DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Cleft palate.
2. Chronic bilateral otitis media.
POSTOPERATIVE DIAGNOSES:
1. Cleft palate.
2. Chronic bilateral otitis media.
OPERATION PERFORMED:
1. Palatoplasty.
2. Bilateral myringotomy and placement of transtympanic ventilation tubes.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia with orotracheal intubation.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 50 mL.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position on the operating table. General anesthesia by mask was uneventfully instituted, IV was started, and then intubation was uneventfully accomplished.
The operating microscope was brought into the field with the right ear first approached. Cerumen was removed from the canal and eardrum was noted to be intact and rather unremarkable. A myringotomy was made halfway between the annulus and the anterior annulus, pretty much at the level of the umbo and parallel to the long process of the malleus. Minimal amount of fluid was suctioned away and the middle ear mucosa appeared to be unremarkable. The Donaldson tube was placed uneventfully. Vasocidin was instilled into the ear and cotton ball was applied near the canal.
The same process was applied on the left side, although there was less cerumen. Myringotomy tubes being completed, attention was now directed to the palatoplasty. The face area was prepped in the usual manner and sterile drapes were applied in the usual fashion. Ampicillin 200 mg had been given for prophylaxis. With excellent illumination by headlight and loupe magnification, the palatoplasty was undertaken.
Dingman mouthgag and a throat pack were put in place; it was removed at the end of the case. The area was carefully examined and it was evident that we would need septal flap to complete the left nasal fistula closure. In addition, it was thought that a turn-down flap from the labiobuccal sulcus at the area of the anterior alveolar defect would be adequate to put a soft tissue plug in place without disturbing the periosteum of the alveolus itself.
Then, 6 mL of 1% lidocaine with 1:100,000 epinephrine was injected uneventfully into the palatal areas for hemostasis. Firm pressure was applied, and once white blanching was confirmed, the procedure was undertaken. A 12 blade was used to open up the free edge of the complete left cleft and deep resection was done with curved tenotomy scissors in soft palate and then a variety of palate resectors in the hard palate.
A 15 blade was used to complete the hard palatal incision along the margin of the dentition and this was raised up with Cottle elevator. Hemostasis was obtained with topical epinephrine on neuro patties and also selected Bovie cauterization. The muscle was taken down from the free edge of the bony palate and the nasal surface was separated along the inferior and particularly medial edges, so that the nasal fistula could be closed.
Attention was now directed to the right side, where we similarly dissected up the soft palate, including separating the muscle from both the nasal and oral surfaces so they could be redirected in the desired horizontal direction. A portion of the septum was kept attached to this particularly, extension posteriorly, so it could be placed into the junction between the hard and soft palates. On the left side, we raised up enough of the septum to allow closure to the nasal surface of the hard palate. Additional hemostasis was obtained with the Bovie. Good condition and vitality of all the tissue was seen.
From the alveolus, a running 4-0 Vicryl was used to close the septal flap to the nasal surface of the hard palate flap all the way back to the point of the choana. The uvula was brought together with a buried 4-0 Vicryl suture and then the soft tissue was brought together with the running 4-0 Vicryl. The nasal surface of the soft palate was closed up to the point of the septal flap also with a running 4-0 Vicryl suture.
The muscle was rather thick, but not particularly long, in the anterior to posterior dimension. The muscle was brought together with two well-placed 4-0 Vicryl mattress sutures. The oral surface was now closed with multiple interrupted sutures of 4-0 Vicryl, including setting in the septal flaps so that the conjunction between the hard and soft palates was closed completely. The flap was sutured with the horizontal mattress suture through and through, holding it down to the nasal surface repair, and several tacking sutures were placed around the periphery.
We did raise up a U-flap in the sulcus and sutured that to the end of the palate repair across the alveolar defect. The throat pack was removed. All the neuro patties and sponges were removed. Suction was done down the esophagus, into the stomach and then also in the pharynx and the nose. No active bleeding. Excellent repair. The mouthgag was then removed. Needle and sponge counts were correct. Anesthesia was ended. The patient was extubated uneventfully and escorted to the recovery area, having tolerated the procedure and anesthesia in satisfactory condition.
