op note help please


Wallingford, CT
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PREOPERATIVE DIAGNOSIS: Left carotid stenosis
POSTOPERATIVE DIAGNOSIS: Left carotid stenosis
TITLE OF OPERATION: Left carotid endarterectomy with patch angioplasty
ANESTHESIA: Regional via cervical block with supplemental local and intravenous sedation.
ESTIMATED BLOOD LOSS: Approximately 100 milliliters. WOUND CLASSIFICATION: Class I. ANESTHETIC CLASS: Class III. FINDINGS: Findings included a very tight calcific stenosis at the bifurcation. Endplate was realized. Excellent flow was noted. Of interest, the patient's blood pressure on presentation in the operating room was approximately 160; after completion of endarterectomy, it dropped into the 1-teens consistently. The plaque was extremely calcific and it was approximately 90% stenosed. There was evidence of previous inter-plaque hemorrhage with subintimal hematoma.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and placed in supine position. Following cervical block by ---, which was performed in the holding area, he was prepped and draped in the usual sterile fashion using ChloraPrep. The prep was tested. The incision was then made along the anterior border of the sternocleidomastoid muscle. This was deepened through skin and platysma. Bleeding points were controlled with clips and cautery when encountered. The common carotid artery was identified; it was encircled up to the appropriate sub-adventitial plane, and the dissection was carried proximally. A large facial vein was divided between clips and ties. The bifurcation was quite high, the patient's neck was quite short, making the dissection somewhat difficult. Visualization, however, was excellent. I was able to clearly mobilize the external carotid as well as the ascending pharyngeal branch. The hypoglossal sling vessels were divided. Care was taken to avoid injury to the hypoglossal nerve. The internal carotid artery was eventually dissected free completely, and there was a palpable endplate noted just after the take-off of the internal carotid. The patient was doubly heparinized. Initial attempts to open plaque on the medial aspect of the artery were unsuccessful, due to the heavily calcified plaque. This actually caused bending of the eye knife. A #11 blade was then used to start the arteriotomy, which was extended with some difficulty using the Pott scissors. The endarterectomy was carried out proximally in the common carotid, the submuscular plane was obtained and the plaque was divided.
Attention was then carried distally, where the external carotid was endarterectomized and a good endplate was noted. We then turned our attention toward the internal carotid junction. There was a surprising adherence of the plaque to the internal carotid at the level of the previously inter-plaque hemorrhage. This actually required dissection using the tenotomy scissors to completely free the plaque from the subintimal plane. A excellent endpoint was realized. The arteriotomy was then closed after removing remaining bits of the intima and musculature using the ring forceps. The endarterectomy was closed using the Hemashield Platinum Finesse graft using 6-0 Prolene, undal 3.5 power magnification Prior to the final sutures, the artery was flushed antegrade and retrograde, flush with the internal carotid, yielding excellent backflow, as did the external and finally the common. The patient remained alert during the procedure, which was somewhat surprising, given the fact that his right internal carotid artery was completely occluded. Nonetheless, vertebral backflow was excellent. The artery was then flushed with heparinized saline with suture side down, and the clamp on the external was released. There was some bleeding noted at the apex of the arteriotomy closure. This was controlled with a pledgeted suture. No further bleeding points were noted. Flow was then reestablished through the common into the external followed by flow into the internal carotid artery. Excellent flow was noted by Doppler. Bleeding points controlled with clips and cautery. FloSeal followed by Surgicel were then placed on the arteriotomy and there was no bleeding noted. The wound was then closed in layers using 3-0 Vicryl for the deep cervical fascia, 3-0 Vicryl for the platysma, and subcuticular 4-0 Prolene for the skin, followed by Steri-Strips, dry sterile dressing and
Tegaderm. The patient tolerated the procedure well and was brought back to recovery room in stable condition.

Thanks for any help!