bmanus
Guru
Any help with this would be greatly appreciated.
DETAILED OPERATIVE REPORT: The patient was brought to the operating
room. Her chest was then prepped and draped, she was given vancomycin
preop. The previous incision was then opened up using electrocautery
and was taken down to the midline of the sternum. The previous wires
were untwisted and then the xiphoid was exposed. We were able to create
a blunt plane under the xiphoid. The excision was then continued up to
the neck where used a previous neck incision also. The wires were then
untwisted and we used the oscillating saw to perform division of the
sternum carefully, taking care to prevent injury to any mediastinal
structures. The division of the posterior table was then completed with
a Mayo scissors, again taking care to prevent any injury to the
underlying cardiac structures or great vessels. Her preoperative CT
scan did show adhesion of the innominate vein to the manubrium. In this
location we were extremely careful and were able to dissect the
innominate vein free and then this allowed us to place retractors for
sternal retraction. Additional dissection was performed under the left
and right hemisternum to allow for decreased tension within the
innominate vein. This was then further dissected off the aortic arch
and a vessel loop was used to isolate this and allow for retraction.
The pericardium was not violated. I opened up the right pleural space
and then asked for lung isolation of the right lung. I then dissected
the innominate artery along with the brachiocephalic SVC junction
cephalad to the innominate artery. The strap muscles and their
attachment to the clavicular head were divided and this exposed the
carotid sheath with the artery and jugular vein. We were now able to
dissect the trachea and retract this to the left, exposing the anterior
cervical table. Additional careful electrocautery dissection exposed
the previously placed metallic cage. We did have a OG2 within the
esophagus and were able to identify and retract this to prevent injury
at all times. At this point, Dr. A scrubbed in and performed his
portion of the procedure with my assist in retraction. Please refer to
the details of his operative report for removal of the existing cage and
replacement with a new expandable cage, along with excision of the
osteophyte. Once this was performed, irrigation was then instilled.
Hemostasis was good. Fluid was aspirated from the right chest. I
tunneled a 19-French Blake drain into the mediastinum and then into the
right chest and an additional Blake drain along the mediastinum. The
patient's sternum was quite thin and fragile from a second sternotomy
and therefore, I performed a Robicsek weave on the right hemisternum.
The chest was then closed with three single wires for the manubrium
followed by four double wires for the sternal body. The sternum came
together nicely. The Blake drains were fixed to suction. The remainder
of the wound was closed with absorbable sutures. The patient tolerated
the procedure well. At this point, due to the length of the case and
also the significant blood loss from both portions of the procedure, it
was felt that the patient should undergo a staged operation with
(Document continuation)
DETAILED OPERATIVE REPORT: The patient was brought to the operating
room. Her chest was then prepped and draped, she was given vancomycin
preop. The previous incision was then opened up using electrocautery
and was taken down to the midline of the sternum. The previous wires
were untwisted and then the xiphoid was exposed. We were able to create
a blunt plane under the xiphoid. The excision was then continued up to
the neck where used a previous neck incision also. The wires were then
untwisted and we used the oscillating saw to perform division of the
sternum carefully, taking care to prevent injury to any mediastinal
structures. The division of the posterior table was then completed with
a Mayo scissors, again taking care to prevent any injury to the
underlying cardiac structures or great vessels. Her preoperative CT
scan did show adhesion of the innominate vein to the manubrium. In this
location we were extremely careful and were able to dissect the
innominate vein free and then this allowed us to place retractors for
sternal retraction. Additional dissection was performed under the left
and right hemisternum to allow for decreased tension within the
innominate vein. This was then further dissected off the aortic arch
and a vessel loop was used to isolate this and allow for retraction.
The pericardium was not violated. I opened up the right pleural space
and then asked for lung isolation of the right lung. I then dissected
the innominate artery along with the brachiocephalic SVC junction
cephalad to the innominate artery. The strap muscles and their
attachment to the clavicular head were divided and this exposed the
carotid sheath with the artery and jugular vein. We were now able to
dissect the trachea and retract this to the left, exposing the anterior
cervical table. Additional careful electrocautery dissection exposed
the previously placed metallic cage. We did have a OG2 within the
esophagus and were able to identify and retract this to prevent injury
at all times. At this point, Dr. A scrubbed in and performed his
portion of the procedure with my assist in retraction. Please refer to
the details of his operative report for removal of the existing cage and
replacement with a new expandable cage, along with excision of the
osteophyte. Once this was performed, irrigation was then instilled.
Hemostasis was good. Fluid was aspirated from the right chest. I
tunneled a 19-French Blake drain into the mediastinum and then into the
right chest and an additional Blake drain along the mediastinum. The
patient's sternum was quite thin and fragile from a second sternotomy
and therefore, I performed a Robicsek weave on the right hemisternum.
The chest was then closed with three single wires for the manubrium
followed by four double wires for the sternal body. The sternum came
together nicely. The Blake drains were fixed to suction. The remainder
of the wound was closed with absorbable sutures. The patient tolerated
the procedure well. At this point, due to the length of the case and
also the significant blood loss from both portions of the procedure, it
was felt that the patient should undergo a staged operation with
(Document continuation)