Reference no: EM13464695
The patient is an unfortunate 37-year-old woman who had a pregnancy associated breast cancer of the right breast with extensive involvement of the breast, clinically a stage III breast cancer. She underwent neoadjuvant chemotherapy with a complete clinical response to therapy with no residual palpable tumor in the breast and no palpable adenopathy. She has elected to undergo a bilateral mastectomy. She will have reconstructive surgery at a later time.
OPERATIVE NOTE: The patient was taken to the operating room. General anesthesia was induced. A Foley catheter was inserted. Her arms were placed on pads. Her legs were placed on pads. Bear hugger was applied and her entire upper torso was sterilely prepped and draped in usual fashion. Symmetric skin sparing mastectomies were planned incorporating the nipple-areolar complex on both sides. We began on the left side. An elliptical incision was made incorporating the nipple-areolar complex, carried down through the skin into the subcutaneous tissue. Flaps were raised circumferentially from the superior aspect to the clavicle, medially to the midline, inferiorly to the inframammary, fold and laterally out to the latissimus dorsi. The breast was then removed from the pectoralis major muscle incorporating the fascia, reflected laterally and truncated. It was marked for orientation, weighed and sent to pathology. Hemostasis was achieved where necessary using electrocautery. There was no evidence of bleeding at the end of the case. Moist laps were placed under the flaps and we moved to the right breast. Again, an elliptical incision was created incorporating the nipple-areolar complex and a little more skin laterally in that breast because the breast was a larger breast on that side. Flaps again were raised from superior infraclavicular and a portion of the breast circumferentially to the midline and subsequently to the inframammary fold and subsequently out to the latissimus dorsi muscle. The breast was removed from the pectoralis major muscle incorporating the fascia, reflected laterally. The clavipectoral fascia was opened and a level I and level II axillary lymph node dissection was performed on both sides, sparing the long thoracic and the thoracodorsal neurovascular bundle, as well as at least 1 intercostal brachial cutaneous nerves. The axillary lymph nodes will be examined for metastasis. There was no palpable adenopathy in level III. The breast and axilla were marked for orientation, weighed and sent to pathology. Irrigation was performed. Hemostasis was achieved where necessary using some Surgiclips and electrocautery. There was no evidence of bleeding at the end of the case.
INDICATIONS FOR SURGERY: The patient is a 59-year-old male with the above diagnosis. The patient had initial application of external fixator and fasciotomies performed by my partner, on November 23rd. The patient had open wounds, initially had application of a wound VAC with the intent to bring him back to the operating room for repeat I and D, possible ORIF, possible wound closure. Preoperatively, the patient's leg was and he had too much soft tissue swelling. He did not have a positive wrinkle sign so the soft tissues were too swollen to proceed with definitive fixation, so the decision for maintaining the fixator and just doing irrigation and debridement along with possible wound closure was made at that time. Risks and benefits were explained to the patient. He made an informed decision to proceed with the above procedure.
PROCEDURE: The patient seen preoperatively. The left lower extremity was marked. He was brought in the operating room, placed on the operating table, given a general anesthetic. The left lower extremity was then thoroughly prepped and draped in standard orthopedic fashion. Once that was done, universal protocol of a time-out was taken to confirm that the left lower extremity was the correct operative site. Once that was done, 3 liters of lactated Ringer's laced with bacitracin was used for both medial and lateral wounds. Any nonviable or necrotic tissue was debrided down. Majority of the muscle seemed healthy, was contractile with electrocautery. There was not an excessive amount of bleeding so the wounds were closed primarily. Both medial and lateral wounds with interrupted subcutaneous 2-0 Vicryl for the subcutaneous layer and a running 4-0 V-Loc for the skin. Wounds were then dressed with Steri-Strips, Xeroform, 4 x 4's and Ace wrap. Xeroform was also placed around the pin sites for the external fixator which was also prepped out from the procedure. The patient was also noted to have some fracture blisters and several abrasions to the skin. Once the leg was dressed, the patient was extubated and
transferred to postanesthesia recovery unit in stable condition. All sponge and sharp counts were correct.
The patient received pre and will receive postoperative antibiotics. He is nonweightbearing. He will be placed back on his anticoagulant treatment most likely Lovenox for DVT prophylaxis and he will be discharged at the discretion of Trauma Service to follow up in the office for reevaluation and determine when definitive fixation will be performed.
Do not code the X-ray or fluoroscopic guidance for this case.
PREOPERATIVE DIAGNOSIS:
1. Comminuted right femur fracture secondary to multiple gunshot wounds.
2. Status post multiple gunshot wounds with open wounds, right thigh.
POSTOPERATIVE DIAGNOSIS:
1. Comminuted right femur fracture secondary to multiple gunshot wounds.
2. Status post multiple gunshot wounds with open wounds, right thigh.
PRINCIPAL PROCEDURE PERFORMED:
1. Irrigation/and excisional debridement with primary closure of multiple gunshot wounds, right thigh, encompassing two wounds measuring 2 cm, one wound measuring 3 cm, one wound measuring 4 cm, one wound measuring 6 cm.
2. Open reduction/internal fixation/trochanteric femoral intramedullary nailing, right comminuted femur fracture, with Stryker GTN femoral intramedullary nail.
The patient is a 25-year-old gentleman status post multiple gunshot wounds. He was brought to the Medical Center as a code yellow multi-trauma patient. He was emergently taken to the operating room last night for exploratory laparotomy. At that juncture, his gunshot wounds to his right thigh were irrigated and packed per the trauma service. He has been cleared for surgical stabilization of his comminuted right femur fracture. X-rays have shown him to have a comminuted midshaft femur fracture secondary to his multiple gunshots. At this juncture, it was elected to bring him to the operating room for surgical stabilization of his fracture, irrigation/debridement of his gunshot wounds, with primary closures of the open wounds. Preoperative consent was obtained from the patient's mother. The patient has been cleared for surgical intervention per the trauma service.
The patient was brought to the operating room from the surgical intensive care unit. He was intubated and sedated. He was transferred onto the fracture table in the supine position. After the establishment of adequate general anesthesia, his right lower extremity underwent an initial irrigation, debridement and closure. The patient was placed on the fracture table and then his right lower extremity was prepped and draped in the usual normal sterile fashion. He did receive preoperative antibiotics. After adequate prepping and draping, his gunshot wounds noted to be five, two of them encompassing approximately 2 cm in length, one measuring 3 cm in length, one measuring 4 cm in length, and the fifth measuring 6 cm in length. All wounds were thoroughly debrided, this encompassing sharp dissection with a scalpel for the skin, subcutaneous tissues muscle and deep tissue. The posterior large wound also had several small bony fragments secondary to the marked comminution of his fracture. These dysvascular fragments with no soft tissue attachment were removed. The wounds were then copiously irrigated with pulsatile lavage. Three liters of pulsatile lavage antibiotic solution were initially irrigated through all the gunshot wounds, followed by an additional 3 liters of normal saline. Status post this, the skin edges were again sharply debrided; the tissue including muscle and subcutaneous tissue were also removed.
The wounds were then closed in layers. The subcutaneous tissues were then reapproximated using 2-0 Vicryl in an interrupted suture ligature fashion. The skin edges were then reapproximated using 2-0 nylon in an interrupted suture ligature fashion. Status post this, the patient was maintained on the fracture table and a gentle reduction of the patient's comminuted fracture was accomplished, this using the fracture table and C-arm fluoroscopic guidance. Approximate measurements of the patient's lower extremities were also obtained using the external ruler from the Stryker GTN trochanteric nail system. Measurements were approximately taken of the left femur and the right two approximate limb lengths. Status post, this reduction was maintained and the patient's right hip and lower extremity were prepped and draped in usual normal sterile fashion. He again did receive preoperative antibiotics.
After adequate prepping and draping, the planned incision was mapped out using C-arm fluoroscopic guidance, this extending from the tip of the trochanter cephalad. The use of x-ray/fluoroscopic guidance was a medical necessity for this procedure, this in an effort to visualize the femur, visualize the reduction and maintain the reduction. The placement of the intramedullary nail necessitated the use of x-ray/fluoroscopic guidance in addition to the locking of the nail. The images were visualized and interpreted by myself. After adequate prepping and draping, the nail insertion wound was taken down clean and sharply through skin and subcutaneous tissues. Dissection down to fascia was accomplished and the fascia incised in line with the skin incision.
It should be noted that after we had the irrigated and debrided the patient's gunshots with closures, the patient's right lower extremity was reprepped and draped with new drapes in a sterile fashion. Dissection down to the fascia was accomplished and the fascia then incised in line with the skin incision. Dissection down to the tip of the trochanter was accomplished. A smooth Kirschner wire was initially utilized and the planned insertion point for a trochanteric nail was accomplished, this placed in the tip of the trochanter and verified to be in good position in the AP, lateral and oblique planes. This was then overreamed using a triple reamer. The guidewire was then placed into this and utilizing the fracture reduction tool, the guidewire was manipulated across the fracture region to the distal aspect of the femur. Intraoperative x-rays again revealed good alignment in the AP, lateral and oblique planes. Sequential reaming was then begun using a 9-mm reamer progressing by 1-mm increments through 14 mm. There was noted to be good positioning of the reamer. The appropriate measurements were taken at this juncture, and the definitive Stryker GTN trochanteric femoral nail was opened. It was then placed onto the inserter, the appropriate amount of rotation dialed in. this placed over the guidewire and then impacted into position. Intraoperative x-rays again revealed good alignment in the AP, lateral and oblique planes. Maintenance of reduction was accomplished.
The guidewire was then removed at this juncture. The nail was locked statically, the external alignment jig utilized for the proximal locking screws, one screw placed transversely with the additional screw placed obliquely. Both screws were found to have excellent bite and fixation. They were verified to be within the intramedullary nail. The distal aspect of the nail was then locked. Using the Cole radiolucent drill and the "perfect circle technique," both locking screws were placed distally in a static mode. Intraoperative x-rays then revealed good alignment in the AP, lateral and oblique planes. Verification that these screws were in the intramedullary nail were accomplished.
All wounds were copiously irrigated with antibiotic solution and suction dried. Hemostasis obtained throughout using Bovie electrocautery. The patient's deep fascia in the nail insertion was reapproximated using #1 Vicryl in an interrupted suture ligature fashion. All subcutaneous tissues, including the percutaneous screw insertion wounds, were reapproximated using 2-0 Vicryl in an interrupted suture ligature fashion, the skin edges reapproximated using staples. Sterile dressings were placed to all wounds, including the gunshot wounds, with sterile Adaptic gauze, sterile 4x4's, sterile ABDs, sterile Webril. A Tegaderm was placed on the proximal aspect with Webril and an Ace wrap to the lower extremity as a whole. The patient was transferred back to the surgical intensive care unit in stable condition, having tolerated the procedure well.
Components utilized in this procedure were the Stryker GTN trochanteric femoral intramedullary nail, 13 x 420, with two proximal and two distal locking screws.