DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Sleep apnea.
2. Nasal obstruction.
POSTOPERATIVE DIAGNOSES:
1. Sleep apnea.
2. Nasal obstruction.
OPERATIONS PERFORMED:
1. Uvulopalatopharyngoplasty (UPPP).
2. Submucosal resection of the septum.
3. Tonsillectomy and adenoidectomy.
4. Bilateral anterior turbinate cautery and outfracture.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This is a (XX)-year-old gentleman with sleep study documented apnea with apnea-hypopnea index of 51 and desaturations to 77%. The patient is unable to tolerate CPAP and has large tonsils and a very large uvula, floppy palate. In addition, the patient has a deviated septum with obstruction and turbinate enlargement. Surgical intervention was recommended since this gentleman could not tolerate CPAP or other modalities.
DESCRIPTION OF OPERATION: The patient was placed in the supine position under general anesthesia via endotracheal tube. Prior to the anesthetic, the palate was marked 0.75 cm below the palate closure level using methylene blue. The patient’s septum was injected with 1% Xylocaine with epinephrine. Neo-Synephrine pledgets were placed. The patient was placed in Crowe-Davis mouth gag suspension, and the tonsils were individually grasped and pulled to the midline. These were dissected with guarded cautery from superior to inferior with the suction cautery used for hemostasis in the tonsillar fossa.
The uvula and palate were taken in the midline, at the prior mark, with methylene blue. This was carried through to the posterior surface, and the midline palate and part of the posterior pillar was resected. Suction cautery was used on the uvular artery. The palate was closed in the midline using interrupted 4-0 Dexon. The tonsillar fossa was closed in the upper one half using interrupted 4-0 Dexon and figure-of-eight mattress Dexon for closure.
The patient was repositioned. A septal incision was made on the left. The mucoperichondrium was elevated off both sides of the septum through a transcartilaginous incision. The swivel knife and Jansen-Middleton forceps were used to resect deviated bone and cartilage above the spur. The 4 mm chisel was used along the maxillary process followed by the suction cautery on the septal artery.
The septum was closed with 4-0 mattress chromic. Both turbinates were fractured out of the area after the inferior polypoid portion and posterior tip had been cauterized. The nose was suctioned of all blood. Doyle splints were placed and sutured with 4-0 nylon. The patient tolerated the procedure well and was taken to the recovery room in good condition with no complications. Estimated blood loss was 100 mL.
