rejenia
Networker
I have the
33530 for redo #1
33864 for #6,7,8,9
36620 #4
33512 #11
Just want to know if i captured everything
POSTOPERATIVE DIAGNOSIS:
Ascending aortic dissection, acute on chronic, symptomatic.
OPERATION:
1. Redo sternotomy.
2. Removal of sternal wires.
3. Lysis of dense adhesions on heart.
4. Right common femoral artery cannulation.
5. Profound hypothermic circulatory arrest.
6. Resuspension, aortic valve.
7. Reconstruction, aortic root.
8. Reconstruction and hemiarch, distal aorta.
9. A 34 mm tube graft interposition.
10. Excision and then reimplantation, 3 proximal vein grafts.
11. Transesophageal echocardiogram (TEE).
DESCRIPTION OF PROCEDURE:
The patient was brought in the operating room, positively identified, and
underwent general anesthetic. Monitoring lines were placed by Anesthesia. He
was sterilely prepped and draped in the standard fashion.
We began by opening the right groin, exposing the right common femoral artery
and vein. Subsequently, we made a sternal incision and carried it down to the
subcutaneous tissues. We removed the 8 previous sternal wires, placed
vertical elevation on the sternum, and using oscillating saw, first opened the
anterior and then posterior tables uneventfully, although his heart and the
innominate vein were right under the sternum.
We used cautery to take down the adhesions on the left and right sides. They
were particularly dense on the left side. I was able to place a Cooley
retractor. We took down the right-sided adhesions, exposing as much of the
aorta as I could. It was immediately apparent that he had a severe dissection
of this aorta, with significant enlargement and with subintimal thrombus
extending along the entire length that was quite significant.
Subsequently I was able to use the IMA retractor on the left side of the chest
in between the lungs and the pericardium. I was able to identify the LIMA and
I put a red vessel loop around the LIMA. It was maintained intact. I had
also identified the 3 previous proximal anastomoses on this aorta and all 3 of
these vein grafts appeared to be open or patent. Subsequently, he was
systemically heparinized. I then placed a 25-French arterial cannula in the
right common femoral artery, using the Seldinger technique, and had good
pulsations.
Subsequently, I placed the triple-stage venous cannula in the right atrium,
the LV vent in the right superior pulmonary vein, and retrograde cannula in
the coronary sinus. I then proceed under cardiopulmonary bypass and
immediately started systemic cooling. We crossclamped the aorta and placed a
14-French Angiocath in the aorta to vent and after giving 2 L of blood
retrograde, began resecting the ascending aorta. Again, there was total
thrombus along the entire length going down into the root and down into the
inferior arch.
I resected the aorta and was able to
circumferentially resect the aorta just above the right and left coronary
ostia. I cleaned the thrombus out between the intima media and the adventitia
and was able to note that there was no perforation through the media. I began
by placing 3 aortic valve resuspension sutures, resuspending the aortic valve.
The cusps were very pliable and there appeared to be an essentially normal
trileaflet valve.
I then cleaned out all the thrombus in the root between the layers and then
put the layers back together again with BioGlue. I then placed approximately
fifteen 4-0 pledgeted Prolene sutures circumferentially around the inside of
the aorta, tacking all the layers together. This reestablished the
aortic root, with well-preserved right and left coronary ostia, as well as the
aortic valve. I had to resect the bypass grafts from the dissected aorta.
The dissection was going up right into the anastomoses and I cut them,
leaving as much length on each of the 3 vein grafts as possible. I also
mobilized the vein grafts as much as possible while keeping them intact.
At this time, we had cooled at 18 degrees for over half an hour. We proceeded
on to the hypothermic circulatory arrest. I placed a retrograde cannula in
the SVC, clamped distally, and began a retrograde cerebral perfusion. I then
removed the crossclamp after establishing our circulatory arrest protocol. I
resected the aorta as necessary distally, going into the arch and up onto the
innominate vein, actually quite high. The lead point of dissection appeared to be proximally at the base of the innominate artery. It was definitely a hemiarch procedure.
Again, extensive thrombus was most extensively inferiorly and we cleaned this
out as far as we could. The thrombus actually appeared to be dark, but fresh.
We then re-established the layers with BioGlue and then again, placed
circumferentially along the inside, approximately 14-15 of 4-0 pledgeted
Prolene sutures in a mattress fashion. Again, we had a nicely stable distal
lumen. We sized for a 34 tube graft, beveled it slightly, and then using
bovine pericardium and 3-0 Prolene suture, completed the distal anastomosis in
a continuous fashion.
We then re-established the cardiopulmonary bypass, De-airing and then clamping
the new Dacron graft, with a circulatory arrest time of approximately 44
minutes.
We then turned our attention to the proximal anastomosis. We had completed the root reconstruction and we completed the proximal anastomosis while rewarming, using again bovine pericardium and 3-0 Prolene suture continuously. Subsequently, we had to reanastomose the vein grafts. We had adequate length. We proceeded to make 3 aortotomies, 1 on the right and 2 on the left, and then completed the 3-vein graft proximal anastomoses, using continuous 5-0 Prolene suture. The DLP cannula had been placed, using eye cautery in the aortic graft, as well.
Having completed all the anastomoses, 2 ventricular wires were placed. We
placed the patient in a head-down position. We did our standard de-airing
technique and then gave 1 liter of warm blood retrograde. We then removed the crossclamp with further de-airing through the DLP cannula. Patient was
basically asystolic and we began pacing at a rate of 60, working up to a rate
of 80, and then he went to a nice sinus rhythm on his own.
We separated well from cardiopulmonary bypass. We immediately removed the arterial cannula from the right common femoral artery. This was oversewn with 4-0 Prolene suture. Then, we used the Doppler to confirm pulsatile flow distal to the site of the cannulation. At that point, we proceeded to give the protamine. The patient tolerated the protamine without any difficulty.
We spent considerable time on hemostasis and gave blood products as well and had very good hemostasis of all the anastomoses.
We also had some oozing from all the raw tissue from the dissection planes and this was controlled as well with electrocautery. After obtaining adequate
hemostasis, we placed a straight 32-French chest tube in the anterior
mediastinum. We placed an angled 32-French chest tube in the right
hemithorax, as I had opened up in the right chest. I had laid a #19 Blake
drain on top of the left heart. I had only resected as much adhesions of the left side as necessary so there was no tension on the ventricle
Final inspection for hemostasis was conducted and then the sternum was closed with wires. The remaining tissue was closed in layers with absorbable suture. The skin was closed with staples. The right groin was closed with absorbable suture in a layered fashion. The skin was closed with staples.
Total bypass time was 211 minutes. Single-technique cross-clamp time was 165
minutes.
COUNTS:
All sponge, needle, and instrument counts were reported as correct.
33530 for redo #1
33864 for #6,7,8,9
36620 #4
33512 #11
Just want to know if i captured everything
POSTOPERATIVE DIAGNOSIS:
Ascending aortic dissection, acute on chronic, symptomatic.
OPERATION:
1. Redo sternotomy.
2. Removal of sternal wires.
3. Lysis of dense adhesions on heart.
4. Right common femoral artery cannulation.
5. Profound hypothermic circulatory arrest.
6. Resuspension, aortic valve.
7. Reconstruction, aortic root.
8. Reconstruction and hemiarch, distal aorta.
9. A 34 mm tube graft interposition.
10. Excision and then reimplantation, 3 proximal vein grafts.
11. Transesophageal echocardiogram (TEE).
DESCRIPTION OF PROCEDURE:
The patient was brought in the operating room, positively identified, and
underwent general anesthetic. Monitoring lines were placed by Anesthesia. He
was sterilely prepped and draped in the standard fashion.
We began by opening the right groin, exposing the right common femoral artery
and vein. Subsequently, we made a sternal incision and carried it down to the
subcutaneous tissues. We removed the 8 previous sternal wires, placed
vertical elevation on the sternum, and using oscillating saw, first opened the
anterior and then posterior tables uneventfully, although his heart and the
innominate vein were right under the sternum.
We used cautery to take down the adhesions on the left and right sides. They
were particularly dense on the left side. I was able to place a Cooley
retractor. We took down the right-sided adhesions, exposing as much of the
aorta as I could. It was immediately apparent that he had a severe dissection
of this aorta, with significant enlargement and with subintimal thrombus
extending along the entire length that was quite significant.
Subsequently I was able to use the IMA retractor on the left side of the chest
in between the lungs and the pericardium. I was able to identify the LIMA and
I put a red vessel loop around the LIMA. It was maintained intact. I had
also identified the 3 previous proximal anastomoses on this aorta and all 3 of
these vein grafts appeared to be open or patent. Subsequently, he was
systemically heparinized. I then placed a 25-French arterial cannula in the
right common femoral artery, using the Seldinger technique, and had good
pulsations.
Subsequently, I placed the triple-stage venous cannula in the right atrium,
the LV vent in the right superior pulmonary vein, and retrograde cannula in
the coronary sinus. I then proceed under cardiopulmonary bypass and
immediately started systemic cooling. We crossclamped the aorta and placed a
14-French Angiocath in the aorta to vent and after giving 2 L of blood
retrograde, began resecting the ascending aorta. Again, there was total
thrombus along the entire length going down into the root and down into the
inferior arch.
I resected the aorta and was able to
circumferentially resect the aorta just above the right and left coronary
ostia. I cleaned the thrombus out between the intima media and the adventitia
and was able to note that there was no perforation through the media. I began
by placing 3 aortic valve resuspension sutures, resuspending the aortic valve.
The cusps were very pliable and there appeared to be an essentially normal
trileaflet valve.
I then cleaned out all the thrombus in the root between the layers and then
put the layers back together again with BioGlue. I then placed approximately
fifteen 4-0 pledgeted Prolene sutures circumferentially around the inside of
the aorta, tacking all the layers together. This reestablished the
aortic root, with well-preserved right and left coronary ostia, as well as the
aortic valve. I had to resect the bypass grafts from the dissected aorta.
The dissection was going up right into the anastomoses and I cut them,
leaving as much length on each of the 3 vein grafts as possible. I also
mobilized the vein grafts as much as possible while keeping them intact.
At this time, we had cooled at 18 degrees for over half an hour. We proceeded
on to the hypothermic circulatory arrest. I placed a retrograde cannula in
the SVC, clamped distally, and began a retrograde cerebral perfusion. I then
removed the crossclamp after establishing our circulatory arrest protocol. I
resected the aorta as necessary distally, going into the arch and up onto the
innominate vein, actually quite high. The lead point of dissection appeared to be proximally at the base of the innominate artery. It was definitely a hemiarch procedure.
Again, extensive thrombus was most extensively inferiorly and we cleaned this
out as far as we could. The thrombus actually appeared to be dark, but fresh.
We then re-established the layers with BioGlue and then again, placed
circumferentially along the inside, approximately 14-15 of 4-0 pledgeted
Prolene sutures in a mattress fashion. Again, we had a nicely stable distal
lumen. We sized for a 34 tube graft, beveled it slightly, and then using
bovine pericardium and 3-0 Prolene suture, completed the distal anastomosis in
a continuous fashion.
We then re-established the cardiopulmonary bypass, De-airing and then clamping
the new Dacron graft, with a circulatory arrest time of approximately 44
minutes.
We then turned our attention to the proximal anastomosis. We had completed the root reconstruction and we completed the proximal anastomosis while rewarming, using again bovine pericardium and 3-0 Prolene suture continuously. Subsequently, we had to reanastomose the vein grafts. We had adequate length. We proceeded to make 3 aortotomies, 1 on the right and 2 on the left, and then completed the 3-vein graft proximal anastomoses, using continuous 5-0 Prolene suture. The DLP cannula had been placed, using eye cautery in the aortic graft, as well.
Having completed all the anastomoses, 2 ventricular wires were placed. We
placed the patient in a head-down position. We did our standard de-airing
technique and then gave 1 liter of warm blood retrograde. We then removed the crossclamp with further de-airing through the DLP cannula. Patient was
basically asystolic and we began pacing at a rate of 60, working up to a rate
of 80, and then he went to a nice sinus rhythm on his own.
We separated well from cardiopulmonary bypass. We immediately removed the arterial cannula from the right common femoral artery. This was oversewn with 4-0 Prolene suture. Then, we used the Doppler to confirm pulsatile flow distal to the site of the cannulation. At that point, we proceeded to give the protamine. The patient tolerated the protamine without any difficulty.
We spent considerable time on hemostasis and gave blood products as well and had very good hemostasis of all the anastomoses.
We also had some oozing from all the raw tissue from the dissection planes and this was controlled as well with electrocautery. After obtaining adequate
hemostasis, we placed a straight 32-French chest tube in the anterior
mediastinum. We placed an angled 32-French chest tube in the right
hemithorax, as I had opened up in the right chest. I had laid a #19 Blake
drain on top of the left heart. I had only resected as much adhesions of the left side as necessary so there was no tension on the ventricle
Final inspection for hemostasis was conducted and then the sternum was closed with wires. The remaining tissue was closed in layers with absorbable suture. The skin was closed with staples. The right groin was closed with absorbable suture in a layered fashion. The skin was closed with staples.
Total bypass time was 211 minutes. Single-technique cross-clamp time was 165
minutes.
COUNTS:
All sponge, needle, and instrument counts were reported as correct.
