DATE: @TD@
PATIENT NAME: @NAME@ 


PREOPERATIVE DIAGNOSIS: 
***

POSTOPERATIVE DIAGNOSIS: 
Same

OPERATION: 
***

SURGEON: William Morrel, MD 

ANESTHESIA: General 

INDICATIONS FOR PROCEDURE:  
***

FINDINGS:  
***

DESCRIPTION OF PROCEDURE
The patient was brought to the operating room on a ventilator.  Shoulder roll was placed and laryngotracheal landmarks marked out.  A 3 cm incision mark was made just below the cricoid.  A timeout was performed.  Lidocaine 1% with 1: 100,000 epinephrine was injected, about 5 cc.  Time was given for this to take effect.  Patient was then prepped and draped in a sterile fashion.  The patient was on 30% FiO2 though this intermittently needed to be changed back to 100% to allow the saturations to return to normal at which point we held the Bovie electrocautery.  

We started by incising the skin taking this down through redundant adipose tissue and through the superficial cervical fascia/platysmal layer down to the strap muscles.  At this point then we changed our dissection to a vertical orientation separating the strap musculature with monopolar electrocautery until we identified what appeared to be a large but, not abnormally so, thyroid isthmus just below the thyroid cartilage.  This was undermined with hemostats until I had a good plane under this.  At this point we had pause cautery to let the saturations returned.  Once they did and the FiO2 was then returned back to 30%, I bluntly dissected tissue connective tissue on top of the trachea below the identified isthmus and identified the trachea below the isthmus.  This point then we divided the isthmus with careful monopolar cautery and divided another layer of connective tissue on top of the trachea until we had clearly identify the cricoid as well as the first 3-4 tracheal rings.  We prophylactically cauterized the thyroid isthmus cut edges given the patient's need for long-term anticoagulation.  At this point then we incised between the first and second cartilaginous ring with a 15 blade, once the anesthesia team and pulled back the tube slightly to avoid damage to the endotracheal tube cuff.  Once we had come fully through the inner mucosa of the trachea, I made a Bjork flap using curved Mayo scissors to incise the second tracheal ring laterally on both the right and left until this was able to be flapped forward.  This was sutured to the subcutaneous tissues with 2 interrupted 3-0 Vicryl's.  The tracheal mucosa appeared healthy and there was no significant bleeding though there was some very mild oozing from the cut edges of the tracheal mucosa which I prophylactically cauterized as well with the bipolar cautery.  This point then an 8 oh cuffed Shiley tracheostomy tube was placed into the tracheotomy and the circuit was hooked up to this.  The cuff was filled with 7 cc of air.  There was good end-tidal CO2 on the anesthesia machine as well as appropriate tidal volumes.  At this point then retractors were removed and the trach was sutured in place with four 2-0 silk sutures on the upper and lower right and left tracheal flanges.  A trach collar was then placed 2 finger tight.  Patient was turned back towards anesthesia.  He was returned to 100% of FiO2.  He was taken to the  CICU in stable condition.

*** 

The patient's care was returned to anesthesia for awakening.  

ESTIMATED BLOOD LOSS: *** mL
 
COMPLICATIONS: None ***

SPECIMENS: ***

DISPOSITION:
The patient was transferred to the recovery room in stable condition.