PREOPERATIVE DIAGNOSIS:
Left carotid stenosis 80%.
POSTOPERATIVE DIAGNOSIS:
Left carotid stenosis 80%.
OPERATION PERFORMED:
Left carotid endarterectomy with Dacron patch angioplasty.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male with a long-standing history of vascular disease. He had recent carotid imaging demonstrating severe stenosis bilaterally. He has had a previous right carotid endarterectomy. He was returned to the operating room today for left carotid endarterectomy for an 80% stenosis.
DESCRIPTION OF OPERATION: The patient was placed in the supine position on the operating table following the induction of general endotracheal anesthesia. The left side of the neck was prepped and draped in the usual sterile fashion. The proposed incision site was infiltrated with 1% Xylocaine with epinephrine.
A skin incision was made with a scalpel along the anterior border of the left sternocleidomastoid muscle. Subcutaneous tissues and platysma were divided. The deep cervical fascia along the anterior border of the sternocleidomastoid muscle was divided. The common facial vein was ligated in continuity with 2-0 silk ties, clipped with Hemoclips, and divided. The common, internal, and external carotid arteries were dissected out and surrounded with vessel loops. Great care was taken to identify the vagus and hypoglossal nerves and to avoid injury to these structures.
Then, 8000 units of heparin was administered intravenously and allowed to circulate for 3 minutes. The internal carotid artery was then occluded followed by occlusion of the common and external carotid arteries. A #11 blade was used to make an arteriotomy in the common carotid artery. The arteriotomy was extended with Potts scissors through the bulb and up the internal carotid artery to a point beyond the distal extent of disease. A 3.0 x 4.0 Heyer-Schulte shunt was inserted and held in place with Javid shunt clamps. Shunt patency was confirmed with the Doppler.
Standard endarterectomy and carotid bifurcation were then performed using the Penfield. Eversion technique was used to facilitate endarterectomy in the external carotid artery. The distal endpoint feathered smoothly at the proximal internal carotid artery level. Any remaining loose atheromatous tissue was removed with plaque forceps. The surface of the artery was irrigated with copious amounts of heparinized saline. A Meadox Hemashield Finesse patch was obtained. The arteriotomy was closed as Dacron patch angioplasty using running 6-0 Prolene suture.
Just prior to completing the angioplasty, the shunt was removed and appropriate back bleeding and flushing maneuvers were performed. The angioplasty was then completed. Just prior to tying down the sutures, the external carotid artery was opened and allowed to backbleed to allow any air to escape from the vessel. The sutures were then tied down. The common carotid artery was opened. After several cardiac cycles, the internal carotid artery was opened. Doppler interrogation revealed normal signals in the common, internal, and external carotid arteries.
Heparin was then reversed with 50 mg of intravenous protamine. Hemostasis was meticulously achieved. The wound was irrigated with antibiotic solution. All vessel loops and retractors were removed. The platysma was closed with running 3-0 Vicryl suture. The skin was closed with a running 4-0 PDS subcuticular suture. Benzoin and Steri-Strips were applied. Sterile dressings placed over the incision. The patient was then awakened and extubated. He was noted to be neurologically intact. He was transferred to recovery room in stable condition.
