Video Consent
VA Form 10-3203 Fill.pdf
Preop
You will need lead, C arm, and C-armor for this case.
Ask the circulator to put 3 mL of epinephrine 1:100,000 per liter of three 3L normal saline bags for the irrigation.
Set the pump pressure to 50-60 to start. Always be aware of the diastolic blood pressure and keep the pump pressure below it.
Ask for a K wire off the field for marking.
Room Setup
The surgeon and scrub tech stand on the side of the pathology. Bovie generator and suction are at the foot of the bed. The endoscopic display, C-arm, and C-arm display are on the opposite side, in that order from head to foot.
Positioning
Positioning is prone. Ideally, you would use a regular bed with a Wilson frame. 
If no Wilson frame is available, you can use a regular bed with gel rolls. For skinny patients, the gel rolls are oriented vertically, parallel with the axis of the bed. For heavier patients, the gel rolls are oriented horizontally, one just below the sternal notch and the other just below the iliac crests.
Arms on arm boards, as high up as they will go.
Marking
Start with an AP shot, mark midline.
Adjust C arm so the end plates are sharp and the pedicles of the caudal vertebral body are aligned with the superior end plate. Then, use the K wire to mark a line intersecting the caudal margin of the ipsilateral pedicle of the superior vertebra and the rostral margin of the contralateral pedicle of the inferior vertebra.
Go to a lateral. Make sure the pedicles and end plates are sharp. Mark the level of the appropriate disc space.
Mark the lateral projection of the tips of the spinous processes.
Mark a point midway between the lateral extensions of the axially-oriented lines, a few centimeters medial to the spinous process mark.
Draping
This is not the same as usual spine draping.
- Four blue towels in a square
- Block drapes
- Ioban
- C armor
- Open C armor and have an assistant hold it out during next step
- Place "liver drape" which is basically a rectangle of ioban with raised edges that will collect irrigant and drain to the suction
- Close C armor on top of liver drape
- Endoscope, light source cable, and irrigation cable go off the top. Create a loop in all three and secure to the drape with an Allis clamp.
- Drill and bipolar go off the bottom.
Procedure
Use 1% lidocaine with epinephrine 1:100,000 to raise a wheal at the marked entry point.
Use an 11 blade to incise the skin, then push the blade along the planned trajectory through the fascia.
Under AP fluoroscopy, advance a long spinal needle (or long Jamshidi if available) to the lateral aspect of the superior articulating process of the caudal vertebra.
Switch to a lateral and make sure the needle is at the junction of the superior articulating process and pedicle of the caudal vertebra. Gently tap the needle with a mallet until it is lodged in the bone.
Place a wire through the bore of the spinal needle, then withdraw the needle. Pass serial dilators over the wire.
If you are doing a trans-SAP approach, you may consider using the trephines to resect part of the SAP. Rotate the trephine counterclockwise in its approach to the spine, this helps it get through the fascia. Once against the bone, rotate clockwise to cut. Never allow the tip of the trephine to pass the medial pedicle line.
Use a pusher tool to push the bone plug out of the tip of the trephine before withdrawing it. Otherwise, it will pull out the wire and dilators and you will have to start over.
Pass the endoscope sheath over the largest dilator with the bevel pointed ventrally such that the tip docks against the superior articulating process. Then, bring the scope in.
To verify that you are against the pedicle, place a Kerrison in the foramen and hook the foot plate around the pedicle, then take an AP shot.
Closure
4-0 Monocryl single subcuticular stitch in the skin. Steri strip. No glue.
DATE OF SURGERY:
SURGEON: Dr.
ASSISTANT: Dr.
PREOPERATIVE DIAGNOSIS: *** disc herniation
POSTOPERATIVE DIAGNOSIS: *** disc herniation
PROCEDURE PERFORMED:
1. *** endoscopic microdiscectomy
ANESTHESIA: GETA
ESTIMATED BLOOD LOSS: 20 ccs
FINDINGS: *** disc herniation
DRAINS: none
COMPLICATIONS: none
DISPOSITION: stable to PACU
INDICATIONS FOR PROCEDURE
HISTORY: Patient is a *** who presented with ***
DIAGNOSTIC STUDY: MRI demonstrated *** disc herniation
SURGICAL RISKS: The patient was well apprised of all objectives, benefits,
risks, and potential complications of the procedure, including but not limited
to: worsening of current status, the possible need for further procedures, the
risk of infection, headaches, CSF leak, possible spinal nerve injury resulting
in paralysis, infection, injury to major vessels causing hemorrhage, stroke,
loss of language function, coma and even death. No assurance was given whether
symptoms would improve following the procedure. Informed consent was obtained and
secured in the chart after the patient voiced understanding of these risks
and decided to proceed with the operation.
DESCRIPTION OF THE PROCEDURE
The patient was transferred to the operating room. He was given preoperative
prophylactic IV antibiotics.
ANESTHESIA: The patient was sedated and intubated without difficulty by the
anesthesia service. Eyes were taped shut after ointment was applied to prevent
corneal abrasion. A Bair Hugger was placed to maintain control of core body
temperature. A Foley catheter was inserted.
POSITIONING: The patient was turned prone on gel rolls. All pressure points were
padded.
OPERATIVE TECHNIQUE:
The patient was prepped and draped in the standard sterile fashion. The C arm
fluoroscopy was draped and brought into the operative field and the *** level
was identified. The level of the spinous processes was marked on the skin on a
lateral shot. The entry point was marked about 2 cm medial to this mark along
the lateral projection of the *** disc level.
A small skin incision was made
with an 11 blade. A spinal needle was introduced into the incision and passed
under fluoroscopic guidance to the junction of the lateral *** pedicle and ***
superior articulating process. A K wire was passed down the bore of the spinal
needle which was then removed. Positioning was verified on fluoroscopy before
passing serial dilators down the K wire. An 11 blade was passed in parallel to
the dilators to enlarge the fascial opening. The endoscopic instrument sheath
was passed over the dilators then the dilators and K wire were removed. Again,
appropriate positioning was verified by fluoroscopy.
The endoscope was
introduced through the sheath and continuous irrigation started at 60 mmHg. Care
was taken to keep the irrigation pressure below diastolic blood pressure. The
radiofrequency probe was used to dissect soft tissue from the superior
articulating process and *** pedicle. The foramen was identified ventral to the
SAP and rostral to the *** pedicle. Several large fragments of herniated disc
were removed from the foramen and ventral epidural space. The traversing ***
nerve root was identified and was pulsating freely at the end of the case.
Bleeding was controlled with a combination of radiofrequency probe and
irrigation. After removal of the disc fragments the cavity was inspected and no
residual fragments were identified. The endoscope and sheath were withdrawn as a
single unit and the walls of the tract inspected for bleeding. Areas of bleeding
were cauterized with the radiofrequency probe.
The subcutaneous tissue was closed with 3-0 Vicryl suture. The skin was closed
with 4-0 Monocryl monofilament absorbable suture. Skin glue was placed over
the incision and a Primapore dressing was placed on top.
All sponge counts, needle counts and instrument counts were correct at the end
of the case. The patient tolerated the procedure well, without any complications and
was transferred in stable condition to the recovery room. Dr. *** was
present during the critical portions of the case.
