DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: End-stage renal disease secondary to IgA nephropathy, requiring hemodialysis access.
POSTOPERATIVE DIAGNOSIS: End-stage renal disease secondary to IgA nephropathy, requiring hemodialysis access.
OPERATION PERFORMED: Right upper arm AV fistula with a Gore-Tex loop graft.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia via LMA along with 0.5% Marcaine with epinephrine for local anesthetic.
SPECIMENS: None.
ESTIMATED BLOOD LOSS: 15 mL.
INDICATIONS FOR OPERATION: This is a (XX)-year-old male with multiple medical problems and end-stage renal disease secondary to IgA nephropathy. He has been having dialysis via a right internal jugular vein PermCath and has had a left AV fistula created in the past; however, due to occlusion of his central vein on the left side, the AV fistula failed in the long term. Subsequently, the patient has been receiving all hemodialysis through this right internal jugular PermCath for approximately 2 years; however, he has been readmitted to the hospital with gram-negative rod bacteremia. This bacteremia was thought to be secondary to his indwelling dialysis catheter; therefore, this was removed. Therefore, the patient and his wife elected to have a right upper arm AV fistula created using a Gore-Tex graft.
DESCRIPTION OF OPERATION: The patient was brought to the operating suite and placed in the supine position. General anesthesia was then induced via LMA mask. Preoperative antibiotics consisting of 1 g of Ancef was administered prior to the first skin incision. The patient’s right arm was then prepped and draped in normal sterile manner.
An approximately 6.5 cm incision was made on the medial aspect of his right upper arm. This incision was then dissected down through the fascia using electrocautery. Once the fascia was opened using sharp dissection with Metzenbaum scissors, the right brachial artery and brachial vein were isolated. Once these 2 vessels were isolated, 2 small approximately 1 cm incisions were made on the medial and lateral aspects of his distal upper arm, and using a 26-French tunneling device, 5 to 7 mm Gore-Tex graft was then placed in a looped manner in the subcutaneous tissue. Starting with the brachial vein, the Gore-Tex graft was anastomosed using a running 6-0 Prolene suture. The brachial artery-to-graft anastomosis was also fashioned using a running 6-0 Prolene suture. The arterial arm of the graft is on the lateral aspect of his upper arm and the venous aspect is on the medial aspect of this arm. Once the arterial and venous limbs were anastomosed, the vascular clamps were removed revealing adequate back flow to the arterial limbs. Using an intraoperative Doppler, there was audible blood flow through the arterial as well as venous limbs. There was a faint palpable thrill in the upper extremity. The two 1 cm incisions in his distal upper arm were then closed in 2 layers using 4-0 Monocryl sutures.
The brachial wound was then closed in 2 layers using interrupted 4-0 Monocryl for the deep dermis and running 4-0 subcuticular Monocryl for the skin. The wounds were then dressed in a normal manner with Dermabond and a loose Ace wrap. The patient was awakened from general anesthesia and brought to the recovery room in stable condition. Needle and sponge counts were correct x2. There were no complications. Estimated blood loss was 15 mL. There were no specimens removed.
