DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiple endocrine neoplasia.
POSTOPERATIVE DIAGNOSES:
1. Pancreatic islet cell tumor.
2. Fibroma, left inner thigh.
3. Primary hyperparathyroidism with four-gland hyperplasia.
OPERATION PERFORMED:
1. Total parathyroidectomy with autoimplantation of cubed parathyroid tissue in left forearm.
2. Distal pancreatectomy with en bloc splenectomy.
3. Excision, left inner thigh fibroma.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient’s left leg was prepped and draped. There was no adenopathy. A fleshy pedunculated mass was identified. She was prepped and draped here. An elliptical incision was made. We excised the mass down to the subcutaneous tissue and achieved hemostasis and sent the mass to pathology. It appeared to be an innocuous growth. The wound was closed with 2-0 nylon mattress sutures.
We then had a preoperative PTH drawn; the number was 206. We then made an incision two fingerbreadths above her sternal notch. We dissected down to the platysma muscle and elevated flaps to the sternum and to the sternal notch and the thyroid cartilage. The strap muscles were then exposed. The cervical fascia was opened, and the thyroid was identified. We began on the right side elevating the strap muscles and rotating the thyroid upward. Note that a NIM monitoring device was used to identify the nerves and preserve them throughout the procedure. At the end of the neck exploration, all nerves were noted to be functioning.
In any case, we explored the neck. We eventually found four hyperplastic parathyroids ranging from anywhere between 200 and 1.2 grams. The largest was in the right upper and left upper. There was no evidence of other parathyroid tissue. The parathyroids were exactly where they should be at the level of the inferior thyroid artery slightly medial and then just above the nerve superiorly. The thyroid was inspected, and it was unremarkable. Upon removal of the parathyroids, the rapid PTH level was 6.
We preserved half of the fourth parathyroid and placed it in ice. We reinspected the neck, assured ourselves of hemostasis with FloSeal and multiple clips, again taking great care to preserve the nerve. Lap, needle, and instrument counts were correct. The strap muscles were reapproximated in midline. The platysma was reapproximated using 3-0 Vicryl as well. Skin was closed with fine absorbable suture. Benzoin, Steri-Strips, and dry dressings were applied.
We then prepped the left arm, identified the brachioradialis, made a small incision, entered the muscular fascia, spread the muscular fibers apart, and inserted the parathyroid tissue which had been diced to approximately a milliliter in size on ice. The parathyroid tissue was secured in the muscle using 3-0 Vicryl. The wound was closed in multiple layers using fine absorbable suture.
We then exchanged instruments and gowns and prepped and draped. A Foley had been inserted initially. Left subcostal incision was made. We entered the abdomen. The abdomen was explored. There were no overt abnormalities. Bookwalter retractor was installed to facilitate exposure. NG tube was positioned. The lesser sac was entered, and preserving the gastroepiploics, all short gastrics and other tissue were taken using a LigaSure all the way up to the hiatus.
The diaphragmatic attachments of the spleen were taken using the endovascular GIA. The left colon was mobilized and its attachments to the spleen were taken down. Splenic flexure was taken down. We could not identify exactly where the mass was but knew it was in the tail. With much inspection, however, it was demonstrated to be just to the other side of the body, just to the left of the superior mesenteric vein. It appeared well encased; did not appear amenable to nucleation. We elevated the pancreas off of the superior mesenteric vein, and just to the left of this, keeping a good margin in mind and noting no other masses or problem, divided the pancreas and the splenic vein and artery using two loads of the endovascular GIA.
The pancreatic staple line was oversewn using 2-0 silk suture. Hemostasis was assured. Remaining retroperitoneal attachments were taken using the LigaSure. Duodenum, colon, and retroperitoneal structures were identified and preserved. The specimen was then amputated. Inferior mesenteric vein was preserved. It was sent off the field. Dr. (XX) confirmed adequate margin with neuroendocrine tumor.
We assured ourselves of hemostasis. Seprafilm was placed throughout the abdomen, including in the lesser sac. The abdomen was further explored, and all lap, needle, and instrument counts were correct. Two large Blake drains were placed near the pancreatic bed and left upper quadrant. The entire head of the pancreas with a small sliver of body was noted to remain intact.
A Seprafilm was placed atop the hollow viscera, and the drains were anchored to the skin using silk suture. The fascia was closed and the posterior sheath using heavy Vicryl suture from either end and the anterior sheath using heavy PDS suture. Subcutaneous tissues were irrigated, and the subcutaneous tissues were approximated using an absorbable stapler. The skin was then closed with the absorbable stapler. Dry dressings were applied to the wound. The patient appeared to tolerate the procedure.
