Surgical Procedures
Content
Kidney Transplant Kidney Failure Transplant Evaluation Procedures
Procedures As kidneys become diseased, they lose their ability to function, a condition called end-stage renal disease (ESRD) or kidney failure. Treatments for kidney failure are hemodialysis, a mechanical process to clean the blood of waste products; peritoneal dialysis, in which toxins are removed by passing chemical solutions through the abdomen; and kidney transplant. None of these options is a cure for kidney failure. But a transplant offers the best prospects, given that the transplanted kidney functions successfully.
Living Donors Kidneys for transplant come from a living donor or a deceased (cadaver) donor. When a kidney is transplanted from a living donor, the donor's remaining kidney enlarges to take over the work of two. As with any major operation, there is a chance of complication. But kidney donors have the same life expectancy, general health and kidney function as others. (See Living Donor FAQs.) FAQs .) Any healthy person can safely donate a kidney. The donor must be in excellent health, well informed about transplantation and able to give informed consent. Costs for living donor surgery, hospitalization, diagnostic tests and evaluation usually are paid by the recipient's insurance. Travel and living expenses are not covered. Insurance coverage will be discussed during the transplant evaluation. If you have a potential living donor, he or she will undergo an evaluation and discuss the possibility of organ donation. Tests will be performed to ensure that the donor and recipient are compatible. In some families, several people are compatible donors. In other families, none are suitable. Since 1999, UCSF has been using a procedure, called laparoscopic donor nephrectomy, to remove kidneys from living donors. We have performed more than 850 of these procedures, making our program one of the most experienced in the country. The procedure uses tiny incisions and a scope or camera, similar to one used to remove a gall bladder. The procedure has a shorter recovery period and the complication rate is very low. In addition, the quality and function of the transplanted kidneys are excellent. The procedure will be described in detail by the surgeon prior to surgery. The operation usually takes three hours. Most patients undergoing laparoscopic surgery for kidney donation require a hospital stay of only two to three days. After discharge from the hospital, the donor is seen for follow-up care in the transplant clinic. If the donor resides outside the San Francisco region, he or she should stay in the area for at least a week after discharge. Donors who undergo laparoscopic surgery often return to work within three to four weeks after the procedure. Special programs for living donor transplants include: y y y y
Blood Type Incompatible Paired Exchange Positive Crossmatch Waiting List Exchange
Cadaveric Donors A cadaveric kidney comes from a deceased donor. The Uniform Anatomical Gift Act allows us to donate organs for transplant when we die and allows our families to provide permission as well. All donors are carefully screened to prevent disease transmission. If you decide to undergo a cadaveric kidney transplant and you're medically eligible, your name will be placed on a cadaver waiting list. A blood sample for antibody level will be sent monthly to the medical center. The waiting period for a cadaver kidney depends upon the availability of a cadaver donor compatible with your blood type and your antibody level. When a kidney becomes available, your referring kidney specialist is contacted for approval. The transplant service will verify that you have no recent infections or medical problems that would interfere with a safe transplant. We will assist you in making arrangements for your transplant.
Transplant Surgery Your surgery may last from two to four hours. During the operation, the kidney is placed in your pelvis rather than the usual kidney location in the back. (Your own kidney will not be removed.) The artery that carries blood to the kidney and the vein that removes blood from it are surgically connected to two blood vessels in the pelvis. The ureter, or tube that carries urine from the kidney to the bladder, is transplanted through an incision in the bladder. After the operation, you will remain in the recovery room for a few hours and then return to the Kidney Transplant Unit. The surgeon will inform your family when the procedure is over. You will be encouraged to get out of bed 12 to 24 hours after surgery and walk as much as you can. Nurses will instruct you in taking your medications, explain the side effects and discuss making lifestyle changes. A cadaver kidney transplant sometimes will be temporarily slow in functioning, a condition called a "sleepy" kidney or acute tubular necrosis (ATN). You may need to undergo dialysis a few times. A "sleepy" kidney usually starts working in two to four weeks. Most transplant recipients must take medication called immunosuppressants to prevent rejection of the transplanted organ. One of the side effects of these anti-rejection drugs is an increased risk for cancer, particularly skin cancer and lymphoma. You should be closely monitored for these conditions.
http://www.ucsfhealth.org/adult/medical_services/organ_transplants/kidney/conditions/kidney/treatm ents.html
Arthroscopic Meniscectomy Editor(s): S. Terry Canale, MD | James H. Beaty, MD Contributor(s): Barry B. Phillips, MD | Adapted from
PRE-PROCEDURE INDICATIONS indications: o Failure of nonoperative management Nonoperative management includes activity modification, antiinflammatory medications, and rehabilitation. Intraarticular steroid injections are also helpful. Ongoing daily symptoms that interfere with activities of daily living or sporting activities CONTRAINDICATIONS y
General
Figure 9 : A, Unstable 2-cm, peripheral tear of meniscus. Meniscus is being repaired with stacked vertical mattress suture. B, Incomplete undersurface tear of medial meniscus. This can
Some meniscal lesions do not necessarily require operative intervention: Vertical longitudinal tears that are stable to probing and are less than 10 mm Partial thickness tears that involve le ss than 50% of the meniscal thickness and are stable to probing o R adial tears less than 3 mm Significant osteoarthritis is a relative contraindication. y Some meniscal lesions can be repaired. o The most common criteria for meniscal repair include: A vertical longitudinal tear more than 1 cm in length located within the vascular zone A tear that is unstable and displaceable into the joint An informed and cooperative patient who is active and under 40 years of age A knee that either is stable or will be stabilized simultaneously with a ligamentous reconstruction A bucket handle portion and remaining meniscal rim that are in good condition EQUIPMENT y Standard knee arthroscopy set ANATOMY Differences between medial and lateral meniscus: o Medial is more semicircular. o Medial is larger. o Medial is anchored more securely to joint capsule. Medial is attached securely to medial collateral ligament (MCL). Lateral is not attached to lateral collateral ligament (LCL). less displacement on knee o Medial undergoes flexion. y Medial meniscus attachments o Anterior horn anchored immediately in front of anterior cruciate ligament (ACL) o Posterior horn anchored between posterior cruciate ligament (PCL) and posterior attachment of the lateral meniscus y Lateral meniscus attachments Anterior horn anchored immediately posterolateral to ACL attachment o Posterior horn anchored anterior to posterior attachment of medial meniscus o The posterior horn of the lateral meniscus has a variable meniscofemoral ligament. y Primarily composed of type I collagen The medial and lateral inferior genicular arteries supply the menisci. y
PROCEDURE
be treated with abrasion to stimulate local healing, followed by placement of one or two sutures. C, Complete 2-cm tear in avascular zone of meniscus. This type of tear is generally treated with excision, but if repair is attempted, use of fibrin clot and other local stimuli should be considered. From Phillips BB: Arthroscopy of lower extremity. I n Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. View
Larger Image
Sample excerpt does not i nclude step-by-step text instructions for performing this procedure Sign up for a FREE TRIAL to view full content The full content of this section includes: Step-by-step text instructions for performing the procedure Clinical pearls providing practical clinical tips from medical experts Patient safety guidelines consistent with Jo int Commission and OHSA standards Links to medical evidence and related procedures
Figure 12 : Two-portal technique for bucket handle tears of lateral meniscus. A, Displaced bucket handle tear of lateral meniscus probed. B, After reduction of displaced bucket handle tear, posterior attachment is partially released with scissors. C, Anterior attachment is released with scissors. D, Tenuous remaining posterior attachment is avulsed with grasper and extracted. From Phillips BB: Arthroscopy of lower extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. View
Larger Image
POST-PROCEDURE TECHNIQUES Post-Procedure: Vertical Longitudinal (Bucket Handle) Tears Post-Procedure: Horizontal, Oblique, R adial, and Complex Tears Post-Procedure: Vertical Longitudinal (Buc ket
Handle)
Tears
POST-PROCEDUR E CAR E Immediate full weight bearing Active and passive range-of-motion exercises begun immediately postoperatively NSAID at 2 weeks R eturn to full activity typically at 4-6 weeks, w hen there is full range of motion COMPLICATION S Deep vein thrombosis R ecurrent effusions Incomplete removal of tear Iatrogenic injury
Synovial cutaneous fistula ANALYSIS
OF R ESULTS
Partial meniscectomy achieves good to excellent results in approximately 90% of patients at 4 ye ars of follow-up. OUTCOMES
AND EVIDENCE Bucket handle tears Partial meniscectomy with preservation of meniscal rim Schimmer et al reported 92% good to excellent results a t 4-year and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients. Articular cartilage damage was the main determinant of long-term function. 62% of patients had good to excellent results if chondral damage was present. 95% had good to excellent results if normal articular cartilage was present at the ti me of arthroscopic surgery. Procedure: Vertical Longitudinal (Bucket Handle) Tears
Post-Procedure:
Horizontal,
Oblique, Radial, and
Complex
Tears
POST-PROCEDUR E CAR E Immediate full weight bearing Active and passive range-of-motion exercises begun immediately postoperatively NSAID at 2 weeks R eturn to full activity typically at 4-6 weeks, w hen there is full range of motion COMPLICATION S Deep vein thrombosis R ecurrent effusions Incomplete removal of tear Iatrogenic injury Synovial cutaneous fistula ANALYSIS
OF R ESULTS
Partial meniscectomy achieves good to excellent results in approximately 90% of patients at 4 ye ars of follow-up. OUTCOMES
AND EVIDENCE Bucket handle tears Partial meniscectomy with preservation of meniscal rim Schimmer et al reported 92% good to excellent results a t 4-year and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients. Articular cartilage damage was the main determinant of long-term function. 62% of patients had good to excellent results if chondral damage was present. 95% had good to excellent results if normal articular cartilage was present at the ti me of arthroscopic surgery. Procedure: Horizontal, Oblique, R adial, and Complex Tears
http://www.proceduresconsult.com/medical-procedures/arthroscopic-meniscectomy-ORprocedure.aspx
What is coronary artery bypass graft (CABG) surgery? CABG is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient¶s own arteries and veins located in the chest (thoracic), leg (saphenous) or arm (radial). The graft goes around the blocked artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.
Download a Free Guide on Coronary Artery Disease and Treatment Options
The goals of the procedure are to relieve symptoms of coronary artery disease (including angina), enable the patient to resume a normal lifestyle and to lower the risk of a heart attack or other heart problems.
At Cleveland Clinic, bypass surgery may be performed in combination with other heart surgeries, when necessary, such as valve surgery, aortic aneurysm surgery or surgery to treat atrial fibrillation (an irregular heart beat).
Who is eligible to receive coronary artery bypass graft surgery? Diagnostic tests have helped your heart doctor identify the location, type and extent of your coronary artery disease. The results of these tests, the structure of your heart, your age, the severity of your symptoms, the presence of other medical conditions, and your lifestyle will help your cardiologist, surgeon and you determine what type of treatment is best.
At Cleveland Clinic, CABG surgery may be combined with other heart surgeries, such as valve surgery, aortic aneurysm surgery or surgery to treat atrial fibrillation (an irregular heartbeat).
What happens during the cardiac bypass surgery? After general anesthesia is administered, the surgeon removes the veins or prepares the arteries for grafting.
There are several types of bypass grafts. The surgeon decides which graft(s) to use, depending on the location of the blockage, the amount of the blockage and the size of the coronary arteries.
Graft Preparation
Grafts used for bypass
y
Internal
mammary arteries [also called IMA grafts or internal thoracic arteries (ITA)] are the most common
bypass grafts used, as they have shown the best long-term results. In most cases, these arteries can be kept intact at their origin because they have their own oxygen-rich blood supply, and then sewn to the coronary artery below the site of the blockage. If the surgeon removes the mammary artery from its origin, it is called a ³free´ mammary artery. Over the last decade, more than 90% of all patients received at least one internal artery graft. y
The radial (arm) artery is another common type of arterial graft. There are two arteries in the arm, the ulnar and radial arteries. Most people receive blood to their arm from the ulnar artery and will not have any side effects if the radial artery is used. Careful preoperative and intraoperative tests determine if the radial artery can be used. If the radial artery is used as the graft, the patient may be required to take a calcium channel blocker medication for several months after surgery. This medication helps keep the artery open. Some people report numbness in the wrist after surgery. However, long-term sensory loss or numbness is uncommon.
y
Saphenous veins can be used as bypass grafts. Minimally invasive saphenous vein removal does not require a long incision. One to two incisions are made at the knee and a small incision is made at the groin. This results in less scarring and a faster recovery. Your surgeon will decide if this method cardiac bypass surgery is a good option for you.
y
The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting.
What are the risks?
As with any surgery, there are risks involved. Your surgical risks are related to your age, the presence of other medical conditions and the number of procedures you undergo during a single operation. Your cardiologist will discuss these risks with you before surgery; please ask questions to make sure you understand why the procedure is recommended and what all of the potential risks are.
Types of coronary artery bypass grafts
Surgical Procedure To bypass the blockage, the surgeon makes a small opening just below the blockage in the diseased coronary artery. If a saphenous (leg) or radial (arm) vein is used, one end is connected to the coronary artery and the other to the aorta. If a mammary artery is used, one end is connected to the coronary artery while the other remains attached to the aorta. The graft is sewn into the opening, redirecting the blood flow around this blockage.
The procedure is repeated until all affected coronary arteries are treated. It is common for three or four coronary arteries to be bypassed during surgery.
Before the patient leaves the hospital, the doctor or nurse will explain the specific bypass procedure that was performed.
Heart-Lung Machine
During surgery, the heart-lung bypass machine (called ³on-pump´ surgery) is used to take over for the heart and lungs, allowing the circulation of blood throughout the rest of the body. The heart¶s beating is stopped so the surgeon can perform the bypass procedure on a ³still´ heart.
Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is still beating. The heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body. More information about off-pump surgery
Minimally Invasive Technique Minimally invasive coronary artery bypass (MIDCAB) surgery is an option for some patients who require a left internal mammary artery (LIMA) bypass graft to the left anterior descending (LAD) artery.
Other minimally invasive surgery techniques include endoscopic or keyhole approaches (also called port access, thoracoscopic or video-assisted surgery) and robotic-assisted surgery.
The benefits of minimally invasive surgery include a smaller incision (3 to 4 inches instead of the 6- to 8-inch incision with traditional surgery) and smaller scars. Other possible benefits may include a reduced risk of infection, less bleeding, less pain and trauma, decreased length of stay in the hospital (3 to 5 days) and decreased recovery time.
Traditional incision
Minimally invasive incision
The surgical team will carefully compare the advantages and disadvantages of minimally invasive CABG surgery versus traditional CABG surgery. Your surgeon will review the results of your diagnostic tests before your surgery to determine if you are a candidate for any of these minimally invasive techniques.
How long does the procedure last? The surgery generally lasts from 3 to 5 hours, depending on the number of arteries being bypassed.
After Surgery After the grafts have been completed during the ³on pump´ procedure, the heart-lung machine is turned off, the heart starts beating on its own, and the flow of blood returns to normal.
Temporary pacing wires and a chest tube to drain fluid are placed before the sternum is closed with special sternal wires. Then the chest is closed with internal stitches or traditional external stitches. Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.
The patient is transferred to an intensive care unit for close monitoring for about one to two days after the surgery. The monitoring during recovery includes continuous heart, blood pressure and oxygen monitoring and frequent checks of vital signs and other parameters, such as heart sounds.
Once the patient is transferred to the step-down nursing unit, the hospital stay is about 3 to 5 more days.
More information about the Cleveland Clinic Heart Surgery Program .
How will I feel after surgery?
For a while after the surgery, you may feel worse than you did before surgery. This is normal and is usually related to the trauma of surgery, not necessarily to the functioning of your heart valves. It may take you from 4 to 10 weeks to fully recover from surgery.
How you feel after surgery depends on your overall health, the results of the surgery, and how well you take care of yourself after surgery. After recovering from surgery, most patients do feel better. To some extent, how you feel will depend on how you felt before surgery.
Patients with more severe symptoms before surgery may experience a greater sense of relief after surgery. Call your doctor if you are concerned about your symptoms or rate of recovery. Recovery
Full recovery from coronary artery bypass graft surgery takes about 2 months, or may be sooner if minimally invasive surgery techniques were used. Most patients are able to drive in about 3 to 8 weeks after surgery. Your doctor will provide specific guidelines for your recovery and return to work, including specific instructions on activity and how to care for your incision and general health after the surgery.
Follow Up Care During the first few months after surgery, you will probably need to visit a few times with the doctor who referred you for surgery. You will need to schedule regular appointments with your cardiologist (even if you have no symptoms). Your follow-up appointments may be scheduled every year, or more often, as recommended by your doctor. Your appointments should include a medical exam. Diagnostic studies (such as an echocardiogram) may be repeated at regular intervals.
You should call your doctor if your symptoms become more severe or frequent. Don¶t wait until your next appointment to discuss changes in your symptoms. Importance
of Making Lifestyle Changes
Coronary artery bypass graft surgery increases the blood supply to your heart, but it does not cure coronary artery disease. You will still need to decrease your risk factors by making lifestyle changes, taking medications as prescribed and following your doctor¶s recommendations to prevention future disease. Lifestyle changes include:
y
Quitting smoking
y
Treating high cholesterol
y
Managing high blood pressure and diabetes
y
Exercising regularly
y
Maintaining a healthy weight
y
Eating a heart-healthy diet
y
Controlling stress and anger
y
Taking prescribed medications as directed
y
Participating in a cardiac rehabilitation program, as recommended
y
Following up with your doctor for regular visits
Information on prevention and making lifestyle changes can be found at Heart and Vascular Health and Prevention.
http://my.clevelandclinic.org/heart/disorders/cad/treatment_heartsurg.aspx
Cervical
Polypectomy
Editor(s): Michael L. Tuggy, MD | Jorge Contributor(s): Beth Choby, MD
G arcia,
MD
PRE-PROCEDURE INDICATIONS y y
Asymptomatic cervical polyps found on routine gynecologic examination Cervical polyps associated with pain, bleeding, or other symptoms CONTRAINDICATIONS
Absolute Contraindications y
y Patient unwilling/unable to consent to procedure Patient unwilling/unable to cooperate with vaginal examination
Relative y
Contraindications
Endometrial polyps or cervical polyps with dense pedicle/blood supply y Polyps larger than several centimeters y Pregnancy y Blood dyscrasias y High likelihood of multiple polyps EQUIPMENT
y y
y
Nonsterile
y
Vaginal
gloves speculum y Colposcope (optional) R ing forceps or cervical biopsy forceps Endocervical curette (Kevorkian) (optional) y Pathology specimen containers y Silver nitrate sticks y Kogan's endocervical speculum ANATOMY
Endocervical polyps originate within the endocervical canal. Ectocervical polyps more often affect postmenopausal women. Endometrial polyps can protrude through the endocervical canal and have extensive blood supply, thus complicating management.
PROCEDURE Sample excerpt does not include step-by-step text instructions for performing this procedure Sign up for a FREE TRIAL to view full content The full content of this section includes: Step-by-step text instructions for performing the procedure Clinical pearls providing practical clinical tips from medical experts Patient safety guidelines consistent with Jo int Commission and O HSA standards Links to medical evidence and related procedures
POST-PROCEDURE CARE
P ost-procedure Management
Monitor the patient for vasovagal rea ctions. y Provide the patient with a sanitary pad. Advise the patient to take a nonsteroidal anti-inflammatory for 24 hours as needed for abd ominal cramping (unless contraindicated). y
y
P ost-procedure P atient y
Education
Advise the patient to avoid tampon use, douching, or sexual intercourse for 1 week. y Advise the patient that active vaginal bleeding warrants timely reevaluation. y Arrange for follow-up at 6 to 8 weeks after the procedure. y R outine gynecologic surveillance is appropriate. COMPLICATIONS y
Post-procedure bleeding or spotting y Post-procedure pain y R ecurrence of polyps y
http://www.proceduresconsult.com/medical-procedures/cervical-polypectomy-FM-procedure.aspx
Procedures As kidneys become diseased, they lose their ability to function, a condition called end-stage renal disease (ESRD) or kidney failure. Treatments for kidney failure are hemodialysis, a mechanical process to clean the blood of waste products; peritoneal dialysis, in which toxins are removed by passing chemical solutions through the abdomen; and kidney transplant. None of these options is a cure for kidney failure. But a transplant offers the best prospects, given that the transplanted kidney functions successfully.
Living Donors Kidneys for transplant come from a living donor or a deceased (cadaver) donor. When a kidney is transplanted from a living donor, the donor's remaining kidney enlarges to take over the work of two. As with any major operation, there is a chance of complication. But kidney donors have the same life expectancy, general health and kidney function as others. (See Living Donor FAQs.) FAQs .) Any healthy person can safely donate a kidney. The donor must be in excellent health, well informed about transplantation and able to give informed consent. Costs for living donor surgery, hospitalization, diagnostic tests and evaluation usually are paid by the recipient's insurance. Travel and living expenses are not covered. Insurance coverage will be discussed during the transplant evaluation. If you have a potential living donor, he or she will undergo an evaluation and discuss the possibility of organ donation. Tests will be performed to ensure that the donor and recipient are compatible. In some families, several people are compatible donors. In other families, none are suitable. Since 1999, UCSF has been using a procedure, called laparoscopic donor nephrectomy, to remove kidneys from living donors. We have performed more than 850 of these procedures, making our program one of the most experienced in the country. The procedure uses tiny incisions and a scope or camera, similar to one used to remove a gall bladder. The procedure has a shorter recovery period and the complication rate is very low. In addition, the quality and function of the transplanted kidneys are excellent. The procedure will be described in detail by the surgeon prior to surgery. The operation usually takes three hours. Most patients undergoing laparoscopic surgery for kidney donation require a hospital stay of only two to three days. After discharge from the hospital, the donor is seen for follow-up care in the transplant clinic. If the donor resides outside the San Francisco region, he or she should stay in the area for at least a week after discharge. Donors who undergo laparoscopic surgery often return to work within three to four weeks after the procedure. Special programs for living donor transplants include: y y y y
Blood Type Incompatible Paired Exchange Positive Crossmatch Waiting List Exchange
Cadaveric Donors A cadaveric kidney comes from a deceased donor. The Uniform Anatomical Gift Act allows us to donate organs for transplant when we die and allows our families to provide permission as well. All donors are carefully screened to prevent disease transmission. If you decide to undergo a cadaveric kidney transplant and you're medically eligible, your name will be placed on a cadaver waiting list. A blood sample for antibody level will be sent monthly to the medical center. The waiting period for a cadaver kidney depends upon the availability of a cadaver donor compatible with your blood type and your antibody level. When a kidney becomes available, your referring kidney specialist is contacted for approval. The transplant service will verify that you have no recent infections or medical problems that would interfere with a safe transplant. We will assist you in making arrangements for your transplant.
Transplant Surgery Your surgery may last from two to four hours. During the operation, the kidney is placed in your pelvis rather than the usual kidney location in the back. (Your own kidney will not be removed.) The artery that carries blood to the kidney and the vein that removes blood from it are surgically connected to two blood vessels in the pelvis. The ureter, or tube that carries urine from the kidney to the bladder, is transplanted through an incision in the bladder. After the operation, you will remain in the recovery room for a few hours and then return to the Kidney Transplant Unit. The surgeon will inform your family when the procedure is over. You will be encouraged to get out of bed 12 to 24 hours after surgery and walk as much as you can. Nurses will instruct you in taking your medications, explain the side effects and discuss making lifestyle changes. A cadaver kidney transplant sometimes will be temporarily slow in functioning, a condition called a "sleepy" kidney or acute tubular necrosis (ATN). You may need to undergo dialysis a few times. A "sleepy" kidney usually starts working in two to four weeks. Most transplant recipients must take medication called immunosuppressants to prevent rejection of the transplanted organ. One of the side effects of these anti-rejection drugs is an increased risk for cancer, particularly skin cancer and lymphoma. You should be closely monitored for these conditions.
http://www.ucsfhealth.org/adult/medical_services/organ_transplants/kidney/conditions/kidney/treatm ents.html
Arthroscopic Meniscectomy Editor(s): S. Terry Canale, MD | James H. Beaty, MD Contributor(s): Barry B. Phillips, MD | Adapted from
PRE-PROCEDURE INDICATIONS indications: o Failure of nonoperative management Nonoperative management includes activity modification, antiinflammatory medications, and rehabilitation. Intraarticular steroid injections are also helpful. Ongoing daily symptoms that interfere with activities of daily living or sporting activities CONTRAINDICATIONS y
General
Figure 9 : A, Unstable 2-cm, peripheral tear of meniscus. Meniscus is being repaired with stacked vertical mattress suture. B, Incomplete undersurface tear of medial meniscus. This can
Some meniscal lesions do not necessarily require operative intervention: Vertical longitudinal tears that are stable to probing and are less than 10 mm Partial thickness tears that involve le ss than 50% of the meniscal thickness and are stable to probing o R adial tears less than 3 mm Significant osteoarthritis is a relative contraindication. y Some meniscal lesions can be repaired. o The most common criteria for meniscal repair include: A vertical longitudinal tear more than 1 cm in length located within the vascular zone A tear that is unstable and displaceable into the joint An informed and cooperative patient who is active and under 40 years of age A knee that either is stable or will be stabilized simultaneously with a ligamentous reconstruction A bucket handle portion and remaining meniscal rim that are in good condition EQUIPMENT y Standard knee arthroscopy set ANATOMY Differences between medial and lateral meniscus: o Medial is more semicircular. o Medial is larger. o Medial is anchored more securely to joint capsule. Medial is attached securely to medial collateral ligament (MCL). Lateral is not attached to lateral collateral ligament (LCL). less displacement on knee o Medial undergoes flexion. y Medial meniscus attachments o Anterior horn anchored immediately in front of anterior cruciate ligament (ACL) o Posterior horn anchored between posterior cruciate ligament (PCL) and posterior attachment of the lateral meniscus y Lateral meniscus attachments Anterior horn anchored immediately posterolateral to ACL attachment o Posterior horn anchored anterior to posterior attachment of medial meniscus o The posterior horn of the lateral meniscus has a variable meniscofemoral ligament. y Primarily composed of type I collagen The medial and lateral inferior genicular arteries supply the menisci. y
PROCEDURE
be treated with abrasion to stimulate local healing, followed by placement of one or two sutures. C, Complete 2-cm tear in avascular zone of meniscus. This type of tear is generally treated with excision, but if repair is attempted, use of fibrin clot and other local stimuli should be considered. From Phillips BB: Arthroscopy of lower extremity. I n Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. View
Larger Image
Sample excerpt does not i nclude step-by-step text instructions for performing this procedure Sign up for a FREE TRIAL to view full content The full content of this section includes: Step-by-step text instructions for performing the procedure Clinical pearls providing practical clinical tips from medical experts Patient safety guidelines consistent with Jo int Commission and OHSA standards Links to medical evidence and related procedures
Figure 12 : Two-portal technique for bucket handle tears of lateral meniscus. A, Displaced bucket handle tear of lateral meniscus probed. B, After reduction of displaced bucket handle tear, posterior attachment is partially released with scissors. C, Anterior attachment is released with scissors. D, Tenuous remaining posterior attachment is avulsed with grasper and extracted. From Phillips BB: Arthroscopy of lower extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. View
Larger Image
POST-PROCEDURE TECHNIQUES Post-Procedure: Vertical Longitudinal (Bucket Handle) Tears Post-Procedure: Horizontal, Oblique, R adial, and Complex Tears Post-Procedure: Vertical Longitudinal (Buc ket
Handle)
Tears
POST-PROCEDUR E CAR E Immediate full weight bearing Active and passive range-of-motion exercises begun immediately postoperatively NSAID at 2 weeks R eturn to full activity typically at 4-6 weeks, w hen there is full range of motion COMPLICATION S Deep vein thrombosis R ecurrent effusions Incomplete removal of tear Iatrogenic injury
Synovial cutaneous fistula ANALYSIS
OF R ESULTS
Partial meniscectomy achieves good to excellent results in approximately 90% of patients at 4 ye ars of follow-up. OUTCOMES
AND EVIDENCE Bucket handle tears Partial meniscectomy with preservation of meniscal rim Schimmer et al reported 92% good to excellent results a t 4-year and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients. Articular cartilage damage was the main determinant of long-term function. 62% of patients had good to excellent results if chondral damage was present. 95% had good to excellent results if normal articular cartilage was present at the ti me of arthroscopic surgery. Procedure: Vertical Longitudinal (Bucket Handle) Tears
Post-Procedure:
Horizontal,
Oblique, Radial, and
Complex
Tears
POST-PROCEDUR E CAR E Immediate full weight bearing Active and passive range-of-motion exercises begun immediately postoperatively NSAID at 2 weeks R eturn to full activity typically at 4-6 weeks, w hen there is full range of motion COMPLICATION S Deep vein thrombosis R ecurrent effusions Incomplete removal of tear Iatrogenic injury Synovial cutaneous fistula ANALYSIS
OF R ESULTS
Partial meniscectomy achieves good to excellent results in approximately 90% of patients at 4 ye ars of follow-up. OUTCOMES
AND EVIDENCE Bucket handle tears Partial meniscectomy with preservation of meniscal rim Schimmer et al reported 92% good to excellent results a t 4-year and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients. Articular cartilage damage was the main determinant of long-term function. 62% of patients had good to excellent results if chondral damage was present. 95% had good to excellent results if normal articular cartilage was present at the ti me of arthroscopic surgery. Procedure: Horizontal, Oblique, R adial, and Complex Tears
http://www.proceduresconsult.com/medical-procedures/arthroscopic-meniscectomy-ORprocedure.aspx
What is coronary artery bypass graft (CABG) surgery? CABG is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient¶s own arteries and veins located in the chest (thoracic), leg (saphenous) or arm (radial). The graft goes around the blocked artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.
Download a Free Guide on Coronary Artery Disease and Treatment Options
The goals of the procedure are to relieve symptoms of coronary artery disease (including angina), enable the patient to resume a normal lifestyle and to lower the risk of a heart attack or other heart problems.
At Cleveland Clinic, bypass surgery may be performed in combination with other heart surgeries, when necessary, such as valve surgery, aortic aneurysm surgery or surgery to treat atrial fibrillation (an irregular heart beat).
Who is eligible to receive coronary artery bypass graft surgery? Diagnostic tests have helped your heart doctor identify the location, type and extent of your coronary artery disease. The results of these tests, the structure of your heart, your age, the severity of your symptoms, the presence of other medical conditions, and your lifestyle will help your cardiologist, surgeon and you determine what type of treatment is best.
At Cleveland Clinic, CABG surgery may be combined with other heart surgeries, such as valve surgery, aortic aneurysm surgery or surgery to treat atrial fibrillation (an irregular heartbeat).
What happens during the cardiac bypass surgery? After general anesthesia is administered, the surgeon removes the veins or prepares the arteries for grafting.
There are several types of bypass grafts. The surgeon decides which graft(s) to use, depending on the location of the blockage, the amount of the blockage and the size of the coronary arteries.
Graft Preparation
Grafts used for bypass
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Internal
mammary arteries [also called IMA grafts or internal thoracic arteries (ITA)] are the most common
bypass grafts used, as they have shown the best long-term results. In most cases, these arteries can be kept intact at their origin because they have their own oxygen-rich blood supply, and then sewn to the coronary artery below the site of the blockage. If the surgeon removes the mammary artery from its origin, it is called a ³free´ mammary artery. Over the last decade, more than 90% of all patients received at least one internal artery graft. y
The radial (arm) artery is another common type of arterial graft. There are two arteries in the arm, the ulnar and radial arteries. Most people receive blood to their arm from the ulnar artery and will not have any side effects if the radial artery is used. Careful preoperative and intraoperative tests determine if the radial artery can be used. If the radial artery is used as the graft, the patient may be required to take a calcium channel blocker medication for several months after surgery. This medication helps keep the artery open. Some people report numbness in the wrist after surgery. However, long-term sensory loss or numbness is uncommon.
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Saphenous veins can be used as bypass grafts. Minimally invasive saphenous vein removal does not require a long incision. One to two incisions are made at the knee and a small incision is made at the groin. This results in less scarring and a faster recovery. Your surgeon will decide if this method cardiac bypass surgery is a good option for you.
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The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting.
What are the risks?
As with any surgery, there are risks involved. Your surgical risks are related to your age, the presence of other medical conditions and the number of procedures you undergo during a single operation. Your cardiologist will discuss these risks with you before surgery; please ask questions to make sure you understand why the procedure is recommended and what all of the potential risks are.
Types of coronary artery bypass grafts
Surgical Procedure To bypass the blockage, the surgeon makes a small opening just below the blockage in the diseased coronary artery. If a saphenous (leg) or radial (arm) vein is used, one end is connected to the coronary artery and the other to the aorta. If a mammary artery is used, one end is connected to the coronary artery while the other remains attached to the aorta. The graft is sewn into the opening, redirecting the blood flow around this blockage.
The procedure is repeated until all affected coronary arteries are treated. It is common for three or four coronary arteries to be bypassed during surgery.
Before the patient leaves the hospital, the doctor or nurse will explain the specific bypass procedure that was performed.
Heart-Lung Machine
During surgery, the heart-lung bypass machine (called ³on-pump´ surgery) is used to take over for the heart and lungs, allowing the circulation of blood throughout the rest of the body. The heart¶s beating is stopped so the surgeon can perform the bypass procedure on a ³still´ heart.
Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is still beating. The heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body. More information about off-pump surgery
Minimally Invasive Technique Minimally invasive coronary artery bypass (MIDCAB) surgery is an option for some patients who require a left internal mammary artery (LIMA) bypass graft to the left anterior descending (LAD) artery.
Other minimally invasive surgery techniques include endoscopic or keyhole approaches (also called port access, thoracoscopic or video-assisted surgery) and robotic-assisted surgery.
The benefits of minimally invasive surgery include a smaller incision (3 to 4 inches instead of the 6- to 8-inch incision with traditional surgery) and smaller scars. Other possible benefits may include a reduced risk of infection, less bleeding, less pain and trauma, decreased length of stay in the hospital (3 to 5 days) and decreased recovery time.
Traditional incision
Minimally invasive incision
The surgical team will carefully compare the advantages and disadvantages of minimally invasive CABG surgery versus traditional CABG surgery. Your surgeon will review the results of your diagnostic tests before your surgery to determine if you are a candidate for any of these minimally invasive techniques.
How long does the procedure last? The surgery generally lasts from 3 to 5 hours, depending on the number of arteries being bypassed.
After Surgery After the grafts have been completed during the ³on pump´ procedure, the heart-lung machine is turned off, the heart starts beating on its own, and the flow of blood returns to normal.
Temporary pacing wires and a chest tube to drain fluid are placed before the sternum is closed with special sternal wires. Then the chest is closed with internal stitches or traditional external stitches. Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.
The patient is transferred to an intensive care unit for close monitoring for about one to two days after the surgery. The monitoring during recovery includes continuous heart, blood pressure and oxygen monitoring and frequent checks of vital signs and other parameters, such as heart sounds.
Once the patient is transferred to the step-down nursing unit, the hospital stay is about 3 to 5 more days.
More information about the Cleveland Clinic Heart Surgery Program .
How will I feel after surgery?
For a while after the surgery, you may feel worse than you did before surgery. This is normal and is usually related to the trauma of surgery, not necessarily to the functioning of your heart valves. It may take you from 4 to 10 weeks to fully recover from surgery.
How you feel after surgery depends on your overall health, the results of the surgery, and how well you take care of yourself after surgery. After recovering from surgery, most patients do feel better. To some extent, how you feel will depend on how you felt before surgery.
Patients with more severe symptoms before surgery may experience a greater sense of relief after surgery. Call your doctor if you are concerned about your symptoms or rate of recovery. Recovery
Full recovery from coronary artery bypass graft surgery takes about 2 months, or may be sooner if minimally invasive surgery techniques were used. Most patients are able to drive in about 3 to 8 weeks after surgery. Your doctor will provide specific guidelines for your recovery and return to work, including specific instructions on activity and how to care for your incision and general health after the surgery.
Follow Up Care During the first few months after surgery, you will probably need to visit a few times with the doctor who referred you for surgery. You will need to schedule regular appointments with your cardiologist (even if you have no symptoms). Your follow-up appointments may be scheduled every year, or more often, as recommended by your doctor. Your appointments should include a medical exam. Diagnostic studies (such as an echocardiogram) may be repeated at regular intervals.
You should call your doctor if your symptoms become more severe or frequent. Don¶t wait until your next appointment to discuss changes in your symptoms. Importance
of Making Lifestyle Changes
Coronary artery bypass graft surgery increases the blood supply to your heart, but it does not cure coronary artery disease. You will still need to decrease your risk factors by making lifestyle changes, taking medications as prescribed and following your doctor¶s recommendations to prevention future disease. Lifestyle changes include:
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Quitting smoking
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Treating high cholesterol
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Managing high blood pressure and diabetes
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Exercising regularly
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Maintaining a healthy weight
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Eating a heart-healthy diet
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Controlling stress and anger
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Taking prescribed medications as directed
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Participating in a cardiac rehabilitation program, as recommended
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Following up with your doctor for regular visits
Information on prevention and making lifestyle changes can be found at Heart and Vascular Health and Prevention.
http://my.clevelandclinic.org/heart/disorders/cad/treatment_heartsurg.aspx
Cervical
Polypectomy
Editor(s): Michael L. Tuggy, MD | Jorge Contributor(s): Beth Choby, MD
G arcia,
MD
PRE-PROCEDURE INDICATIONS y y
Asymptomatic cervical polyps found on routine gynecologic examination Cervical polyps associated with pain, bleeding, or other symptoms CONTRAINDICATIONS
Absolute Contraindications y
y Patient unwilling/unable to consent to procedure Patient unwilling/unable to cooperate with vaginal examination
Relative y
Contraindications
Endometrial polyps or cervical polyps with dense pedicle/blood supply y Polyps larger than several centimeters y Pregnancy y Blood dyscrasias y High likelihood of multiple polyps EQUIPMENT
y y
y
Nonsterile
y
Vaginal
gloves speculum y Colposcope (optional) R ing forceps or cervical biopsy forceps Endocervical curette (Kevorkian) (optional) y Pathology specimen containers y Silver nitrate sticks y Kogan's endocervical speculum ANATOMY
Endocervical polyps originate within the endocervical canal. Ectocervical polyps more often affect postmenopausal women. Endometrial polyps can protrude through the endocervical canal and have extensive blood supply, thus complicating management.
PROCEDURE Sample excerpt does not include step-by-step text instructions for performing this procedure Sign up for a FREE TRIAL to view full content The full content of this section includes: Step-by-step text instructions for performing the procedure Clinical pearls providing practical clinical tips from medical experts Patient safety guidelines consistent with Jo int Commission and O HSA standards Links to medical evidence and related procedures
POST-PROCEDURE CARE
P ost-procedure Management
Monitor the patient for vasovagal rea ctions. y Provide the patient with a sanitary pad. Advise the patient to take a nonsteroidal anti-inflammatory for 24 hours as needed for abd ominal cramping (unless contraindicated). y
y
P ost-procedure P atient y
Education
Advise the patient to avoid tampon use, douching, or sexual intercourse for 1 week. y Advise the patient that active vaginal bleeding warrants timely reevaluation. y Arrange for follow-up at 6 to 8 weeks after the procedure. y R outine gynecologic surveillance is appropriate. COMPLICATIONS y
Post-procedure bleeding or spotting y Post-procedure pain y R ecurrence of polyps y
http://www.proceduresconsult.com/medical-procedures/cervical-polypectomy-FM-procedure.aspx
