This edition first published 2019
© 2019 by John Wiley & Sons Ltd
Edition History [1e, 2009]
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Library of Congress Cataloging‐in‐Publication Data
Names: Armenakas, Noel, author. | Fracchia, John A., author. | Golan, Ron, author.
Title: Operative dictations in urologic surgery [electronic resource] / Noel A. Armenakas, John A. Fracchia, Ron Golan.
Description: Hoboken, NJ : Wiley Blackwell, 2019. | Includes bibliographical references and index. |
Identifiers: LCCN 2019003282 (print) | LCCN 2019004182 (ebook) | ISBN 9781119524304 (Adobe PDF) | ISBN 9781119524335 (ePub) | ISBN 9781119524311 (pbk.)
Subjects: | MESH: Urologic Surgical Procedures–methods
Classification: LCC RD572 (ebook) | LCC RD572 (print) | NLM WJ 168 | DDC 617.460597–dc23
LC record available at https://lccn.loc.gov/2019003282
Cover Design: Wiley
Cover Image: © Blend Images ‐ ERproductions Ltd/Getty Images
To all the past, present, and future residents who continue to inspire us
and from whom we never cease to learn.
This is an essential book for all urological surgeons. It should be studied by urological residents as well as mature urological surgeons to enhance the knowledge of information needed in an operative report.
The details of the necessary information in an operative report are provided for virtually all urological procedures that I can think of, including open surgery as well as endoscopic, percutaneous, laparoscopic, and robotics. Each procedure has a template that serves as a valuable guide for the detailed information to be included in the operative record so it provides essential information should the surgeon need to recall what was done if complications occur or the procedure fails, and it is available for review years later if necessary.
In addition, the operative record is a legal document, and detailed procedures are necessary should a medico‐legal issue arise. In my review of operative dictations in medico‐legal issues, I find operative reports are frequently inadequate and deficient in details of the operation. A sound operative report can address many issues that can potentially arise, and this book provides the necessary guidance in a format that will result in an excellent, comprehensive report even in the most complex procedures.
Another wonderful aspect of this book is that it serves as a verbal atlas for the 126 surgical procedures provided. A surgeon can read the examples of each procedure and, with previous understanding of anatomy and pathology, can know in detail, from start to finish, how the procedure is done. I find this a rewarding feature.
The authors, Professors Armenakas and Fracchia, are outstanding surgeons who have successfully demonstrated in this book the detailed methodology of composing an operative dictation. They have included Dr. Golan, the chief urology resident at Cornell, to have input and insight from a young surgeon, which adds diversity and completeness to the project.
This is a unique book and a “must” for every urologist.
Teaching is the highest form of understanding.
——Aristotle——
The impetus for writing Operative Dictations in Urologic Surgery arose from the need for a dedicated operative dictation text that describes each surgical procedure in a stepwise, methodical, and detailed format. The available urologic surgical atlases, which are exceptional, provide a hybrid operative description combining high‐level illustrations with a narrative. Our objective was to focus and expand on the narrative and create a step‐by‐step “cookbook”‐type description in a comprehensive, all‐inclusive operative dictation format. In addition, for each procedure we have included the indications, essential steps, variations and complications. Space is provided after each section to allow for user notes.
It was not possible to describe every operation with their infinite variations. Instead, we have chosen 126 of the most relevant adult and pediatric urologic surgical procedures, and included both open and minimally invasive techniques. Although there are many technical options for each procedure, ranging from the sutures used to the details of each surgical step, we have attempted to incorporate a comprehensive operative description that is accurate, informative, and universally applicable. Details including types of retractors, sutures, dressings, etc. are meant only as a guide and will understandably vary from surgeon to surgeon.
In undertaking the preparation of this textbook, we have referenced multiple texts and atlases, including Hinman's Atlas of Urologic Surgery, Glenn's Urologic Surgery, Atlas of Urologic Clinics, and Campbell‐Walsh Urology. These valuable resources, coupled with our personal surgical experiences totaling more than 75 years in aggregate, provide the basis of this book. Each of us separately and independently reviewed and critiqued all of the material. For this reason, we decided not to assign authorship to any of the individual chapters.
We acknowledge and thank all our teachers and residents who have educated, guided, and inspired us throughout the years. It is our hope and expectation that Operative Dictations in Urologic Surgery will serve preoperatively as a valuable and informative resource in preparation for surgery and will assist postoperatively in creating a dictation that is comprehensive, accurate, and medico‐legally sound. We are grateful for the opportunity to share these operative dictations with you and welcome your comments and suggestions.
Please send email communications to: operativedictations@gmail.com
Preoperative diagnosis: Adrenal tumor
Postoperative diagnosis: Same
Procedure: Right/Left adrenalectomy
Indications: The patient is a _____‐year‐old male/female with a ____cm right/left adrenal tumor presenting for an adrenalectomy.
Description of Procedure: The indications, alternatives, benefits, and risks were discussed with the patient and informed consent was obtained.
The patient was brought onto the operating room table, positioned supine, and secured with a safety strap. Pneumatic compression devices were placed on the lower extremities.
After the administration of intravenous antibiotics and general endotracheal anesthesia, a 16 Fr urethral catheter was inserted into the bladder and connected to a drainage bag.
The patient was placed in the lateral decubitus position at a 45° angle with the lower leg flexed 90° and the upper leg extended. An axillary roll was positioned to protect the brachial plexus and a gel pad placed to support the back. Multiple pillows were used to pad beneath and between both the upper and lower extremities to ensure adequate cushioning. The kidney rest was elevated and the table flexed and adjusted horizontally, obtaining optimal flank exposure. The patient was secured to the table with 3 in. surgical tape and safety straps, and was prepped and draped in the standard sterile manner.
The radiographic images were in the room.
A time‐out was completed, verifying the correct patient, surgical procedure, site, and positioning, prior to beginning the procedure.
The space between the 10th and 11th ribs was palpated and an incision made at this level from the mid‐axillary line and extended medially to the lateral border of the rectus abdominis muscle. Using electrocautery, the latissimus dorsi and external oblique muscles were incised, exposing the underlying ribs. The intercostal attachments were transected, taking care to avoid injury to the pleura and neurovascular bundle on the inferior surface of the rib. The internal oblique muscle was divided with cautery and the transversus abdominis carefully split in the direction of its fibers, avoiding entry into the peritoneum. A generous paranephric space was created by sweeping the peritoneum medially and the retroperitoneal connective tissue superiorly and inferiorly. A self‐retaining retractor (e.g. Bookwalter, Omni‐Tract) was appropriately positioned to optimize exposure, using padding on each retractor blade.
The parietal peritoneum was incised on the white line of Toldt and the colon reflected medially, exposing Gerota's fascia.
The dissection was continued cranially, using gentle downward traction from lateral to medial. Multiple small adrenal branches were ligated using an electrothermal bipolar tissue sealing device (LigaSure)/surgical clips, freeing all apical adrenal attachments. (Alternatively, these vessels can be clamped, divided, and ligated with chromic or silk ties). The adrenal gland was retracted laterally exposing the remaining medial vascular and lymphatic attachments, which were divided between surgical clips. Finally, the inferior surface of the adrenal gland was dissected off the renal capsule using sharp and blunt dissection, and meticulous hemostasis obtained with electrocautery.
Once the specimen was completely freed, it was removed and sent to pathology for evaluation. The retroperitoneum was irrigated with warm sterile saline and hemostasis was again confirmed. Prior to closure, the vascular stumps, visceral organs and pleura were inspected and found to be intact. The self‐retaining retractor was removed, the kidney rest lowered, and the table taken out of flexion.
The incision was closed using running 1‐0 polydioxanone (PDS) to approximate the three muscle layers individually, taking care not to entrap the neurovascular bundle. 3‐0 chromic sutures were used on Scarpa's fascia and the skin approximated with a subcuticular 4‐0 poliglecaprone (Monocryl) suture. A sterile dressing was applied and the patient repositioned supine.
At the end of the procedure, all counts were correct.
The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.
Estimated blood loss: Approximately ________ml
Suitable candidates must be willing and able to catheterize and have normal renal function. They should be free of any small (if using ileum) or large (if using colon) bowel disease.
Preoperative diagnosis: Neurogenic bladder
Postoperative diagnosis: Same
Procedure: Augmentation cystoplasty
Indications: The patient is a ____‐year‐old male/female with a severely debilitating poorly compliant bladder presenting for augmentation cystoplasty.
Description of Procedure: The indications, alternatives, benefits, and risks were discussed with the patient/patient's family and informed consent was obtained.
The patient was brought onto the operating room table, positioned supine, and secured with a safety strap. All pressure points were carefully padded and pneumatic compression devices were placed on the lower extremities.
After the administration of intravenous antibiotics and general endotracheal anesthesia, the lower abdomen and external genitalia were prepped and draped in the standard sterile manner.
A time‐out was completed, verifying the correct patient, surgical procedure, and positioning, prior to beginning the procedure.
A ___Fr urethral catheter was inserted into the bladder and the bladder distended with sterile normal saline to aid in dissection of the bladder wall from the peritoneum.
A midline abdominal incision was made from the umbilicus to the pubic symphysis. The subcutaneous tissue was incised with electrocautery, exposing the underlying rectus abdominis aponeurosis. This was incised at the linea alba and the rectus abdominis muscles separated at the midline and retracted laterally, taking care not to injure the underlying inferior epigastric vessels.
The peritoneum was freed posteriorly to the level of the trigone and the bowel was thoroughly packed into the upper abdomen. A self‐retaining retractor (e.g. Bookwalter, Omni‐Tract, Balfour) was appropriately positioned to optimize exposure, using padding on each retractor blade. The bladder wall was identified and four 2‐0 polyglactin (Vicryl) sutures were used to outline a wide U‐shaped posterior incision extending from the bladder dome to an area just superior to where the ureters enter the bladder; this created a large, anteriorly based bladder flap with a posteriorly facing opening.
The bowel packing was removed and attention was focused on isolating an appropriate ileal segment. The distal ileum was inspected and a 25 cm segment of ileum was chosen, 15–20 cm from the ileocecal valve and marked with a silk suture. With the aid of transillumination, the ileocolic and right colic arteries were identified. An avascular mesenteric window was opened on each side of the desired ileal segment using an electrothermal bipolar tissue sealing device (LigaSure) to incise and ligate the mesentery on both sides, avoiding injury to the main intestinal vasculature. (Alternatively, the mesentery can be incised and its blood vessels individually clamped, divided and doubly ligated with chromic or silk ties.) Additional hemostasis was achieved using 3‐0 chromic/silk ties. The isolated ileal segment was transected at its proximal and distal antimesenteric borders, using a GIA60 stapler.
The continuity of the distal ileum was restored using a stapled technique as follows: The antimesenteric corners of the proximal and distal ileal segments were identified, and a small segment of tissue was resected off each end of the stapled suture lines. One limb of the GIA60 stapler was inserted into the proximal and the other into the distal ileal segment with care taken not to injure the bowel mesentery. The ileal segments were rotated ensuring that the antimesenteric bowel walls faced each other prior to firing the stapler. Four small clamps were then placed on the ends of the transected bowel. The two clamps on the lines of the original bowel transection were held together, while the others were spread apart, creating a wide opening. A TA55 stapler was used to complete the functional end‐to‐end ileoileal anastomosis. The staple line was checked confirming its integrity, and additionally reinforced with interrupted 3‐0 silk sutures. The mesenteric window was closed with a running 4‐0 chromic to avoid internal herniation. The ileoileal anastomosis was returned to its natural position in the abdomen with the isolated ileal segment placed caudal to it.
Attention was then turned to the isolated ileal segment, which was opened at its antimesenteric border. Both staple lines were resected to avoid subsequent stone formation. The bladder mucosa was copiously irrigated with sterile normal saline. The posterior wall of the ileal segment was folded back on itself and sutured together with running, locking 3‐0 Vicryl sutures, creating a bowel cup to be anastomosed to the bladder.
The augmentation opening in the bladder was measured and the superoanterior wall of the ileal segment was closed with interrupted 3‐0 Vicryl sutures to match this opening. The configured ileal segment was sewn onto the opened bladder using running, locking 3‐0 Vicryl sutures, proceeding from the most inferoposterior aspect cephalad.
An 18 Fr urethral catheter was inserted into the bladder and the bladder distended with 300 ml sterile normal saline confirming a watertight reconstruction. (Note: If a suprapubic tube is desired for drainage, it can be placed through the lateral bladder wall, not through the ileal segment.)
Having completed the enterocystoplasty, the abdomen was irrigated with warm sterile normal saline and examined for any bleeding. Meticulous hemostasis was obtained. A surgical drain (e.g. Jackson‐Pratt) was placed in the retroperitoneum and brought out at the skin through a separate stab incision, where it was secured with a 2‐0 silk suture. Prior to closure, the ureters, bladder, bowel, mesentery and abdominal wall were inspected and found to be intact without any evidence of devascularization or injury.
The self‐retaining retractor was removed and the abdominal incision was closed using a running 2‐0 chromic to approximate the rectus muscles and 1‐0 polydioxanone (PDS) for the rectus aponeurosis. 3‐0 chromic sutures were used on Scarpa's fascia and the skin approximated with a subcuticular 4‐0 poliglecaprone (Monocryl) suture. The incision was reinforced with sterile adhesive strips and a sterile dressing applied. The urethral catheter was connected to a drainage bag.
At the end of the procedure, all counts were correct.
The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.
Estimated blood loss: Approximately ___________ml