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nn– Click Here to Submit Redacted Surgery Case Study –nn nnADMISSION DATE: 11/28/2017nnnSURGERY DATE: 11/28/2017nnSURGEON: Dr. G, MD PREOPERATIVE DIAGNOSES:n
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- Degenerative lumbar spine (L4-L5).
- Obesity (BMI 32).
- History of multiple surgeries including umbilical hernia repair with mesh.
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nPOSTOPERATIVE DIAGNOSES:n
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- Degenerative lumbar spine (L4-L5).
- Obesity (BMI 32).
- History of multiple surgeries including umbilical hernia repair with mesh.
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nOPERATION:n
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- Unusually difficult anterior exposure for lumbar spine arthroplasty (L4- L5).
- lntraoperative fluoroscopy.
- Vessel Guard patch.
- Abdominal x-ray reading.
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nSPINE SURGEON: M E J. DOnnASSISTANT: M M, SAnnANESTHESIA: General endotracheal.nnESTIMATED BLOOD LOSS: Minimal during my part of the surgery.nnCOMPLICATIONS: None.nnFINDINGS: Very large osteophytes making the vascular dissection extremely difficult in addition to the obesity and scar tissue from the umbilical hernia repair with mesh.nnSPECIMENS REMOVED: None during my part of the surgery.nnINDICATION FOR SURGERY: This is a 56-year-old male with an early stage of obesity, who has a degenerative lumbar spine and needs anterior exposure for lumbar spine arthroplasty at the level of the disk L4-L5. The patient had multiple prior abdominal surgeries including right adrenalectomy and umbilical hernia repair with mesh.nnPROCEDURE IN DETAIL:nnThe patient was brought into the operating room and placed on the table in the supine position. After the general anesthesia was administered, the intraoperative fluoroscopy was used to identify the level of the disk L4-L5 and the projection of the disk at the level of the anterior abdominal wall was marked with a transversal line in the abdomen, which was immediately below the umbilical scar. At this point, the abdomen was prepped and draped in the usual sterile fashion. Due to the obesity of the patient and expected scar from the umbilical hernia repair, it was decided to proceed with longitudinal incision, which was placed at the level of the midline, a little bit to the left of the midline below and above the previously placed line with incision extended from the infraumbilical area towards the left side of the umbilical area. The incision was deepened through the subcutaneous tissue and through the fascia. The fascia! flaps were elevated and the left rectus muscle was retracted as lateral as possible. In the upper part of the incision, this dissection was more difficult due to the scar tissue from the previously placed mesh, and the mesh was encountered at this level and needed to be divided a little bit to complete mobilization of the rectus abdominis muscle. In the lower part of the incision below the arcuate line, the retroperitoneal space was entered. A little bit more difficult dissection of the retroperitoneal space was encountered, particularly in the upper part of the abdomen due to the obesity of the patient and probably stiffness of the tissue from the prior surgery. The retroperitoneal space was entered and at this point, the heavy peritoneal sac was carefully dissected and mobilized together with the ureter and pushed to the right side. The ureter was carefully protected. The vascular dissection was started above the left iliac vessel.nnKeeping the dissection close to the lateral wall of the left iliac artery, this artery was mobilized as distal as possible close to the groin. The patient had a rather large amount of fat and also stiff inflamed lymph nodes covering the iliac vessels making the vascular dissection quite very difficult. Using gentle blunt dissection, the iliac vessels were progressively.started to be dissected and pushed to the right side. On the left side of the disk space L4-L5, quite very large osteophytes were encountered. After this initial step of vascular dissection although very difficult, was completed with no incidents. The dissection was further continued using gentle blunt dissection. Below the disk space L4-L5, tedious dissection was done through the inflamed fat and lymphatic tissue to look for the iliolumbar vein and in the vicinity of the disk space, no iliolumbar vein was identified. This dissection allowed further mobilization of the lower part of the iliac vein, which was possible to be pushed further to the right side. Although the dissection of the iliac vessel was rather more extended than normal, it was still extremely difficult to push the vessels all the way to the right side of the spine encountering the right side of the spine also very large osteophyte. At this point, the needle was inserted in the disk exposed and using intraoperative fluoroscopy, the level of the spine exposure was demonstrated. The SynFrame was placed maintaining the exposure al the level of the disk L4–L5 with the impression that the vessels were mobilized all the way to the right side above and to the right of the larger osteophyte in the right side of the spine. It was rather unusually difficult dissection, which was completed at this point with no incidents. At this point, Dr. J came into the operating room and the case was turned to Dr. J for the orthopedic part of the spinal procedure. During the surgery performed by Dr. J, he noticed that it is impossible to obtain dissection on the right side of the spine and asked me to come back to the operating room and to proceed further mobilization of the iliac vessels. I came back to the operating room and I have noticed that now with additional release and destruction of the disk space L4-L5, it was possible with additional blunt dissection to push the left iliac vessel completely further to the right side and it was possible to keep in place these vessels all the way to the right side of the spine with reverse lip retractor. After this was completed with no incidents, I discussed with Dr. J the anatomical landmarks and he felt that now he would be able to complete the procedure with complete diskectomy all the way to the right side of the disk space. I turned the case back to Dr. J for his completion of surgery and after his part of the surgery was completed, I came back to the operating room and I took over the case again. Very good hemostasis was noted. No injury was seen. At this point, a 5 x 7.5 Vessel Guard patch was chosen and was sutured in place with 2 stitches with 4-0 PDS suturing the right side of the patch to the right side of the spine. The patch was able to cover completely the artificial disk implanted and the entire anterior aspect of the spine exposed. At this point, very carefully and gently the retractor blades were removed allowing the great vessels, the left iliac vessels, and the peritoneal sac to come back in a normal anatomical position on top of the patch. At the end of the procedure, very good hemostasis was noticed. Very good flow through the left iliac vessels. No ureteral injuries and no lymphatic leak. At this point, the abdomen was closed in a standard fashion using continuous running #1 looped PDS for the fascial layer. The subcutaneous tissue was irrigated. Local anesthesia was injected. At this point, the intraoperative fluoroscopy was used to x-ray the abdomen for the instrument count and no instruments were found in the surgical field. The subcutaneous tissue was closed with continuous running 2-0 Vicryl and the skin was closed with continuous running 4-0 Monocryl subcuticular closure. Steri-Strips and sterile dressing were applied. The patient tolerated the procedure well and left the operating room in stable condition.