DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left L5-S1 disk herniation.
POSTOPERATIVE DIAGNOSIS: Left L5-S1 disk herniation.
OPERATION PERFORMED: Left L5-S1 microdiskectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ESTIMATED BLOOD LOSS: Less than 20 mL.
COMPLICATIONS: None.
SPECIMENS: None.
HISTORY: The patient has a left-sided L5-S1 disk herniation with mass effect on the left S1 nerve root. The patient was brought in for a left L5-S1 microdiskectomy.
DESCRIPTION OF OPERATION: The patient was brought to the operating room where general endotracheal anesthesia was induced. He was positioned prone, and the lumbar skin was prepped with Betadine. The C-arm fluoroscopy was used to localize the trajectory from the skin aiming towards L5-S1 interspace from approximately 3 cm lateral to the midline.
When the trajectory was confirmed on AP and lateral fluoro images, the skin incision was made as a parasagittal linear incision measuring about 2.5 cm. The incision was then infiltrated with 0.5% Marcaine with 1:200,000 dilution epinephrine and the dilating tubes were passed. A 5 cm METRx self-retaining retractor was used to maintain exposure. The overlying muscle was removed, and the inferior lamina of L5 was thinned with a high-speed drill. Under the operating microscope, a series of rongeurs were used to remove the inferior L5 lamina. The ligamentum flavum and underlying periosteum were removed. The epidural fat was removed, and the dura of the thecal sac and S1 nerve root sheath were exposed.
Under the operating microscope, the nerve root sheath was retracted medially, and there was a large subligamentous disk herniation noted to be compressing the left S1 nerve root. A tiny hole was made in the posterior longitudinal ligament exposing the herniated disk. Pituitary grasping forceps was used to remove the herniated disk, and there was no longer any compression of the left S1 nerve root. The field was irrigated with bacitracin solution and Gelfoam was placed in the epidural space. The muscle was then infiltrated with 0.5% Marcaine with 1:200,000 dilution of epinephrine.
The muscle was closed with interrupted 3-0 Vicryl suture. The dermis was closed with interrupted 3-0 Vicryl suture. The skin edge was closed with running 4-0 Monocryl subcuticular suture. Dermabond was applied to the wound, and the patient was returned into the supine position, extubated, and transferred to the recovery room in stable condition. Sponge and needle counts were correct at the end of the procedure.
