42mm cookie cutter was used. The patient was placed supine again. A scalpel was used to de-epithelialize the area of the new NAC and the dermis was incised in a cruciate fashion. The nipple-areolar complex was exteriorized on each side and sutured in place with interrupted 3-0 Monocryl sutures, followed by a running 4-0 subcuticular Monocryl suture. The vertical incision was closed with 3-0 deep dermal sutures, followed by 4-0 running subcuticular Monocryl suture. This was also performed for the contralateral breast. Exofin was placed over the IMF incisions, followed by steris and telfa tegaderm on the NAC, and we placed a surgical bra with fluff. The patient tolerated the procedure well.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:
The patient was seen in the preoperative holding area. The procedure and risks, as listed above, and benefits were again discussed in detail. Preoperative markings were made with the patient in erect position. The planned incision, implant type, location and approximate size were again confirmed with the patient, who understood and agreed with the operative plan. The patient was then taken to the operative suite and placed in supine position. All bony prominences were padded. SCD boots were placed. Arms were placed in 90 degrees of abduction. Perioperative antibiotics were given. A proper timeout was taken, which all present parties were in agreement. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion.

Breasts were dissected simultaneously. An incision was made in the inframammary fold, approximately 6cm inferior from the nipple about 5 cm in length. A plane above the pectoralis muscle was dissected using electrocautery and blunt dissection. This was carried around medially, superiorly and laterally to the preoperative markings of the breast base. Visual and manual inspection of the pocket was performed to ensure a smooth contour, as well as hemostasis. The pocket was irrigated with saline and a 285 mL breast implant sizer was placed into the newly created pocket. This was deemed too large for her frame and a 225ml sizer was placed. This appeared more appropriate to the size the appearance the patient had indicated she wanted. The incisions were temporarily closed with staples and on visual inspection, the sizer seemed to be in a good position and was anatomically pleasing. Final corrections were performed to correct any asymmetry or under-dissection. The patient's incisions were then opened again and hemostasis ensured. The pocket was irrigated with triple antibiotic and the area around the incision re-prepped with betadine and fresh towels. Every instrument from this point on was dipped in betadine prior to being placed in the cavity. The silicone prosthesis was then opened and bathed in antibiotic solution. The implant was confirmed to be the correct one selected and then inserted into the pre-pectoral space in a minimal touch technique using a funnel. The inferior mammary fold was re-established using 3-0 PDS. The wounds were then closed using interrupted fascial 3-0 PDS, deep dermal interrupted 3-0 Monocryl and a running 4-0 Monocryl. The incisions were then dressed with Steri-Strips followed by Telfa and Tegaderm. Large foam tape was used to secure the breast in appropriate position. Final dressing consisted of a surgical compression bra, which was placed on the patient. The patient was turned over to the anesthesia team and was awakened easily. Overall the patient tolerated the procedure well.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report

The patient was taken to the the operating room and following patient and procedure confirmation, anesthesia was started. A pre-operative time-out was performed for our portion of the procedure, confirming site, laterality, patient and procedure to be performed. The patient was then re-prepped and draped.

Nipple reconstruction was performed using C-V flaps that were marked pre-operatively with the patient standing. The procedure as below, was performed for each breast. An incision was made using a 15-blade along the C-V flap marking. The flap was elevated using a knife. The V components of the flap were then turned inward to create the projected portion of the nipple. These were secured in place using 5-0 Chromic. The C component of the flap was then turned downward to construct the roof of the new nipple. This was secured using 5-0 Chromic suture.

The limbs of the nipple incisions were dressed with steri-strips and Exofin. Bacitracin was applied to each nipple projection. Once the Exofin was dry, nipple guards were secured in place using 4×4 gauze and Tegederms.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:

The patient was marked in the pre-operative area and the patient was brought back to the operative suite, placed in supine position.  All bony prominences were padded.  SCD boots were placed. Perioperative antibiotics were given.  A proper timeout was taken, which all present parties were in agreement.  The preoperative markings were reinforced and remarked.   The surgery started with removing each nipple/areola complex, a 25 mm diameter cookie cutter was used to mark the new areola. It was then elevated as a full thickness skin graft. Both the right and left NACs were placed in saline moistened gauze in small containers and saved for use later in the case.  Hemostasis was achieved at these sites. An incision was made along the superior markings of the breasts. Using electrocautery a flap was then raised in the subcutaneous plane superficial to the breast parenchyma leaving adequate subcutaneous fat to perfuse the skin flaps. Next, the breasts were undermined to the inframammary folds. A demarcator was used to mark the inferior incision. The inferior incision was made sharply and using electrocautery, the subcutaneous tissues were dissected down to the pectoralis fascia and the breast was removed.   Then each side was copiously irrigated with warm saline and complete hemostasis was achieved using electrocautery Bovie.  A 15 french round Blake drain was placed in each wound bed and exited out in the inferior outer portion of the chest wall, they were secured with a 3-0 nylon. The incision was then temporarily closed with skin staples which demonstrated that there was a tensionless closure. The patient was sat up on the flexed bed to confirm symmetry and to choose the appropriate placement for the nipple graft. Using the 25 mm cookie cutter, the new positions of the nipples were marked along the lateral edge of the pectoralis muscle and at the level of the 4th intercostal space.  The circle were created into horizontal ellipses measuring 2.5cm x 1 cm and were then deepithelialized with a 15 blade on each side.  The nipple areolar complex grafts were defatted with the iris scissor and using an 11 blade they were pie crusted. They were then placed onto the bleeding dermal beds. They were inset using 5-0 chromic sutures circumferentially.   The deep tissue was approximated with 3-0 PDS suture. Deep dermals were placed with 3-0 monocryl stures. Lastly the subcutaneous tissue was closed using a running 3-0 V-Loc.      Bolsters were formed from xeroform, mineral oil soaked cotton, and sutured into place with 3-0 Silk, and placed over each nipple graft.   Exofin glue was placed on the inferior incision. A Biopatch was placed at each drain site. Telfa and tegaderm were used to cover the bolster. A compression garment was placed on the patient's chest.   All counts were correct. Dr. Malliaris was present for the entirety of the case.  The patient had pectoralis nerve block performed by anesthesia. The patient was then subsequently extubated and brought to the PACU in stable condition and was discharged home with outpatient followup.  

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-Operative Plan: PACU discharge Compression vest Okay to remove outer dressings in 2 days and shower Keep bolster in place

Learning points/Pimp Questions:

Operative Report:
1. Irrigation of left lower extremity wound
2. Excisional debridement of skin and subcutaneous tissue of left lower extremity wound using scissors/adson forceps and bovie electrocautery 15x15cm + 20x4cm total area of debridement.
3. Application of Acell micromatrix powder and 3-layer wound matrix covering wound 1225 cm squared.
4. Application of negative pressure wound therapy, 1225 cm squared.

INDICATIONS FOR PROCEDURE: The patient is a 24 year old woman with traumatic left lower extremity Morel-Lavallee lesion that has undergone prior washouts and debridements with the trauma surgery team. Plastic Surgery was consulted to assist in closure given the extent of the wound. Based on the size, we recommended application of Acell. The details of the procedure including risks and benefits were discussed with the patient. She voiced understanding and agreed with the plan. Written and verbal consent was obtained.

DESCRIPTION OF PROCEDURE: The patient was transported to Operating Room #4 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered general anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The left leg was elevated using a candy cane. The wound vac was removed in its entirety. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed.

The wound was sharply debrided of necrotic subcutaneous tissue including fat at the anterior medial aspect of the distal thigh and skin/subcutaneous tissue at the anterior lateral aspect of the proximal lower leg. The areas of excisional debridement were 15x15cm and 20x4cm, respectively. Adson forceps/scissors as well as bovie electrocautery were used for the excisional debridement. The remainder of the wound was mechanically debrided with a laparotomy pad and with the back end of the forceps. The wound was thoroughly irrigated with 3L and adequate hemostasis was obtained. Three 15 French round fluted Blake drains were placed under the skin flaps– two at the superior aspect, medially and laterally, and one at the inferior aspect. The drains were sutured in place with 2-0 Nylon and attached to drainage bulbs. There was undermining at the lateral aspect of the wound superiorly and inferiorly. The skin flaps were tacked down to the wound bed with 3-0 Vicryl sutures. The wound in its entirety now measured 1225 sq cm.

At this time, Acell micromatrix powder was mixed with normal saline into a paste. The paste was applied to the entire wound bed, ensuring application into the undermined areas as well. The Acell wound matrix sheets were laid over the paste and stapled in place. Adaptic was then laid over the Acell sheets and also stapled in place. Black sponge negative pressure wound therapy was applied to the wound with two “lily pad” suction sites attached with a Y-connector to the vac device. Adequate seal was noted on 125 mmHg suction. The drain sites were dressed with BioPatches and Tegederm.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions: