DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left L5-S1 herniated nucleus pulposus.
2. Morbid obesity.
POSTOPERATIVE DIAGNOSES:
1. Left L5-S1 herniated nucleus pulposus.
2. Morbid obesity.
OPERATION PERFORMED: Left L5-S1 microdiskectomy.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
OPERATIVE FINDINGS: Herniated nucleus pulposus.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 70 mL.
DESCRIPTION OF OPERATION: The patient was seen in the preoperative holding area, and the surgical site was marked. After successful induction of general endotracheal anesthesia, the patient was placed on the Andrews table. The patient’s orbits, peripheral nerves, and bony prominences were padded and protected. The back was then prepped and draped in the usual sterile fashion. The patient was administered 2 g of Ancef prior to the incision. Safe time-out was performed.
A left L5-S1 paraspinal exposure was performed. An extra system was used throughout the case due to the deep nature of the incision and extra need for retraction. The skin was incised with a scalpel, and dissection was carried out with electrocautery. Another radiograph was obtained to confirm the L5-S1 interlaminar space prior to proceeding with the laminar foraminotomy.
High-speed bur was used to take down the leading edge of L5. Ligamentum flavum was released. Decompression was carried out to the medial wall of the left S1 pedicle. The patient was found to have a large extruded disk fragment. This was carefully mobilized from the thecal sac and nerve. Nerve root retractor was placed, and the disk herniation was removed.
With the diskectomy completed, the disk space was irrigated and free fragments were removed. We did have to use extra long retractors throughout the case to enable us to safely work within the spine. With the decompression and diskectomy completed, attention was turned to closure.
All bleeders were controlled using bipolar cautery. At the time of closure, the wound was copiously irrigated. The wound was closed in layers with interrupted 0 Vicryl in the fascia and 2-0 for the subcutaneous tissue. Subcutaneous tissue was injected with Marcaine. The skin was closed with 3-0 Monocryl and Steri-Strips. A sterile dressing was applied. The patient was awoken from anesthesia and transferred to the PACU in stable condition. All counts were correct x2 at the end of the procedure.
