DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Recurrent right-sided epistaxis.
POSTOPERATIVE DIAGNOSIS: Recurrent right-sided epistaxis.
OPERATIONS PERFORMED:
1. Right sphenopalatine artery ligation.
2. Right anterior ethmoidectomy.
3. Left sinus exploration.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Approximately 150 mL.
SPECIMENS: None.
OPERATIVE FINDINGS: There were no remarkable findings in the nasal cavity. The patient did have synechia of the left middle turbinate to the septum. This was most likely due to her previous multiple packings of the sinus cavities.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female who has had a history of recurrent right-sided epistaxis requiring multiple packings. The decision was made to take the patient to the operating room for an elective right sphenopalatine artery ligation and anterior ethmoidectomy. The risks and benefits of the procedure were explained to the patient, and the decision was made to proceed.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in the supine position on the operating room table. General face-mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned. Afrin-soaked pledgets were placed in the areas bilaterally allowing for decongestion. After approximately 5 minutes, the nasal pledgets were removed, and 4 mL of 1% lidocaine with 1:100,000 epinephrine was injected in the left and right nasal cavities. Injection sites included the septum, middle turbinate, and the superior uncinate. The Afrin-soaked nasal pledgets were placed back into the nares for approximately another five minutes. The patient was then draped. The nasal pledgets were removed. Left nasal cavity exploration was performed. Of note, there was synechia of the septum to the middle turbinate. No other lesions or masses were noted in the inferior, middle, and superior meatus. There was no evidence of superficial vasculature, which may be responsible for bleeding. The septum appeared clean of any local trauma. The nasopharynx was clear, and the left eustachian tube was open.
Attention was then turned towards the right nasal cavity. A 0-degree endoscope was used to visualize the right nasal cavity. Again, there was some mild scarring of the middle turbinate to the lateral nasal wall. A Straightshot microdebrider was used to resect the inferior half of the middle turbinate to allow access to the uncinate, maxillary sinus, the grand lamella and the sphenopalatine artery canal. The uncinate was removed with backbiting forceps. The Straightshot microdebrider was used to complete the uncinectomy.
A large maxillary antrostomy was then performed with the microdebrider. This was begun at the natural os of the maxillary sinus and carried posteriorly to the posterior antral wall. The opening of the antrostomy went to the superior border of the inferior turbinate. The superior border went to the lamina papyracea. A caudal elevator was then used to elevate the mucosa over the region of the sphenopalatine artery. The artery was then identified. A 2 mm Kerrison rongeur was then used to open up the canal of the sphenopalatine artery. This was carried laterally to the posterior antral wall. The bony encasing of the artery was opened to allow a 270-degree view around the artery. The branch point of the posterior nasal artery was identified. A Freer was then used to loosen the superior and inferior tissues from around the artery to allow placement of hemoclips. Approximately three hemoclips were then placed laterally to the branch point of the sphenopalatine artery. The clips were well secured to the artery. Suction Bovie cautery was then used medially to the clips for local cauterization.
Attention was then turned towards the anterior ethmoidectomy. The ethmoid bulla was removed with the microdebrider. The microdebrider was carried superiorly into the anterior ethmoids. The nasofrontal recess was identified. The skull base was identified. There was no evidence of injury to the skull base. There was an area of thin bone. The anterior ethmoid artery was not directly identified, and thus, there was no cautery performed at this location.
The nose was then thoroughly irrigated with copious amounts of warm normal saline. Approximately 5 mL of FloSeal was then injected into the maxillary sinus and the anterior ethmoids for hemostasis and healing. One Doyle splint was used on the right nasal cavity to prevent further synechia. This was sewn in place with #3 Prolene. The nasal cavities were again thoroughly irrigated with warm normal saline and suctioned. There was no evidence of bleeding at the end of the case. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
