Trollope
Informed Consent
After reviewing the procedure with ?? and having ?? read and sign our Informed Consent Sheet,
the patient was brought to the Endoscopy Suite and an intravenous line was started in the ??
forearm. During the course of the procedure ?? received a total dose of ?? mg Demerol and ??
mg Versed.
Colonoscopy
After reviewing the procedure with ??, and having ?? read and sign our Informed Consent Sheet,
the patient was brought to the Endoscopy Suite and an intravenous line was started in the ??
forearm. During the course of the procedure ?? received a total dose of ?? mg Demerol and ??
mg Versed.
The Olympus video colonoscope was inserted to the cecum without difficulty. An excellent view
of the entire colon was obtained. The ileocecal valve and appendiceal orifice were clearly
identified and were normal.
As the scope was withdrawn no polyps or other abnormalities were seen.
IMPRESSION: Normal colonoscopy.
RECOMMENDATIONS: Re-colonoscope in ?? years.
Colonoscopy Informed Consent
The procedure, risks and details of colonoscopy and possible colonoscopic polypectomy were discussed with the
patient. The main complications of bleeding and perforation were emphasized. A detailed explanation of how the
procedure would be performed was given. The patient seemed to understand the procedure and what was involved,
and was given one of our Informed Consent Sheets for preparation. An appointment will be made to undergo the
exam in the near future.
Hemorrhoidectomy
It is painful enough and irritated enough to require local excision. This was described using
Frank Netter drawings.
The area was infiltrated with 0.5% Xylocaine with epinephrine and the area of thrombosis
excised. The clot was removed from the base and meticulous hemostasis obtained. The wound
was packed open with Gelfoam gauze.
The patient was given complete instructions on postoperative care and for dressing changes and
soaking. Given an analgesic and Ela-Max Cream for local application to the wound.
Instructions
Was given one of our patient information booklets about fissures and started on a high bulk diet
and stool softeners. Will start sitz bath several times a day and apply Analpram. Explained that
surgery is usually not needed but occasionally a fissurectomy/sphincterotomy becomes
necessary. Will see again in one month. Gave the patient information about Botox which would
be our next step in therapy if the patient does not respond to standard initial medical
management.
Abscess
5 cc of 1% Xylocaine with epinephrine were gently infiltrated over the surface of the most
prominent point of the abscess cavity, and a #15 blade used to perform a small elliptical incision
over this area with release of pus. This resulted in good drainage.
Will start on sitz baths, was placed on oral antibiotics, and the patient was given handouts for
postoperative management as well as prescriptions for p.o. Keflex and Vicodin for pain.
Went over in detail with the patient the possibility that this may or may not end up being a fistula
in ano, and the fact that a fistulotomy in the future may or may not be needed, depending on how
this heals.
Gastroscope
The Olympus video gastroscope was inserted through the oropharynx and esophagus without
difficulty.
Rubber banding
Patient enters today for evaluation of rectal bleeding.
Anoscopy revealed hemorrhoidal tissue. After explaining the procedure, risks and benefits of the
procedure, a rubber band placed today on a hemorrhoid in the ?? position. Tolerated it well.
Will wait 6-8 weeks before doing another.
Pilonidal cystectomy
Operative Note:
Dr. Trollope: ??enters today for pilonidal cystectomy.
Following the establishment of general anesthesia, the patient was rolled onto his side and
prepped and draped in standard fashion. The pilonidal was elliptically excised with
encompassing of all the external skin openings in the midline. This was unroofed down to the
base of the abscess where all the hair and debris and granulation tissue was completely unroofed
and debrided. Side tracts were unroofed as well.
Meticulous hemostasis was then obtained with the cautery and the wound infiltrated with 0.5%
Marcaine. The wound was then packed open with Adaptic and antibiotic ointment and packed
open with gauze. A simple external dressing was then applied and the patient taken to the
recovery room in satisfactory condition.
Inguinal hernia repair
Operative Note:
Dr. Trollope: Mr. enters today for ??inguinal hernia repair with a laparoscopic approach. He is
well informed as to the comparative risks and benefits of a laparoscopic procedure versus a
standard open procedure.
Following the establishment of general anesthesia, he was prepped and draped in the standard
fashion. A transverse incision was made below the umbilicus and dissection carried through the
skin and subcutaneous tissue. The anterior rectus sheath was opened and the rectus muscle
retracted laterally. The Origin balloon-dissecting catheter was brought along the posterior
surface of the rectus muscle and inflated under direct vision. Dissection was carried out laterally
to elevate the inferior epigastric vessels superiorly and to demonstrate the lateral peritoneal
reflection. Medially the dissection was carried down onto the base of the bladder and onto the
pubic symphysis and Cooper's ligament.
Two inferior trocars were then placed, two 5 mm in the midline under direct vision with no
injury to the viscera and without entry into the abdomen. Under direct vision, dissection was
begun in the ?? inguinal area. The inferior epigastric vessels were used to identify the internal
ring and lateral dissection carried out to encircle the cord. The testicular vessels as well as the
vas were readily identified.
??(FINDINGS)
Next, two pieces of polypropylene mesh 4 x 5-1/2 inches were cut in elliptical fashion. The first
one was cut to provide a lateral keyhole slit to wrap around the internal ring to provide a new
internal ring for passage of the cord. The first piece of mesh was placed with the keyhole around
the cord and secured in the superior lateral position with care taken to avoid the Origin tacker
being placed in the inferolateral area where the inguinal nerves are and with no Origin tacker
placed over the femoral vessels. This was secured, however, along transversalis fascia above
and along Cooper's ligament in the medial area. Care was taken again to avoid injury with the
Origin tacker over the femoral vein. The second piece of mesh was then placed over this to
provide a sandwich mechanism over the cord to prevent any new herniation along the internal
ring. A final inspection at this time was made for bleeding. The prevesical space was irrigated
with antibiotic solution and Marcaine and the trocars removed. The fascia was closed with 2-0
Vicryl and the skin with subcuticular 3-0 Vicryl. The wound was infiltrated with another 15 cc
of 0.5% Marcaine. Simple external dressings were applied and the patient taken to the recovery
room in satisfactory condition.
Bilateral inguinal hernia repair
Dr. Trollope: Mr. enters today for repair of bilateral inguinal hernias with a laparoscopic
approach. He is well informed as to the comparative risks and benefits of a laparoscopic
procedure versus a standard open procedure.
Following the establishment of general anesthesia, he was prepped and draped in the standard
fashion. A transverse incision was made below the umbilicus and dissection carried through the
skin and subcutaneous tissue. The anterior rectus sheath was opened and the rectus muscle
retracted laterally. The balloon-dissecting catheter was brought along the posterior surface of the
rectus muscle and inflated under direct vision. Dissection was carried out laterally to elevate the
inferior epigastric vessels superiorly and to demonstrate the lateral peritoneal reflection.
Medially the dissection was carried down onto the base of the bladder and onto the pubic
symphysis and Cooper's ligament.
Two inferior trocars were then placed, two 5 mm in the midline under direct vision with no
injury to the viscera and without entry into the abdomen. Under direct vision, dissection was
begun in the left inguinal area. The inferior epigastric vessels were used to identify the internal
ring and lateral dissection carried out to encircle the cord. The testicular vessels as well as the
vas were readily identified.
??(FINDINGS)
Next, two pieces of polypropylene mesh 4 x 8 inches were cut in elliptical fashion. The first
piece of mesh was placed on the left with the keyhole around the cord and secured in the superior
lateral position with care taken to avoid staples being placed in the inferolateral area where the
inguinal nerves are and with no staples placed over the femoral vessels. This was secured,
however, along transversalis fascia above and along Cooper's ligament in the medial area. Care
was taken again to avoid injury with staples over the femoral vein. An identical procedure was
then performed on the right side. A single piece of mesh 4 x 10 inches was then placed across
the right and left inguinal areas to cover the first piece of mesh and to sandwich the cord to
prevent any new herniation along the internal ring. This was stapled in place identically to the
first pieces. A final inspection at this time was made for bleeding. The prevesical space was
irrigated with antibiotic solution and Marcaine and the trocars removed. The fascia was closed
with 2-0 Vicryl and the skin with subcuticular 3-0 Vicryl. The wound was infiltrated with
another 15 cc of 0.5% Marcaine. Simple external dressings were applied and the patient taken to
the recovery room in satisfactory condition.