Pre-op

Before the case begins, know the pathology and approach for prior resections.  Know what kind of reconstruction was done for prior EEA's.  Pay particular attention to medications the patient is on including steroids, DDAVP, and Synthroid.  If the patient is on steroids they will need stress dosing, usually 100q8 hydrocortisone, to be given prior to induction of anesthesia.  Gardner also likes a preinduction arterial line to be placed.

Positioning

Patient begins positioned supine on the operating table and is intubated. Pre-position SSEPs are obtained if the patient is older than 60 years old.  A Foley is placed.  The bed is rotated such that the head is to the right of anesthesia and the feet are to the left.  The bed is positioned such that the left axilla is just above the metal cross In the tile the floor where the tiles meet.  The patient is moved up until the top of the shoulders is at the break between the headboard and the rest of the bed.  Patient is moved slightly to the right such that they are not lying exactly in the middle of the bed but are biased slightly to the patient's right, towards the operators.  The right arm is tucked.  A blanket is placed over the chest and the belly is left uncovered for a fat graft. 

Eye Padding

First, tape the eye closed with a single piece of vertically-oriented tape. Then, fold a 4x4 piece of gauze to the size of the orbit. Place the gauze on the orbit such that the folded parts are against the brow ridge and the nose. Secure in place with Tegaderms. 

Fascia Lata

First, bend the knee and internally rotate the hip. Put a pink foam donut under the heel. Put a folded pillow under the knee. Put a thin purple foam over the lower leg and go around with 3-inch tape to secure the leg to the bed and hold it in an internally-rotated position. 

Mark the head of the fibula and the greater trochanter. When the leg is held in the internally-rotated position, the location of the IT band stands out on the lateral leg as a shallow linear depression (red arrows). 

Mark a 3-inch linear incision parallel to the IT band midway between the marks for the greater trochanter and fibular head in the rostral-caudal dimension. The mark should be midway between the IT band and the mid-sagittal line in the medial-lateral dimension. 

Quiz questions

• What nerve is at risk of injury with a fascia lata harvest incision that is too high? 
  • Lateral femoral cutaneous nerve

Antibiotics

As of 2023:

Discharge