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1 POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left groin parallel to the left inguinal ligament after the skin had been infiltrated with 0.5% plain Marcaine. Subcu was incised. Superficial epigastric vessels were identified, clamped, transected and ligated with 2-0 Vicryl. Scarpa’s was incised. The external oblique aponeurosis was identified and incised. The incision was carried down to the external ring superior to the internal ring. The ilioinguinal nerve was identified, freed from the surrounding tissues and retracted medially. The cord structures were encircled with a Penrose drain. A large lipoma of the lumbar spinal cord was dissected off all the way to the base, clamped, transected, and ligated with 2-0 Vicryl. The cremasteric muscles were transected at the anteromedial aspect of the cord structures. A hernia sac was identified, which was a small indirect hernia. The sac was dissected all the way to the level of the preperitoneal fat. The contents were mobilized. Then, there was a large bulge in the direct space, almost occupying the entire direct space. It was dissected from the surrounding tissues. Deep epigastric vessels were identified. The fascia was transected. Deep epigastric vessels were skeletonized and retracted cephalad anteriorly. The transversalis was transected circumferentially. The direct space was bluntly dissected until completely dissecting the direct and indirect space. A Prolene Hernia System mesh was placed. The innerlay was unfolded inferiorly, superiorly, medially and laterally. The transversalis was closed over it with 2-0 Vicryl. The overlay was unfolded and sutured to the pubic tubercle inferiorly, cut at the 1 ‘o’clock location, wrapped around the cord structures and placed over the internal oblique muscle. The wound was irrigated. Cord structures were placed in the usual anatomic location. The external oblique aponeurosis was closed with 3-0 Vicryl. Again, the gallbladder was also placed in the usual anatomic location. The external oblique aponeurosis was closed with 3-0 Vicryl. Subcu was closed with interrupted 4-0 Monocryl. Each layer was infiltrated with 0.5% plain Marcaine. The skin was closed with subcuticular 4-0 Monocryl. Dermabond was applied. The patient tolerated the procedure well under general anesthesia and left the operating room to Recovery in good condition. 2 PCS CODE 1 DX CODE 2.PREOPERATIVE DIAGNOSIS: High-grade asymptomatic right carotid artery stenosis. POSTOPERATIVE DIAGNOSIS: High-grade asymptomatic right carotid artery stenosis. PROCEDURE PERFORMED: Percutaneous transluminal angioplasty and stenting of the right internal carotid artery. (This was done under the Choice protocol.) ANESTHESIA: Local. INDICATION: The patient is a 72-year-old gentleman who is 10 years status post head and neck surgery for cancer, status post radiation, and has a tracheotomy in place. He has developed a high-grade asymptomatic right carotid artery stenosis. After reviewing the risks, benefits and alternatives of his options, he wished to proceed with carotid artery stenting, due to his high anatomical risk factors and high risk of nerve injury. He was enrolled under the Choice post market registry protocol. After the patient was correctly identified and consented, he was taken to the cardiac cath lab and placed in supine position. The right groin was prepped and draped in usual sterile fashion and anesthetized with 1% local. Using anatomical landmarks, the right common femoral artery was punctured with a micropuncture needle in a retrograde fashion. A 0.018-inch wire was then passed under fluoroscopy into the aorta. The needle was exchanged out for a 5-French coaxial dilator and subsequently for a 5-French sheath. Omni flush catheter was then taken into the arch in an LAO projection and aortogram was then performed. This demonstrates a mildly to moderately atherosclerotic aortic arch without any evidence of stenosis. The origins of the great vessels are identified, and these are widely patent without severe disease. The visualized portions of the right subclavian, vertebral, left subclavian, and left vertebral arteries are all widely patent without any evidence of severe disease. The left common carotid artery is patent proximally. The right common carotid artery arises from the innominate in a normal variant. The patient was then systemically heparinized, and his ACT was kept over 220 seconds throughout the entire case. The right common carotid artery was negotiated and then cannulated with a with a Bernstein catheter. With a catheter in the common carotid, angiogram was performed, which demonstrates a high-grade atherosclerotic lesion of the proximal right internal carotid artery MAC with 80-90% stenosis. Distal to this, the artery is widely patent. The external carotid artery is identified and is otherwise normal. An angled guide wire was then advanced deep into the external carotid artery branches and then the catheter was then tracked into this area. Using an exchange technique over an Amplatz wire, an 8-French JR guiding catheter was then advanced through sheath that had been exchanged into the groin and placed with its tip in the distal common carotid artery. With the catheter in this position, a Spider wire embolic protection filter wire was then advanced very carefully through internal carotid artery lesion and placed 5 cm distal to the area of treatment. The filter wire was deployed and a follow-up angiogram demonstrates excellent position without any evidence of embolism or vasospasm. After making appropriate measurements, an Abbott Xact 6 mm × 30 mm self-expanding stent was then deployed across the lesion under fluoroscopy with the filter in place. The stent opened and moved forward slightly but was otherwise in good position. With the stent completely deployed, a 6 × 20 mm balloon was then used to post dilate the stent to form full apposition. A follow-up angiogram was done, which demonstrates excellent treatment of the lesion with less than 20% residual stenosis. The filter wire is in place and does not appear to have a severe amount of debris within it. The filter was then retracted and removed and a cervical carotid angiogram demonstrated wide patency of the common internal and external carotid arteries. The AP and lateral views of the unilateral cerebral carotid demonstrated wide patency with excellent flow through the MCA distribution and cross filling without any evidence of embolism or vasospasm. The guiding catheter and sheath were then removed with direct manual compression held over the groin for 30 minutes. The patient was given protamine to reverse the heparin and then loaded with Plavix, given the placement of the stent. He maintained hemodynamic and neurological stability throughout the entire case. The wound was then cleaned, dried, and dressed using gauze and Tegaderm. The patient appeared to tolerate the procedure well. There were no immediate complications. The patient was taken to recovery room in stable condition. A total of 70 mL of contrast was used for the entire case. ONLY CODE THE DX CODE AND THE SENTING OF THE ARTER 3.PREOPERATIVE DIAGNOSIS: 1. Gangrene right foot. POSTOPERATIVE DIAGNOSIS: 1. Gangrene right foot. OPERATION: 1. Right below the knee amputation. ANESTHESIA: General LMA. PROCEDURE: The patient was brought to the operative suite where a general LMA anesthesia was induced. A Foley catheter was inserted and the right foot was secluded in an isolation bag and the right lower extremity circumferentially prepped and draped in its entirety. Beginning on the right side, the skin was marked with a marking pen 4 finger breadths below the tibial tuberosity anteriorly with a long posterior flap. The skin was incised circumferentially and the anterior musculature sharply divided, exposing the tibia. The tibia was cleaned with a periosteal elevator and then transected with the Stryker saw. The fibula was exposed and transected with the bone cutter and the amputation completed by sharply incising the posterior musculature. Bleeding vessels were ligated with 2-0 silk ligature. There appeared to be adequate bleeding at this level for primary healing the tibia was then cleaned with a bone rasp and the fibula with a tongeur. The wound was irrigated and ultimately closed without significant tension utilizing interrupted 2-0 vicryl sutures for reapproximation of the fascia and skin staples for reapproximation of the skin. The tibial tuberosity is found on the proximal anterior portion of the tibia, so the qualifier for high is selected. The right side was dressed with sterile gauze fluff dressing and a Kerlix roll. Estimated blood loss throughout the procedure was approximately 150 ml. The patient received one unit intraoperatively of packed cells because of preoperative anemia. She was transported in stable condition to the recovery room. 1 . 1 DX CODE AND 1 PCS CODE

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