PREOPERATIVE DIAGNOSIS: End-stage renal disease.

POSTOPERATIVE DIAGNOSIS: End-stage renal disease.

PROCEDURES PERFORMED:
1.  Attempt at right internal jugular vein aspiration.
2.  Left internal jugular venogram.
3.  Placement of left internal jugular hemodialysis catheter under fluoroscopic guidance.

SURGEON:  John Doe, MD

ANESTHESIA:  Local MAC.

COMPLICATIONS:  None.

DISPOSITION:  The patient tolerated the procedure well, stable to floor.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old woman who has had approximately two years of dialysis catheters. The most recent catheter had been placed in March. She presented with a bout of sepsis. The catheter fell out on its own, and her blood cultures now have been positive for 48 hours. It has been recommended that she have a new catheter access placed. It has also been recommended that she consider long-term dialysis access as well. Risks, indications, and techniques of catheter insertion were discussed. The patient understood and was agreeable.

PROCEDURE FINDINGS:
1.  Unable to thread wire into the right internal jugular vein and aspiration of the right internal jugular vein was difficult. Multiple attempts were made in aspirating this vein.
2.  Tortuous course of the left internal jugular vein.
3.  Left internal jugular venogram showed reflux into an anomalous vein; however, there was direct flow into the superior vena cava with the vein being widely patent. Postoperative chest x-ray pending.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and was identified as the patient. She was then placed supine on the operating room table, and LMA anesthesia was induced. She was prepped and draped in the normal sterile fashion using a PCMX prep. Multiple attempts at aspiration of the right internal jugular vein were made. The artery was inadvertently aspirated on two occasions and then eventually the jugular vein was able to be aspirated. However, a wire was unable to be threaded beyond 1-2 cm and continued to coil.

Therefore, conversion was made to a left-sided approach. Multiple attempts were made, but the vein was difficult to aspirate. Therefore, ultrasound guidance was utilized to aspirate the vein. The vein was identified and aspirated directly. The wire was placed. The wire anatomy was noted to be quite tortuous and the wire continuously wanted to thread into an anomalous vein. A 16 gauge Angiocath was then placed over the wire. Venogram was performed. A guidewire was then utilized to select the appropriate vein and course. The tract was then serially dilated, and the wire was exchanged back out for a J wire. The tract was serially dilated. Dilator and sheath were placed over the wire and the dilating wire withdrawn. The catheter was placed through the peel-away sheath and this was peeled away.

The position of the catheter was determined under fluoroscopy to be appropriate. Exiting site in the chest wall was determined. Tract was anesthetized. Catheter was tunneled appropriately. Both tracts were aspirated for blood and flushed without difficulty. The area was inspected. Hemostasis was adequately achieved with the use of pressure. A 4-0 Vicryl subcuticular stitch was used to repair the J wire site. A 4-0 Vicryl pursestring stitch was placed around the catheter and then this was sutured to the catheter. Appropriate dressings were applied. Postoperative chest x-ray was obtained. Results are pending at this time. The patient was transferred to the floor in stable condition.

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REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Severe peripheral vascular disease with ulceration of bilateral lower extremities.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male, well known to this facility, who has a history of right lower extremity fem-pop bypass as well as amputation of the toe secondary to peripheral vascular disease. He does have significant history of diabetes, hypertension, dyslipidemia, and also has a history of coronary artery disease. The patient was seen in the office yesterday where it was found that he had significant necrosis of his left toes, including significant amount of purulence and malodorous discharge. The patient also has a significant nonhealing ulcer to the left heel involving skin and much of the soft tissue as well as the heel pad. This also has a malodorous discharge as well as being purulent and boggy in nature. The patient also has a significant nonhealing ulcer to the right heel, which shows possible evidence of deep tissue penetration and possible osteomyelitis. It was discussed with the patient and the patient’s daughter that he will most likely benefit from above-the-knee amputation on bilateral lower extremities secondary to the fact that he is not ambulatory and the fact that his peripheral vascular status significantly limits his ability of healing further amputations.

PAST MEDICAL HISTORY:  Significant for coronary artery disease, peripheral vascular disease, amputation, history of diabetes, hypertension, dyslipidemia, as well as end-stage renal disease.

PAST SURGICAL HISTORY:  Significant for coronary artery bypass grafting, right lower extremity femoral popliteal bypass, amputation of toes, creation of right arm AV fistula.

ALLERGIES:  NKDA.

HOME MEDICATIONS:  Include Coumadin, Toprol, Zocor, Glucotrol, Trental, and aspirin.

SOCIAL HISTORY:  The patient does have a significant history of smoking, however, quit approximately 30 years ago. No history of alcohol or drug abuse. The patient is currently a nursing home resident due to significant physical limitations as well as mental status changes recently.

FAMILY HISTORY:  The patient denies any history of end-stage renal disease or peripheral vascular disease.

REVIEW OF SYSTEMS:  Fourteen-point review of systems was performed. Pertinent positives as above in the HPI. The patient currently denies any chest pain, shortness of breath, difficulty breathing, orthopnea or PND. The patient denies any abdominal pain, nausea, vomiting, diarrhea, constipation or blood in the stool. The patient denies any hematuria or dysuria. The patient denies any unexpected weight loss, weight gain or other significant changes.

PHYSICAL EXAMINATION:  The patient’s current vital signs are temperature 98.2, respirations 18, blood pressure 98/60, and pulse rate of 120. The patient is chronically ill appearing, however, in no acute distress. Normocephalic and atraumatic. Extraocular muscles are intact. Pupils are equal and reactive. The patient does have poor dentition, however, no evidence of any oral lesions or pharyngitis present. Neck is soft and supple. The patient has easily palpable bilateral carotid pulses. No evidence of carotid bruits on auscultation. The patient is currently in atrial fibrillation with rapid ventricular rate approximately of 122 as confirmed by electrocardiogram. There are no murmurs or rubs appreciated. Lungs are clear to auscultation bilaterally. No evidence of any wheezing, rales or rhonchi present. The patient does have equal and symmetric chest wall expansion. Abdomen is protuberant; however, soft and nontender. No evidence of any organomegaly or abdominal masses appreciated on physical examination. On lower extremities, the patient has 2+ bilateral femoral pulses. No appreciable popliteal, dorsalis pedis or posterior tibialis pulses on lower extremities. As mentioned in the history of present illness, the patient does have significant necrosis to the toes of the left lower extremity as well as significant nonhealing ulcer to his left foot. Both the ulcer and the necrotic toes demonstrate significant purulence as well as significant erythema involving the soft tissues. The right lower extremity demonstrates a circular nonhealing lesion on the lateral aspect of the right heel. Again, there is significant amount of erythema present as well as some slight purulence with significant evidence of nonhealing ulceration. The patient does have a significant amount of erythema involving the bilateral lower extremities, left greater than right, primarily involving the anterior aspect. The patient’s upper extremities have easily palpable brachial and radial pulses. He does have an AV fistula in the right arm, which has been recently accessed by dialysis. On neurologic examination, the patient is alert, however, is not currently oriented to person or place. This is the patient’s normal status, according to his daughter, in the recent weeks with no significant changes noted.

IMPRESSION AND PLAN:
1.  Severe peripheral vascular disease with necrosis and ulceration of bilateral lower extremities. The patient would benefit significantly from bilateral above-the-knee amputations secondary to the fact that the significance of his peripheral vascular disease will greatly inhibit any healing for further amputations. Also the fact that the patient is nonambulatory at this time and will unlikely become ambulatory in the future precludes the need for consideration of a lower limb prosthesis. These options were discussed with the daughter as well as significant risks associated with surgery, including risk of infection, pneumonia, acute myocardial infarction, stroke, and possible death. All these risks again were discussed with the patient and the patient’s daughter. The patient’s daughter expressed understanding of all these and wished to proceed.
2.  Coronary artery disease. The patient is currently being evaluated for suitability for surgery; however, it is not felt that the patient’s coronary status will anyway affect the decision to proceed with surgery.

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PREOPERATIVE DIAGNOSIS:  Nonhealing diabetic foot ulcer on the left fifth metatarsal.

POSTOPERATIVE DIAGNOSIS:  Nonhealing diabetic foot ulcer on the left fifth metatarsal.

OPERATION PERFORMED:  Debridement of left foot ulcer with amputation of fifth metatarsal.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

SPECIMENS REMOVED:  Left fifth metatarsal and necrotic skin and subcutaneous tissue.

INDICATIONS FOR OPERATION:  The patient has had a previous left fifth digit ray amputation. She presents with a chronic nonhealing ulcer to the lateral aspect of her left foot with exposed fifth metatarsal with documented osteomyelitis. The patient has a superficial heel ulcer as well as a small superficial ulcer of the metatarsal head of the left great toe. The patient has been on multiple antibiotics and has failed to heal these lesions. She has been taken to the operating room today for debridement and amputation of the fifth metatarsal.

DESCRIPTION OF OPERATION:  After informed consent was obtained and all risks and benefits had been discussed with the patient and the patient’s family, preoperative preparations were made, and the patient was brought to the operating room where she was placed supine on the operating table. General endotracheal anesthesia was administered per Anesthesia, and the patient was intubated without difficulty. The patient was given 1 gram of IV Ancef.

The left foot was circumferentially prepped from the knee down and then sterilely draped with sterile towels and sterile drapes in the usual surgical fashion. A time-out was then performed by the operative team confirming that the patient was present in the room for debridement of a left foot ulcer with fifth metatarsal amputation. A #10 blade was then used to make a circumferential incision around the foot ulcer to include a small rim of normal skin down to the bone of the fifth metatarsal. Bovie electrocautery was used to continue dissection through the subcutaneous tissue and underlying tendons down to the fifth metatarsal. The skin and soft tissue was then excised using Bovie electrocautery and passed off the table. Hemostasis was then obtained using Bovie electrocautery.

Bone cutter was then used to transect the proximal and distal ends of the fifth metatarsal, and the fifth metatarsal was amputated at the cuneiform articulation and passed off the table. Rongeurs were then used to remove the remaining bone fragments. After the dissection was completed, the cuboid bone along with the lateral portion of the third cuneiform was exposed. The remaining distal aspect of the fifth metatarsal was removed using the rongeurs. Good hemostasis was obtained using Bovie electrocautery. All necrotic subcutaneous tissue, fat, muscle and tendon were debrided.

The wound was then pulsavac’d using 3 liters of normal saline mixed with bacitracin. The wound was then inspected. The wound was very clean. Hemostasis was once again obtained using Bovie electrocautery. The wound was then packed using a wet Kerlix covered with dry gauze and wrapped with Kerlix and secured in place using an Ace wrap. The patient tolerated the procedure well and without difficulties. The patient was extubated in the operating room in good condition and transferred to the PACU. There were no complications. The patient received 250 mL of crystalloid in the operating room. Estimated blood loss was less than 50 mL.

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PREOPERATIVE DIAGNOSIS:  Infected left axillofemoral bypass, defunctionalized.

POSTOPERATIVE DIAGNOSIS:  Infected left axillofemoral bypass, defunctionalized.

OPERATION PERFORMED:  Excision of infected left axillofemoral bypass.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General, orotracheal intubation.

DRAINS:  None.

SPECIMENS:  Swab to microbiology. Graft to microbiology.

INDICATIONS FOR OPERATION:  This is a patient with aortoiliac arterial occlusive disease who has undergone an aortobifemoral bypass in the distant past. The patient at some point underwent a femorofemoral bypass and a left axillofemoral bypass. The patient then presented with a draining sinus in his left groin and eventually underwent a redo aortobipopliteal bypass via the obturator foramen. The patient is approximately three years out from that procedure. The patient presented with erythema and drainage from his left flank over the previously defunctionalized left axillofemoral bypass.

DESCRIPTION OF OPERATION:  The patient was placed supine with the left flank slightly elevated. A large Tegaderm was placed over the draining purulent wounds in the left flank. The left upper extremity, chest, left flank, and lateral abdomen were then prepped and draped in the usual aseptic fashion. Ioban was placed over the previous left axillary incision site.

The patient’s previous left infraclavicular incision was opened. The fibers of the pectoralis major muscle were split. The pectoralis minor was retracted laterally. The thrombosed left axillofemoral graft was identified. The graft was clamped. The graft was not filled with blood, suggesting a more proximal occlusion. The graft was transected. The distal aspect of the graft was advanced down the tunnel. The stump of the graft was oversewn with 3-0 Prolene suture in the standard fashion. The wound was irrigated. The wound was closed in layers using 2-0 and 3-0 Vicryl sutures. The skin was closed with staples. A dry sterile dressing was applied and covered with an occlusive adhesive dressing. This area was then covered with a towel.

The left flank was exposed. The previously placed Tegaderm was removed, and the area was prepped with ChloraPrep. A longitudinal incision was made connecting the draining sinuses. A DeBakey aortic clamp was advanced through the tunnel, and the tract was opened longitudinally. The distal end of the graft had previously been transected. The graft was removed. A swab of the area was sent for microbiology. A portion of the graft was sent to microbiology. The tract was irrigated and examined for hemostasis. The tract was scraped, removing loose granulation tissue. The area was treated with a pulsed irrigation system. The wound was packed with dry gauze. The patient tolerated the procedure well. There were no apparent complications.

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PREOPERATIVE DIAGNOSIS:  Left femorotibial vein bypass stenosis.

POSTOPERATIVE DIAGNOSIS:  Left femorotibial vein bypass stenosis.

OPERATION PERFORMED:  Revision of left femorotibial bypass with patch angioplasty.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General, orotracheal intubation.

DRAINS:  None.

SPECIMENS:  None.

DESCRIPTION OF OPERATION:  The patient was placed supine. The abdomen, both groins, and left lower extremity were prepped and draped in the usual aseptic fashion. A longitudinal incision was made in the left groin. The common femoral artery was identified at the level of the inguinal ligament. The dissection was continued distally. The patient was systemically heparinized. The profunda femoris was identified and dissected free from the surrounding tissue. The vein graft was identified and dissected free for 4 cm distal to the anastomosis. Following an adequate circulation time, the common femoral was clamped with an angled DeBakey clamp. The profunda was controlled with a straight bulldog.

A longitudinal arteriotomy was made in the hood of the graft and extended proximally and distally. Retrograde hemorrhage from the graft was controlled with a Pruitt balloon occlusion catheter. A tight web-like stenosis was noted in the proximal portion of the vein graft. The stenosis was related in the intimal hyperplasia. Traction sutures were placed medially and laterally. A Hemashield Finesse patch was selected and prepared. The distal aspect of the repair was started with a horizontal mattress stitch of 5-0 Prolene suture. The medial and lateral aspects of the repair were then completed using U-clips. The patch was then placed in the appropriate degree of tension and cut to length in a taper. The proximal aspect of the patch was attached using 5-0 Prolene suture in a horizontal mattress fashion. The remainder of the repair was completed with U-clips.

Prior to completion of the medial aspect of the repair, the area was flushed antegrade and retrograde. The balloon was removed and the repair was completed. Flow was initially reestablished into the profunda femoris. Following several cardiac cycles, flow was reestablished into the vein graft. Several repair stitches of 6-0 Prolene suture on a BV-1 needle were utilized. The area was irrigated and examined for hemostasis. Surgicel was placed over the patch. The wound was closed in layers using 2-0 and 3-0 Vicryl sutures. The skin was closed with 3-0 nylon vertical mattress stitches. A palpable graft pulse was evident at the knee. The patient tolerated the procedure well. There were no apparent complications.

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PREOPERATIVE DIAGNOSIS:  Right foot rest pain and tissue loss.

POSTOPERATIVE DIAGNOSIS:  Right foot rest pain and tissue loss.

OPERATION PERFORMED:  Right femoral to posterior tibial artery bypass with translocated nonreversed greater saphenous vein.

SURGEON:  John Doe, MD

DRAINS:  None.

SPECIMEN:  None.

DESCRIPTION OF OPERATION:  The patient was placed supine. The abdomen, both groins, and the right lower extremity were prepped and draped in the usual aseptic fashion. An oblique incision was made in the right groin. Common femoral, profunda femoris and superficial femoral arteries were dissected free from the surrounding tissue and encircled with vessel loops. The greater saphenous vein was identified at the level of the proximal thigh. The vein was of good diameter and quality. The vein was traced retrograde to the saphenofemoral junction. The vein was then mobilized from the groin wound to the mid leg. The patient was systemically heparinized. The vein was then harvested. The saphenofemoral junction was treated with a 5-0 Prolene stitch in the standard fashion. The vein was then placed in vein solution. The vein was distended and examined for defects. Small branches were ligated. No sutures were required. The vein was opened proximally. The proximal valve was excised. The vein was marked with methylene blue to ensure proper orientation.

Attention was then turned to the proximal leg. The below-knee popliteal artery was dissected free from the surrounding tissue in the standard fashion. The vessel was soft. No pulse was detected. The longitudinal arteriotomy was made. An attempt was made to pass a #3 Fogarty balloon catheter distally. If the catheter went easily, the anastomosis would be performed at this level. Secondary to the fact that the catheter did not pass distally, the dissection was continued distally. The tibioperoneal trunk was identified. The proximal peroneal and posterior tibial arteries were dissected free from the surrounding tissue and encircled with vessel loops.

The vein was then returned to the field. The common femoral artery was clamped with an angled DeBakey clamp. Straight bulldogs were placed on the profunda branches, and the superficial femoral artery was controlled with an angled DeBakey clamp. A longitudinal arteriotomy was made. Traction sutures were placed medially and laterally. The profunda origin was widely patent. The graft was sewn end-to-side to the distal common femoral artery using 5-0 Prolene suture. The running open technique was utilized. A single stitch was placed at the toe of the anastomosis. Prior to completion of the anastomosis, the area was flushed antegrade and retrograde. The vein was clamped with atraumatic plastic disposable bulldog.

Prior to starting the anastomosis, the vein was tunneled from the groin to the distal incision. An incision was made in the medial aspect of the distal right thigh and the popliteal fossa was entered. Following completion of the proximal anastomosis, the vein graft was allowed to distend. The LeMaitre valvulotome was used to lyse the valves. Brisk pulsatile bleeding was evident at the distal aspect of the vein graft. The vein graft was then clamped proximally with two separate plastic disposable bulldogs. The distal section was complicated by overlying veins. Several vein repairs were required. Dense plaque was noted at the tibioperoneal trunk. The longitudinal arteriotomy was made in the tibioperoneal trunk, extending into the posterior tibial artery. The Pruitt balloon occlusion catheter was used to control retrograde hemorrhage from the posterior tibial artery and the peroneal artery. The previous arteriotomy in the below-knee popliteal artery was closed with running 6-0 Prolene sutures. One stitch was begun proximally and distally and run toward the midpoint. The graft was placed in the appropriate degree of tension with the knee extended and cut to length in a bevel.

An end-to-side anastomosis was completed to the distal tibioperoneal trunk with the toe of the anastomosis on the posterior tibial artery. The running open technique was utilized. A single stitch was placed at the toe of the anastomosis. Prior to completion of the anastomosis, the area was flushed antegrade and retrograde. Following completion of the anastomosis, an area of hemorrhage was noted in the proximal posterior tibial artery. This did require several stitches to control.

The area was irrigated and examined for hemostasis. Topical hemostatic agents were applied. Palpable pulse was evident distal to the anastomosis. PT Doppler signal was evident at the ankle. The wounds were irrigated and examined for hemostasis. The wounds were closed in layers using 2-0 and 3-0 Vicryl sutures. The skin was closed with a 3-0 nylon vertical mattress stitches in the proximal portion. The remainder of the skin was closed with staples. A dry sterile occlusive dressing was applied. The patient tolerated the procedure well. There were no apparent complications. The patient was transported awake, alert and extubated to the postanesthesia care unit without incident. Triphasic posterior tibial Doppler signal was evident at the ankle and a biphasic DP Doppler signal was evident upon arrival.

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