Dictation Templates

Dear Doctor;

This child underwent today as an outpatient. Everything went well. Instructions for care were reviewed with the family. Thank you
for allowing us to participate in this child's care.

Sincerely,

Charles L. Snyder MD
Pediatric Surgery

Dear Doctor :
This young man was seen in clinic today for ingrown toenails.
These have been troublesome for one or two years on an intermittent basis.
He had an office procedure for treatment about one year ago.

PMH:
Surgeries: None
Medications: None
Allergies: None
Medical Problems: None
Immunizations: UTD

ROS:
Endocrine: None
Hematology: None
Neurological: None
Growth and Development: Normal
Pulmonary: None
Carrdiac: None
GI: None
GU: None
Musculoskeletal: None

FH / SH : As documented

Physical Exam:
S - Warm and Dry
H - Normocephalic and atraumatic
Eye - PERRLAC, EOMI, clear conjunctiva
Ear - Normal
Oropharynx - Normal
Neck - Supple, full ROM, no TM or masses, no adenopathy
Chest - BS = clear
CV - S1 S2 normal, no M or G
Abdomen - Soft nontender, no masses, no organomegaly. BS normal.
B / E - Good perfusion, no C C or E, Atraumatic. There are bilateral ingrown lateral great toenails, without cellulitis or sign of active infection. The medial aspects of the nails are normal.
Neuro - Normal for age, nonfocal, GCS 15

Other Data - None

Impression: Bilateral ingrown GT toenails

Dear Doctor :

This child was seen in clinic today in order to evaluate for
circumcision revision.

PMH:
Surgeries: Circumcision
Medications: None
Allergies: None
Medical Problems: None
Immunizations: UTD

ROS:
Endocrine: None
Hematology: None
Neurological: None
Growth and Development: Normal
Pulmonary: None
Cardiac: None
GI: None
GU: No history of balanitis or UTI.
Musculoskeletal: None

FH / SH : As documented

Physical Exam:
S - Warm and Dry
H - Normocephalic and atraumatic
Eye - PERRLAC, EOMI, clear conjunctiva
Ear - Normal
Oropharynx - Normal
Neck - Supple, full ROM, no TM or masses, no adenopathy
Chest - BS = clear
CV - S1 S2 normal, no M or G
Abdomen - Soft nontender, no masses, no organomegaly. BS normal.
B / E - Good perfusion, no C C or E, Atraumatic
Neuro - Normal for age, nonfocal, GCS 15
GU - Normal testes bilaterally, without sign of inguinal hernia. He has penile adhesions and redundant skin, and the meatus is normally positioned.

Other Data - None
Impression: Redundant foreskin and adhesions.
Plan: Risks and benefits of operation and alternative treatments were reviewed with the family at length, and they agreed to proceed. We plan to schedule the child for freehand circumcision revision. I will contact you at the time of the operation.

Thank you for allowing us to participate in this child's care.

Sincerely,

Charles L. Snyder MD
Pediatric Surgery

HPI:

PMH:
Surgeries: None
Medications: None
Allergies: None
Medical Problems: None
Immunizations: UTD

ROS:

Physical Exam:
S - Warm and dry without lesions
H - Normocephalic and atraumatic
Eyes - PERRLAC EOMI, clear conjunctiv
ENT - Oropharynx normal, TM's clear
Neck - FROM without TM or masses, trachea midline
Chest - BS equal normal breath sounds
CV - S1S2 nl without M or G
Abdomen: Soft and nontender. No HSM, no masses. BS normal.
Back and Extremity - No CC or E, full ROM, intact pulses
Neuro - GCS 15 Awake and alert. Appropriate for age. CN II - XII intact.
GU Male - Both testicles are descended. They feel normal in size, shape, and consistency. The phallus is normal. There is no sign of inguinal hernia.
GU Female - The external genitalia are grossly normal. There is no sign of inguinal hernia.

Impression:

Plan:

Dear Doctor :

This child was seen in clinic today in order to evaluate an inguinal hernia.

PMH:
Surgeries: None
Medications: None
Allergies: None
Medical Problems: None
Immunizations: UTD

ROS:
Endocrine: None
Hematology: None
Neurological: None
Growth and Development: Normal
Pulmonary: None
Cardiac: None
GI: None
GU: Normal
Musculoskeletal: None

FH / SH : As documented

Physical Exam:
S - Warm and Dry
H - Normocephalic and atraumatic
Eye - PERRLAC, EOMI, clear conjunctiva
Ear - Normal
Oropharynx - Normal
Neck - Supple, full ROM, no TM or masses, no adenopathy
Chest - BS = clear
CV - S1 S2 normal, no M or G
Abdomen - Soft nontender, no masses, no organomegaly. BS normal.
B / E - Good perfusion, no C C or E, Atraumatic
Neuro - Normal for age, nonfocal, GCS 15
GU - Normal external genitalia. There is a reducible inguinal hernia on the ______.

Other Data - None

Impression: Unilateral inguinal hernia, ______

Plan: Risks and benefits of operation and alternative treatments were reviewed with the family at length, and they agreed to proceed. We plan to schedule the child for inguinal hernia repair and diagnostic contralateral laparoscopy. I will contact you at the time of the operation.

Thank you for allowing us to participate in this child's care.

Sincerely,

Charles L. Snyder MD
Pediatric Surgery

Procedure: Laparoscopic Appendectomy
Anesthetic: General
Surgeon: Charles L. Snyder MD
Preoperative Diagnosis: Appendicitis
Postoperative Diagnosis: Same

Indications for Operation:
This patient had a history, physical findings, and radiographic and laboratory studies consistent with the diagnosis of appendicitis. The patient was admitted, hydrated, and taken to the operating room today for appendectomy. The risks and benefits of the procedure, including but not limited to infection, bleeding, scarring, bowel obstruction, abscesses, the need for reoperation, and the possibility of an error in diagnosis, were reviewed with the family. They understood and accepted these, and wished to proceed electively today.

Description of Procedure:
The patient was placed in a supine position, given a general anesthetic, and prepped and draped in the usual sterile fashion. An open technique was used to insert a 12 mm umbilical port through the umbilicus, and after insufflating to a pressure of 12, a 45 degree scope was inserted. 5 mm LLQ and 5 mm lower midline ports were inserted under direct visualization. The appendix was mobilized, and the mesoappendix divided with the vascular endoGIA. The intestinal endoGIA was used to divide the appendix at the healthy cecal base. The appendix was removed in its entireity through the 12 mm port. Hemostatsis was excellent. The pelvis was irrigated, and the abdomen examined carefully. No other abnormalities were identified. The ports were withdrawn, Marcaine injected, and the abdomen decompressed. The fascia at the umbilicus was closed wit Vicryl. Absorbable sutures were used to close the skin incisions. The patient tolerated the procedure well and left in satisfactory condition.

Preoperative Diagnosis: Right lower quadrant pain, suspected appendicitis
Postoperative Diagnosis: perforated appendicitis
Procedure: Laparoscopic Appendectomy
Anesthesia: General Endotracheal
Attending Surgeon: Charles Snyder, MD
Fellow:
Complications: none
Estimated Blood Loss: minimal
Specimen: appendix

Findings: Acute suppurative appendicitis with gross evidence for perforation.
No other gross abnormalities were noted during laparoscopic evaluation.

Indications for operation:
This child had a history of abdominal pain
and a physical examination consistent with acute appendicitis.
Preoperative radiographic evaluations also were suggestive of acute
appendicitis. Thus, the child was brought to the operating for exploration
and possible appendectomy. The risks and benefits of laparoscopic
appendectomy, including but not limited to: bowel injury, abscess,
wound infection, bleeding, and need for an open procedure were
reviewed with the family. They understood and gave written consent to
proceed.

Description of procedure:

The child was brought into the operating room. After successful general
endotracheal anesthesia, he was prepped and draped in the standard surgical
fashion. The patient's name, medical record number, and procedure were
confirmed by the entire OR staff.

A vertical mid-line incision through the umbilicus was created and a 12 mm Step
trochar placed with ease utilizing the natural defect of the umbilical fascia.
Pneumoperitoneum was established with carbon dioxide to a pressure of 12 mmHg.
We were able to visualize the entire abdominal cavity. The findings described
above were encountered. Two 5 mm trochars were placed in the following
locations under direct vision: left lower quadrant, and lower midline. The
appendix and surround bowel were stuck in the right lower quadrant. There was
gross purulence. Using a combination of blunt and electrocautery dissection,
the appendix was mobilized to its base at the cecum. Once the appendix was free
from surrounding attachments, the appendix was grasped and a window in the
appendiceal mesentery was created at the base of the appendix. The mesentery
was divided with a single fire of the Endo-GIA stapler utilizing a vascular
load. Hemostasis was adequate. The base of the appendix was then amputated
from the cecum using a single fire of the Endo-GIA utilizing a standard staple
load. The appendix was the removed from the abdomen through the umbilical port
and passed of the field for pathologic examination. Fluid in the pelvis was
removed by suction and locally irrigated with normal saline. The right lower
quadrant was re-inspected and appeared to be free of bleeding. Satisfied with
out hemostasis and noting no other abnormalities, the 5 mm ports were removed
under direct visualization. The 12 mm trochar was removed from the umbilicus
and the insufflation was evacuated. The fascia at the umbilicus was
re-approximated with 0 vicryl. The umbilical skin was closed with interrupted
5.0 plain gut suture. A compressive dressing of gauze ball and tegaderm was
applied to the umbilical wound. The skin of the two 5mm port sites was closed
with subcuticular 4.0 vicryl suture and covered with benzoin and steri-strips
were applied.

The sponge and needle counts were correct following the completion of the
procedure. At the end of the case, the patient was awoken from general
anesthesia and transported to the post-anesthesia care unit for
recovery.

Date of Procedure:
Preoperative Diagnosis: need for central venous access
Postoperative Diagnosis: same
Procedure: Placement of hickman/ broviac catheter
Anesthetic: General Endotracheal
Surgeon: Charles Snyder, MD
Fellow:
Complications: none
Estimated Blood Loss: 5 ml
Specimens: none

Indications for operation:

This child required central venous access. He was brought to the
operating room for broviac placement. The risks and benefits of the
proposed procedures were discussed with the legal guardian of the
child who gave written consent to proceed.

Description of procedure:

The child was brought into the operating room. After successful general
endotracheal anesthesia, he was prepped and draped in the standard surgical
fashion. The patient's name, medical record number, and procedure were
confirmed by the entire OR staff.

The child was rotated into Trendelenberg position. The ______
subclavian vein was cannulated with a needle and the wire placed under
fluoroscopic guidance. A separate stab incision was created on the
anterior chest wall and the catheter tunneled into the neck incision
such that the cuff was well within the subcutaneous tunnel. The
introducer sheath was placed over the wire and the catheter was
positioned through the introducer sheath using fluoroscopic guidance.
Fluoroscopy then confirmed the tip of the catheter to be at the SVC/RA
junction. The catheter was secured at the exit site with two silk
sutures. The small incision below the clavicle was closed with
absorbable suture. A
sterile dressing was applied. The catheter flushed and drew easily.

At the end of the case, the patient left in satisfactory condition.

Operative Note
Preoperative diagnosis: Suspected Airway Foreign Body
Postoperative diagnosis:
Procedure: Rigid bronchoscopy with foreign body removal
Anesthetic: General via bronchoscope with MAC
Surgeon:
Fellow:
Complications: none
Specimens: none
Estimated Blood Loss: minimal
Findings:

Indications for operation:
This child had history and physical examination findings suggestive of a foreign body in the airway. The risks and benefits of the procedure and potential complications were reviewed with the family/legal guardian who gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general IV sedation, via an indwelling intravenous line, the eyes were protected with a towel wrap and a roll under the shoulders was placed. The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
Direct laryngoscopy was performed, lidocaine was injected below the cords, and a XXX Fr Bronchoscope inserted without difficulty. Inhalational anesthesia was administered via the bronchoscope and HeShe remained hemodynamically stable with adequate oxygen saturations. The trachea and mainstem bronchi were inspected. The findings noted above were encountered. A grasping forceps was inserted via the bronchoscope and the foreign body removed in its entirety. The bronchoscope was reinserted to confirm the complete removal of the foreign body. Secretions were suctioned from the tracheo-bronchial tree and the bronchoscope was withdrawn. There was no injury to the teeth, lips, or oropharynx.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
The staff surgeon was present for this case and directed this operation.

Preoperative Diagnosis: Phimosis or Penile adhesions

Postoperative Diagnosis: Same

Procedure: Freehand Circumcision
Surgeon: Charles L. Snyder MD
Indications for Operation:
This child had a history of penile adhesions / phimosis. The family wished to have him circumcised. Risk and benefits and alternatives were extensively reviewed with them prior to the procedure, and they agreed to proceed.

Description of Operation:
The patient was brought to the OR, given a general anesthetic, and prepped and draped in the usual sterile fashion. The adhesions were taken down, a dorsal slit was made, and the glans penis re-prepped. The excess foreskin was removed. After adequate hemostasis was obtained, the shaft and preputial skin were reapproximated with chromic sutures. A penile block or caudal block was performed with Marcaine for Postoperative analgesia. Antibiotic ointment was applied. The cosmetic result was excellent, hemostasis was excellent, and he left in satisfactory condition.

Preoperative DIAGNOSIS: Possible hypospadias
Postoperative DIAGNOSIS: Cutaneous chordee
OPERATIVE PROCEDURE: Release of chordee and freehand circumcision
SURGEON(S): CHARLES SNYDER, MD
ANESTHESIA: General
COMPLICATIONS: None
INDICATIONS:
This child has a history of apparent hypospadias and a dorsal slit was made. We found his meatus appeared to be normally positioned, but he did have some chordee and glans tilt. We brought him to the OR today for repair of this. The risks, benefits, alternative modes of treatment and complications were reviewed with the family and they understood and accepted and wished to proceed.

DESCRIPTION OF PROCEDURE:
He was given general anesthetic and prepped and draped in the usual sterile fashion. Adhesions were taken down and the glans reprepped. It was evident that he had some degree of continuous chordee, but that his meatus was normally positioned. We degloved his penis, removed the excess foreskin and then reapproximated the shaft and preputial skin. This nicely relieved the chordee and made a nice cosmetic result. Antibiotic ointment was applied after Marcaine was injected for a penile block. He tolerated everything well and left in satisfactory condition

Preoperative Diagnosis:
Postoperative Diagnosis: Same
Procedure: Laparoscopic Cholecystectomy
Surgeon: Snyder, Charles L.
Assistant:
Anesthesia: General

Indications for Procedure:
Risks, benefits, and alternatives were discussed with the family regarding laparoscopic cholecystectomy. Their questions were answered and they wished to proceed.

Description of Procedure:
With the patient in the supine position, after adequate endotracheal anesthesia the abdomen was prepped and draped in the usual sterile fashion. A 10 mm cannula was inserted through the umbilicus and the abdomen was insufflated with CO2. A 45 degree operating telescope was inserted into the peritoneal cavity. Inspection of the abdomen revealed no significant abnormalities. Three 5 mm operating instruments were inserted into the abdominal cavity under direct vision. The gall bladder was inspected and no significant abnormalities were visualized. The gall bladder was retracted superiorly. The cystic duct was identified and circumferentially dissected using electrocautery and blunt dissection. It was seen to be clearly entering the gallbladder. The cystic duct was doubly clipped proximally and singly clipped distally. It was divided. In a similar fashion, the cystic artery was dissected circumferentially. It was clipped and divided in an identical fashion to the cystic duct. The gallbladder was removed from the gall bladder fossa using electrocautery. The gall bladder was removed via the umbilical cannula site. Hemostasis was assured. The instruments and cannulas were removed under direct visualization and hemostasis was assured. The umbilical cannula was removed and the abdomen was desufflated. The fascia of the umbilical cannula site was approximated using Vicryl suture. The skin was closed using chromic. The stab incisions were closed in sequential layers using Vicryl. 0.25% Marcaine was instilled into the subcutaneous tissue for post operative pain control. Sterile dressings were applied. Sponge, needle and instrument counts were correct at the end of the case. The patient tolerated the procedure well and was taken to post anesthesia care unit in good condition. Dr. was present for the entire case.

Preoperative diagnosis: Pulmonary insufficiency
Postoperative diagnosis: Same
Procedure: ECMO cannulation
Anesthetic: General
Complications: None
Surgeon: Charles L. Snyder MD
Asst:

Indications for Operation:
This patient had worsening oxygenation and ventilation, refractory to conservative management with permissive hypercapnia. It was the feeling of neonatology consultatants and the surgical team that ECMO was necessary to sustain life. US of the head and heart demonstrated no contraindications. The risks and benefits of the procedure were all reviewed at length with the parents, who understood and accepted them and wished to proceed today.

Description of Procedure:
In the NICU, the head was rotated to the left and the right neck and chest prepped. Fentanyl and Pavulon were used. The right neck was incised, and dissection carried down to the internal jugular vein and the common carotid artery. Both were looped proximally and distally with silk sutures. The patient was systemically heparinized. The arterial and venous cannulas were brought to the field, and appropriate lengths measured.
An arteriotomy was made in the artery after ligation of the cranial side. The 8 Fr arterial cannula was advanced in and the artery secured around the catheter. The catheter was secured to the skin. An venotomy was made in the veinafter ligation of the cranial side. The 10 Fr venous cannula was advanced in and the vessel secured around the catheter. The catheter was secured to the skin. An 8 Fr "brain drain" venous cannula was inserted towards the cranial venous side and similarly secured.
The ECMO circuit was connected in standard fashion, taking care to avoid any air in the system. Good flows and excellent hemostasis was noted. CXR is pending at the time of this dictation. The baby was left in satisifactory condition.

Preoperative diagnosis: Gastroesophageal reflux and feeding disorder
Postoperative diagnosis: Same
Procedure:

1. Thal fundoplication
   
2. Gastrostomy
   

   
   

Anesthetic: General
Surgeon: Charles L. Snyder MD
Complications: None
Assistant:

Indications for operation:
This child had a history of GER. An upper GI showed no obstruction distally. The work-up is well-documented. The risks and benefits of the procedure, alternative modes of treatment and possible complications, were all exhaustively reviewed with the family who understood and accepted and wished to proceed electively today.

Description of procedure:
The child was taken to the operating room, placed on the table in the supine position, and prepped and draped in the usual sterile fashion. A vertical midline incision was used, located halfway between the xiphoid and umbilicus. The peritoneal cavity was entered without difficulty. The left triangular ligament was divided, and the left lobe of the liver reflected to expose the distal esophagus and GE junction. The phrenoesophageal membrane was divided. The distal esophagus was skeletonized, and looped with an umbilical tape. Gentle downward traction was applied, while the posterior crura were identified and dissected free. The anterior and posterior vagal trunks were identified and preserved. The hiatus was reapproximated in the posterior midline with figure of eight sutures of silk, the latter of which was continued through the posterior wall of the esophagus (partially) as a limiting suture.
Attention was turned to the floppy anterior wall of the stomach at the left posterolateral GE junction. The stomach was then brought up along the left posterolateral aspect of the esophagus, transversely to incorporate stomach esophagus and diaphragm, and then down the right posterolateral aspect of the esophagus to complete the wrap. This was done with a running Gore-Tex suture. The NG tube was then repositioned, and it moved easily. Hemostasis was excellent throughout, and the liver was allowed to return back to its normal position.
A gastrotomy was made in the anterior stomach, and a gastrostomy button advanced in easily. A purse-string suture of silk was used to secure it, and a second concentric purse-string used to invert the stomach around the button. An exit site in the left upper quadrant was selected, and the gastrostomy button brought out thru the site. The stomach was secured with interrupted silk sutures to the inner surface of the anterior abdominal wall.
At the conclusion of the operation hemostasis was excellent. The fascia was closed with a running PDS suture, and the skin with absorbable and running subcuticular suture. Steri-strips and Benzoin, and a sterile dressing were all applied. The patient tolerated the operation quite well and left in satisfactory condition.

Preoperative diagnosis: Gastroesophageal Reflux Disease, Feeding disorder
Postoperative diagnosis: Same
Procedure: Laparoscopic nissen fundoplication and gastrostomy placement
Surgeon:
Fellow:
Anesthetic: General Endotracheal
Complications: none
Estimated blood loss: minimal

Indications for operation:
This child had refractory GER and feeding problems despite maximal medical management. The risks and benefits of operation were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
The child was placed in a frog-leg position, the arms and legs padded appropriately, and the abdomen was then prepped and draped in the usual sterile fashion. A vertical mid line incision through the umbilicus was created and a 5 mm Step cannula placed thru the natural umbilical fascial defect. Pneumoperitoneum was established and small stab incisions were placed in the following locations under direct vision: right upper quadrant, right epigastrium, left epigastrium, and left mid abdomen. The liver was placed on traction using a c-retractor attached to a Ferguson post and the esophageal hiatus identified. A point along the greater curvature was chosen to take down the gastrocolic mesentery. This dissection proceeded cephalad where the short gastric vessels were divided using electrocautery. The phrenoesophageal membrane was divided. The distal esophagus was minimally skeletonized, and adequate intrabdominal esophagus was assured by dissecting the crura posteriorly. The anterior and posterior vagal trunks were identified and preserved. The esophageal hiatus was reapproximated posteriorly with a single 2.0 silk incorporating the posterior wall of the esophagus. We then placed crural stitches utilizing 3.0 silk (from the body of the esophagus to the diaphragmatic crura) at the 7, 11, 2 and 5 o'clock positions. Attention was turned to creation of the Nissen fundoplication. The gastric fundus was passed behind the esophagus such that the greater curvature line of demarcation came to the midportion of the esophagus anteriorly. A 360 degree fundoplication was the completed over a XX Fr bougie utilizing three 2.0 silk sutures. The most cephalad stitch incorporated the anterior wall of the esophagus and diaphragm. Once completed, the fundoplication length measured 2 cm. The bougie was then removed and the ports were withdrawn under direct vision.
We then proceed to place the gastrostomy tube. The stomach was grasped along the greater curve by an instrument inserted through the left upper quadrant incision. This area was pulled up to the anterior abdominal wall, and two transabdominal sutures of #1 Prolene were placed on either side of the chosen site for gastrostomy under direct vision. With the stomach on traction, a guide wire placed placed into the lumen of the stomach through a needle. The needle was removed, and the gastrotomy sequentially dilated uneventfully to 20F over the wire. The chosen gastrostomy Mic-Key button was then placed into the stomach over the wire and the balloon inflated with the specified amount of saline. The balloon was clearly within the lumen of the stomach. The wire and dilator were withdrawn.
Each port site was instilled with 0.25% Marcaine under direct vision and the pneumoperitoneum was abolished. The umbilical fascia was reapproximated with 3-0 Vicryl and this area was infiltrated with Marcaine. The umbilical skin was closed with 5-0 plain gut suture. The stab wounds were closed with steri strips. A compressive dressing was applied to the umbilicus and sterile dressings placed overlying the stab wound incisions.
At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
The staff surgeon was present for this case and directed this operation.

DX: 537.3 CPT: 43870 CODE: 44.62
Procedure: Gastrostomy Closure
Preoperative diagnosis: Gastrocutaneous Fistula
Postoperative diagnosis: Same
Surgeon: Charles L. Snyder, MD
Anesthetic: General
Assistant:
Complications: None

INDICATIONS: This child had a gastrostomy site which was either longstanding or had failed to close. The risks, benefits, and alternatives modes of treatment and complications were reviewed with the family who understood, accepted and wished to proceed.

DESCRIPTION OF PROCEDURE: The child was given general anesthetic, prepped and draped in the usual sterile fashion. An elliptical
incision around the gastrostomy opening was used to free up the tract and mobilize the stomach. Two silk traction sutures were placed, and
the tract excised. The stomach was closed in two layer, with running Vicryl followed by interrupted Lembert sutures of silk. The stomach was returned to the peritoneal cavity, and the fascia was closed with
PDS. Sterile dressings were applied and the child left in satisfactory condition.

Preoperative diagnosis: Feeding disorder
Postoperative diagnosis: same
Procedure: Laparoscopic Gastrostomy
Surgeon: Snyder, Charles L.
Fellow:
Anesthetic: General Endotracheal
Complications: none
Estimated Blood Loss: minimal

Indications for operation:
This child had an inability to take enough nutrition by mouth to support adequate growth. The risks and benefits of laparoscopic gastrostomy, including but not limited to: infection or bleeding, injury to surrounding structures, and need for an open procedure were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
A vertical mid line incision through the umbilicus was created and a 5 mm step cannula placed therein. Laparoscopy was performed, the findings are described above. A pneumoperitoneum was established and a small stab incision was placed in the left upper quadrant. The stomach was grasped along the greater curve by an instrument inserted through the left upper quadrant incision. This area was pulled up to the anterior abdominal wall, and two transabdominal sutures of #1 Prolene were placed on either side of the chosen site for gastrostomy under direct vision. With the stomach on traction, a guide wire placed placed into the lumen of the stomach through a needle. The needle was removed, and the gastrotomy sequentally dilated uneventfully to 20Fr over the wire using a Cook dilator set. The chosen gastrostomy Mic-Key button was then placed into the stomach over the wire and the balloon inflated with the specified amount of saline. The balloon was clearly within the lumen of the stomach. The wire and dilator were withdrawn. The pneumoperitoneum was reduced and the Prolene sutures tied to secure the button against the anterior abdominal wall. The pneumoperitoneum was then completely abolished. The fascia at the umbilicus was closed with 0 Vicryl and this area was infiltrated with �% Marcaine. The umbilical skin was closed with 5-0 plain gut suture. A compressive dressing was applied to the umbilicus.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
The staff surgeon was present for this case and directed this operation.

Preoperative Diagnosis: Feeding disorder
Postoperative Diagnosis: Same
Surgeon: Charles L. Snyder,MD
Anesthetic: General
Complications: None

INDICATIONS:
This child had a history of a feeding disorder and required open gastrostomy placement. The risks, benefits, and alternatives modes of treatment and complications were reviewed with the family who understood, accepted and wished to proceed.

DESCRIPTION OF PROCEDURE:
The child was given general anesthetic, prepped and draped in the usual sterile fashion. A vertical incision was used. Dissection was carried down to the stomach, which was delivered up. A pursestring suture was placed in the anterior wall, a gastrostomy created through which an 18 French 1.7 button was inserted. The button was secured, and a second concentric pursestring used to invert the first. An exit site in the left upper quadrant was selected, the gastrostomy brought out the exit site, and the stomach tacked up to the anterior gastric wall with interrupted silk sutures. The fascia was closed with 2-0 PDS. Sterile dressings were applied and the child left in satisfactory condition.

Preoperative DIAGNOSIS: Gastroschisis.
Postoperative DIAGNOSIS: Gastroschisis.
OPERATIVE PROCEDURE: Silo removal and abdominal wall closure.
SURGEON(S):
ASSISTANT:
ANESTHESIA: General.
Estimated blood loss: Less than 5 mL

INDICATIONS:
The patient is a newborn that had a silo placed at birth. It has now reduced down to flush with the fascia and comes in for his final closure.

DESCRIPTION OF PROCEDURE:
After he was anesthetized, he was positioned, prepped and draped supine. The silo was carefully removed. We then freed up the skin from the fascia and the freed up any adhesions around the inner part of the abdominal wall. The remaining bowel reduced very nicely and easily. We then placed interrupted figure of eight 2-0 vicryl sutures on the fascia, approximating the fascia with the umbilical stump in the midline. We then placed a pursestring suture of 5-0 monocryl with the skin to recreate the umbilicus. We dressed the neoumbilicus with Xeroform. The baby tolerated the procedure well with little increase in his ventilatory pressures.
The patient was returned to the NICU in satisfactory condition. Dr. Ostlie was present and scrubbed throughout the entire procedure.

Preoperative diagnosis: Hirschprung's Disease
Postoperative diagnosis: Same
Procedures: Laparoscopic Assisted Endorectal Pull-through
Surgeon: CG
Fellow: Troy L. Spilde, MD
Anesthetic: General Endotracheal
Complications: none
Specimens: rectal biopsies

Indications for operation:
This child had Hirschprung's Disease suggested by barium contrast enema and suction rectal biopsy. The risks and benefits of laparoscopic assisted pull-through, including but not limited to: bleeding, infection, inability to perform procedure laparoscopically, and need for diverting colostomy were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, HeShe was prepped and drpped in the standard surgical fashion. The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
The child was placed in a lateral position on the operating table, placed in a frog-leg position and the legs, perineum and abdomen prepped and draped in the usual sterile fashion. A vertical mid line incision through the umbilicus was created and a 5 mm step cannula placed therein. A pneumoperitoneum was established and 5 mm cannulas were placed in the following locations under direct vision: right upper quadrant, right lower quadrant. A single stab incision was placed in the left hemiabdomen. The colon was inspected and a transition zone was noted at XXXXXX cm. This area was brought out the umbilical incision which was slightly enlarged to accomplish this. A full thickness biopsy was taken along the antimesenteric border and sent to patholgy for a stat frozen section assessment for ganglion cells. The report returned with presence of ganglion cells at this level. This was verbally confirmed by conversation with Dr. XXXXX from Patholgy. Pneumoperitoneum was reestablished. There was no evidence for patent processus vaginalis on either side. The colon was retracted cephalad and the retroperitoneal attachments of the descending and sigmoid colon were taken down taking care to identify both ureters and sweeping them from the field of dissection. The rectum was then mobilized down to the levator ani along the retrorectal space. The inferior mesenteric artery was taken between clips at the level of the abdominal aorta. This afforded adequate mobilization of the ganglionated segment to the deep pelvis.
Attention was then turned to the perineum. Prior to the operative procedure, the rectum had been irrigated with one half strength betadine. The anoderm was retracted with 2-0 silk sutures placed circumferentially. The dentate line was identified and 1/4 % Marcaine with epinephrine was injected circumferentially just below the mucosa just distal to the dentate line. A circumferential incision was created with cautery just distal to the anal columns. This submucosal dissection proceeded cephalad until the peritoneal cavity was entered and the mobilized portion of rectum and sigmoid colon were easily delivered onto the perineum. The colon was pulled thru the perineum to the level of the previously performed full thickness biopsy on the sigmoid colon. Correct orientation of the ganglionated segment was assured. The anterior portion of the pull-through segment was opened and the anoplasty was performed with interrupted 4-0 Vicryl sutures securing full thickness bites of the pull-through to the anal mucosa. The anoplasty was continued circumferentially after the remainder of the distal pull-through segment was amputated. The latter was sent off the field for gross and pathologic examination. The anoplasty easily accepted a XXXXX Haggar dilator.
Attention was returned to the abdomen. Laparoscopy was performed again to confirm the correct orientation of the pull-through as it coursed into the pelvis. The pelvis was irrigated and fluid removed by suction. Port sites and the stab incision were instilled with 1/4 % Marcaine under direct vision and the pneumoperitoneum was abolished. The fascia at the umbilicus was reapproximated with 3-0 Vicryl and this area was infiltrated with � % Marcaine. The umbilical skin was closed with 5-0 plain gut suture. The stab wounds were closed with steri-strips. The 5 mm port site incisions were closed by reapproximating the abdominal wall musculature with 4-0 Vicryl. A compressive dressing was applied to the umbilicus and sterile dressings placed overlying the stab wound incisions. Antibiotic ointment was applied over the perineum.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
Dr. Snyder was present for this case and directed this operation.

Preoperative Diagnosis: Hirschprung's disease
Postoperative Diagnosis: same
Procedure: laparoscopic-assisted Duhamel pullthrough procedure
Anesthesia: General Endotracheal
Surgeon: Charles L. Snyder, MD
Fellow:
Complications: none
Estimated Blood Loss: minimal
Specimen: Intestinal segments

INDICATIONS FOR OPERATION:
This child is status-post diverting colostomy. The risks and benefits of laparoscopic Duhamel pullthrough procedure, including but not limited to: bowel
injury, abscess, wound infection, and bleeding were reviewed with the family. They understood and gave written consent to proceed.

DESCRIPTION OF PROCEDURE:
The child was brought into the operating room. After successful general endotracheal anesthesia, he was prepped and draped in the standard surgical fashion (from nipples to toes). The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
A small incision was made in the umbilicus and a 5 mm step-trochar was placedthrough the natural umbilical defect. Pneumoperitoneum was achieved with CO2
insufflation. Two stab incisions were placed (one in the left lower quadrant and one just above the pubic symphysis slightly to left of midline) under
direct visualization and two 3 mm graspers were introduced through these incisions. Using a combination of blunt dissection and electrocautery the colon
was mobilized from its attachments laterally and to the stomach. Once we were satisfied with the complete mobilization of the colon we turned out attention
to its removal. The colostomy was freed from its attachments to the skin, subcutaneous tissue, and fascia using electrocautery. The colostomy was
returned to the abdomen. A midline incision was created from umbilicus to pubis and was carried down through the muscle layers using electrocautery. The peritoneum was entered taking care to avoid injury to the underlying
structures. The mobilized colon was brought out through the incision. The distal end of the colon was divided at the peritoneal reflection using a blue load on the GIA stapler. The mesentery to the colon and the distal ileum was
taken using suture ligatures. The colon was removed from the field and sent to pathology as a specimen labeled "colon". The remaining small bowel appeared of
normal caliber. Attention was then turned to dissecting posterior to the rectal stump. Taking care to avoid injury to structures lateral and anterior to the
rectal stump we carefully dissected posterior to the rectum in the natural avascular plain. Care was taken to avoid injury to the ureters and vas deferens
which were located lateral to our dissection plain. Satisfied with the extent of our dissection we turned our attention to the anal dissection. The baby's
legs were retracted cephalad adequately exposing the anus. Two silk traction
sutures were placed laterally on either side of the anus. A full-thickness semi-circular incision was made through the rectal wall 0.5 cm proximal to the
dentate line. Once the full-thickness incision was created we were able to locate our abdominal dissection plain. Two 3-0 silk sutures were placed in the
midline on the posterior wall of the rectum and were tagged. Two vicryl sutures were placed laterally (one on each side) at the corners of our semi-circular
incision and were tagged. Two vicryl sutures were placed in the midline posteriorly and were tagged. A blunt-tipped clamp was placed through the incision into the abdomen taking care to remain in the midline. The tip of the clamp was directed into position through the abdomen. The appropriate orientation of the ileum was determined so that the mesentery was not torsed and the orientation was marked with a vicryl suture on the portion of the bowel that should be anteriorly placed. Several silk sutures were placed through the staple line in order to provide traction. The sutures were fed into the clamp and the ileum was pulled through our dissection plane and through the
semi-circular incision. The staple line was opened using electrocautery and the ileo-anal anastomosis was perfored circumferentially starting with the
previously placed tacking sutures. The pouch was created with blue loads on the GIA stapler. The resulting spur on the native rectum was opened using
electrocautery and a corresponding enterotomy was created in the ileum. This resulting common enterotomy was closed with running vicryl suture followed by
imbricating interrupted silk sutures. The abdomen was irrigated with warm saline. The fascia at the midline incision and the stoma site were closed with
2-0 PDS suture. The subcutaneous tissue was closed with vicryl suture. The skin was closed with running 5-0 monocryl suture followed by mastisol and
steri-strips. The patient tolerated the procedure well. There were no apparent complications. Lap, sponge, and needle counts were correct times two at the endof the case. The child was transferred to the PACU in stable condition.
Dr. Snyder was present throughout and directed this case.

Procedure: Tubularized incised urethral plate urethroplasty
Anesthetic: General
Complications: None
Preoperative diagnosis: Hypospadias
Postoperative diagnosis: Hypospadias

Indications for procedure:
This baby had a history of hypospadias, and was scheduled for elective repair today. The various types of possible repairs and the indications for them were reviewed at length with the family. The potential risks of the procedure, including but not limited to infection, bleeding, total breakdown of the repair and need for reoperation, a urethrocutaneous fistula, diverticular formation, stricture, an unacceptable cosmetic result, and numerous other problems were reviewed at great length with the family. They understood and accepted and wished to proceed electively today.

Description of procedure:
He was brought to the operating room, given a general anesthetic, and prepped and draped in the usual sterile fashion. A traction suture was placed in the glans penis, and an 8 French feeding tube inserted through the urethral opening to decompress the bladder. The glans wings were injected with Xylocaine with epinephrine. Marks were made for the repair, and the urethral plate incised vertically in the midline to act as a hinge. The penis was completely degloved back to its base. The penis was nice and straight, with no evidence of chordee. Glans wings were mobilized well on either side. A vascularized island onlay of skin was created from the residual tissue and distal shaft skin on the ventral side of the penis. This was fully mobilized, to prevent any problems with torsion or twisting.
We then re-approximated the edges of the urethral plate in the vertical midline with interrupted 7-O Vicryl suture, over the 8 French feeding tube. The onlay graft was secured over the neourethra for a second layer of closure. The glans wings were then brought around and closed in the midline with 6-0 PDS. The superficial glans was approximated with 7-0 Maxon horizontal mattress sutures for the fourth and final layer of the repair. Byers flaps were created, the circumcision completed, and the shaft and preputial skin approximated with chromic. The 8 French feeding tube was removed, and replaced with a 6 French soft Silastic stent, which was sutured in place with a Prolene suture. Hemostasis was excellent throughout. The cosmetic result was excellent. A three layer pressure Tegaderm dressing was applied. We were quite satisfied with the result. He was left in satisfactory condition for the caudal block.

Preoperative Diagnosis: Unilateral inguinal hernia
Postoperative Diagnosis: Bilateral inguinal hernia
Anesthetic: General
Affected side:
Complications: None
Surgeon: Charles L. Snyder MD

Indications for operation:
This patient had a history consistent with unilateral inguinal hernia. The patient was scheduled for elective repair today. The risks and benefits of the procedure, including but not limited to infection, bleeding, recurrence, and injury to the testicle or cord structures were all reviewed at length with the family, who understood and accepted and wished to proceed today.

Description of procedure:
The patient was taken to the operating room, placed on the table in the usual supine position, and prepped and draped in the usual sterile fashion. A transverse incision was made, and dissection carried down to the external oblique aponeurosis. This was split in the direction of its fibers, and the ilioinguinal nerve identified and preserved. A hernia sac was identified, freed from the cord structures, clamped, and divided, and followed to the internal inguinal ring. A cannula was inserted, and the abdomen insufflated to a pressure of 12. The 70 degree laparoscope was inserted, and the contralteral side evaluated. A hernia was identified. The scope was withdrawn, and the abdomen completely decompressed.The hernia sac was then doubly stick ligated with PDS stick ligatures. The distal sac was widely opened and partially excised. Any hydrocele fluid was evacuated.
The contralateral side was explored through a transverse incision. Dissection was then carried down to the external oblique aponeurosis. This was split in the direction of its fibers, and the ilioinguinal nerve identified and preserved. A hernia sac was identified, freed from the cord structures, clamped, and divided, and followed to the internal inguinal ring. The floor was intact.
The external oblique was re-approximated with a running Vicryl suture, and Scarpa's fascia closed with a similar suture. The skin was closed with interrupted everting absorbable suture material.
Marcaine was injected for Postoperative comfort. The patient tolerated the operation quite well, and after a sterile dressing was applied, the patient left in satisfactory condition.

Preoperative diagnosis: Unilateral inguinal hernia
Postoperative diagnosis: Inguinal hernia, Unilateral
Affected Side:
Procedures: 1. Repair of inguinal hernia 2. Diagnostic laparascopy (negative)
Anesthetic: General
Complications: None
Surgeon: Charles L. Snyder MD

Indications for operation:
This patient had a history consistent with inguinal hernia. The patient was scheduled for elective repair today. The risks and benefits of the procedure and alternative treaments were all reviewed at great length with the parents, who understood and accepted them and wished to proceed today.

Description of procedure:
The patient was taken to the operating room, placed on the table in a supine position, and prepped and draped in the usual sterile fashion. A transverse incision was made, and dissection carried down to the external oblique aponeurosis. This was split in the direction of its fibers, in the ilioinguinal nerve identified and preserved. A hernia sac identified. The sac was mobilized, clamped and divided, and followed to the internal inguinal ring. The sac was opened and cannulated. The abdomen was insufflated to a pressure of 12 mm Hg. The 70 degree scope was used to examine the contralateral side. No hernia was found. The scope was withdrawn and the abdomen decompressed. The hernia sac was doubly stick ligated with PDS stick ligatures. The distal sac was widely opened and partially excised. Any hydrocele fluid was evacuated. The floor was intact. The external oblique was reapproximated with a running Vicryl suture, and Scarpa's fascia closed with a similar suture. The skin was closed with interrupted everting absorbable suture material. The patient tolerated the operation quite well, and after a sterile dressing was applied, left in satisfactory condition.

Preoperative diagnosis: Unilateral inguinal hernia
Postoperative diagnosis: Bilateral inguinal hernia
Procedures: 1. Bilateral inguinal hernia repair 2. Diagnostic laparascopy
Anesthetic: General
Complications: None
Surgeon: Charles L. Snyder MD
Affected side:

Indications for operation:
This patient had a history consistent with unilateral inguinal hernia. The patient was scheduled for elective repair today with diagnostic laparoscopy of the contralateral side and possible contralateral inguinal hernia repair. Since the opposite side was asymptomatic, in the event we could not insert the scope or adequately visualize the other side, it would not be explored. The risks and benefits of the procedure and alternative treatments were all reviewed at length with the parents, who understood and accepted them and wished to proceed today.

Description of procedure:
The patient was taken to the operating room, placed on the table in a supine position, and prepped and draped in the usual sterile fashion. A transverse incision was made, and dissection carried down to the external oblique aponeurosis. This was split in the direction of its fibers, and the ilioinguinal nerve identified and preserved. A hernia sac identified and mobilized, then followed to the internal inguinal ring. The sac was opened and cannulated. The abdomen was insufflated to a pressure of 12 mm Hg. The 70 degree scope was used to examine the contralateral side. A hernia opening was identified. The scope was withdrawn and the abdomen decompressed. The hernia sac was doubly stick ligated with PDS stick ligatures. The distal sac was widely opened and partially excised. Any hydrocele fluid was evacuated. The floor was intact. The external oblique was reapproximated with a running Vicryl suture, and Scarpa's fascia closed with a similar suture. The skin was closed with interrupted everting absorbable suture material.
An incision was then made on the contralteral side, and dissection carried down to the external oblique aponeurosis. This was split in the direction of its fibers, and the ilioinguinal nerve identified and preserved. A hernia sac was identified and mobilized. The distal sac was widely opened and partially excised. Any hydrocele fluid was evacuated. The floor was intact. The hernia sac was doubly stick ligated with PDS stick ligatures. The external oblique was reapproximated with a running Vicryl suture, and Scarpa's fascia closed with a similar suture. The skin was closed with interrupted everting absorbable suture material. The patient tolerated the operation quite well, and after a sterile dressing was applied, left in satisfactory condition. Marcaine was injected locally.

Anesthetic: General
Surgeon: Charles L. Snyder MD
Complications: None
Preoperative diagnosis: Ingrown toenail
Postoperative diagnosis: Same

Indications for operation:
This child had a history of ingrown toenail. The risks and benefits of partial nail resection were reviewed at length with the patient and family Preoperatively. These included but were not limited to infection, bleeding, bone infection, recurrence, scarring, and the need for further operation. They understood and accepted these risks and wished to proceed electively today.

Description of procedure:
The patient was given a general anesthetic, prepped and draped in the usual sterile fashion. Marcaine was used for a digital block. The ingrown portion of the nail was elevated and a section of ingrown nail excised. The nail matrix was curetted, cauterized, and the overgrown paronychial tissue excised. A sixty-second treatment with Phenol was applied, followed by a copious alcohol flush. Antibiotic ointment and a sterile non - stick dressing was applied, and the patient left in satisfactory condition.

Preoperative diagnosis: Hyperbilirubinemia
Postoperative diagnosis: Biliary Atresia
Procedures: 1) Open Liver Biopsy 2) Kasai Hepatic Portoenterostomy
Surgeon: Snyder, Charles L.
Fellow:
Anesthetic: General Endotracheal
Complications: none
Specimens: liver biopsy

Indications for operation:
This baby had persistent conjugated hyperbilirubinemia. Preoperative laboratory assessment and imaging was suggestive of biliary atresia. We were asked to perform open cholangiography and liver biopsy with the intent of proceeding with portoenterostomy should cholangiography confirm biliary atresia. The risks and benefits of the procedure including, but not limited to need for further operation, failure of the Kasai portoenterostomy to drain the biliary tree, bleeding, cholangitis, infection were reviewed with the family who gave written consent to proceed.

Findings:
The gallbladder was diminutive. Cholangiography was not performed given the atrophic nature of the gallbladder which did not communicate with the biliary tree, the later of which was atretic upon dissection of the porta hepatis. Dissection of the hilar plate revealed significant atresia of the bilary system. The portal vein and hepatic artery were normal in appearance and the right and left arterial and venous systems were anatomically normal. A Kasai portoenetrostomy was constructed with a 30 cm retrocolic roux-en-Y limb taken 10 cm distal to the ligament of treitz deep into the hilar plate. There were no intraoperative complications. Blood loss was 5 cc.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure was confirmed by the entire OR staff.
A weight appropriate dose of pre-operative antibiotics was given intravenously. A Foley catheter was placed under sterile conditions. A transverse abdominal incision above the umbilical fissure just below the right costal margin was made. Cautery was used to divide the abdominal wall musculature. The peritoneal cavity was entered without difficulty. The gallbladder was identified and noted as described above. Cholangiography was not possible given the findings as described. The subcostal incision was enlarged. The ligamentous attatchments of the liver were taken down with cautery such that the liver was delivered up into the wound. The porta hepatis was dissected and the findings as described above noted. A cystic duct artery was identified, ligated and divided. The fibrous cone of the hilar plate was incised using a 12 blade and excised en bloc. It was passed of the field after marking its orientation with silk sutures. The hilum was packed and attention turned to construction of the roux limb. The ligament of Trietz was identified. A point 10 cm distal to the ligament was chosen and divided withn a GIA stapler. A appropiate mesenteric arcade was chosen and a 30 cm Roux limb brought through an avascular area of the transverse mesocolon to reach the porta hepatis without tension. An end to side jejunojenustomy was created in a two layer fasion (inner layer 3-0 Vicryl, outer layer 4.0 silk) after excision of the proximal jejunal staple line. We then returned our attention to the hilum of the liver. The roux limb suture line was excised. Bleeding in the hilar plate had subsided. A portoenterostomy was created with a running 4-0 PDS suture without complication. We then performed an open liver biopsy by excising a wedge of the liver in section 5 and controlling bleeding with 0 chromic suture and cautery. Core liver biopsies were then taken from the right lobe using a core needle device (2 full cores). The liver biopsies were then passed off the field fresh for pathologic examination. The liver was returned to its normal anatomic position. A 7 Blake drain was passed into the subhepatic space and brought out through a stab incision in the right lower abdomen. The remainder of the abdominal organs was returned to the abdomen. The fascia of the abdominal wall was closed in layers by employing 2-0 Vicryl. Scarpas fascia was closed using 4-0 Vicryl. The skin was closed with a subcuticular 4-0 chromic suture. The skin was sealed with a dermabond dressing and the drain secured to the skin with a piece of Hypafix tape.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
Dr. Snyder was present for this case and directed this operation.

Codes: ICD 598.8 CPT
Anesthetic: General
Surgeon: Charles L. Snyder MD
Complications: None
Preoperative diagnosis: Meatal Stenosis
Postoperative diagnosis: Same

Indications for procedure:
Displaced urinary stream. Risks and benefits, alternative treatments, and complications were exhaustively reviewed with the family, and they agreed to proceed.

Description of Procedure:
The patient was taken to the operating room, given a general anesthetic, and prepped and draped in the usual sterile fashion. The meatus was cannulated, and a small slit was made in the ventral direction. Interrupted 7-O Maxon suture was used to approximate the
mucosa and skin of the glans. Cosmetic result was excellent. The neomeatus was now of adequate size. A penile block was performed with
Marcaine. Antibiotic ointment was applied, and he left the operating room in satisfactory condition.

Preoperative diagnosis: Pectus Excavatum, s/p NUSS Bar repair
Postoperative diagnosis: Same
Procedure: Nuss Bar Removal
Surgeon:
Fellow:
Anesthetic: General Endotracheal
Complications: none

Indications for operation:
This child had a severe pectus excavatum and prior repair with insertion of a NUSS substernal bar in the past. The result is satisfactory. At this time, we have recommended removal of the bar. The risks and benefits of the procedure were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, HeShe was prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
The child was placed on two operative tables in the supine position where general anesthesia was administered without complication. The tables were then arranged to allow for circumfrential draping of the chest. The previously created lateral incisions were opened with a 15 blade. Dissection ensued down to the bar with electrocautery. The stabilizers were identified, dissected free from the chest wall and removed from the bar. The bar was then grasped and withdrawn without complication.
The patient remained hemodynamically stable. The wounds were then closed with multiple layers of 3-0 Vicryl. The skin was closed with a running 5-0 Monocryl suture in a subcuticular fashion. The skin was dressed with Benzoin and steri strips and covered with Telfa and Hypafix.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
Dr. Snyder was present for this case and directed this operation.

Procedure: 1) Orchiopexy 2) Unilateral inguinal hernia repair
Complications: None
Preoperative diagnosis: Undescended testicle, unilateral
Postoperative diagnosis: Same + Inguinal hernia
Surgeon: Charles L. Snyder MD
Asst:
Affected side:
Anesthetic: General

Indications for operation:
This patient had an undescended testicle. It was palpable in the inguinal canal. The patient was scheduled for elective exploration and orchiopexy today, with possible inguinal hernia repair. The risks and benefits of the procedure, including but not limited to, infection, bleeding, injury to the testicle or vas, atrophy of the testicle, need for reoperation, recurrence of inguinal hernia, impaired fertility, as well as the heightened risk of malignancy were thoroughly reviewed with the family Preoperatively. They understood and accepted these risks, and wished to proceed today.

Description of procedure:
The patient was given a general anesthetic, and prepped and draped in the usual sterile fashion. A transverse inguinal incision was used, and dissection carried down to the external oblique. Marcaine was injected at the start of the procedure. The external oblique aponeurosis was split in the direction of its fibers, and the cremasteric fibers divided. The testicle was delivered up, and pedicled from the internal inguinal ring. A traction suture was placed through the testicle. Gentle downward traction was applied, and the hernia sac carefully dissected away from the cord structures. The sac was clamped, divided, and followed proximally to the internal inguinal ring. Additional mobilization was carried out circumferentially around the cord well into the retroperitoneum to allow the testicle to reach down into the hemiscrotum under no tension. The hernia sac was suture ligated with two PDS sutures at the internal inguinal ring.
The testicle easily reached down into the hemiscrotum. The canal was enlarged, and the testicle passed down through it, taking care not to twist it. A dartos pouch had been created in the scrotum, and the testicle was pexed into place with interrupted peritesticular absorbable suture material. Once we confirmed that the testicle was in adequate position, with good positioning of the cord structures, and adequate hemostasis, the external oblique was then reapproximated with running absorbable suture material. Scarpa's fascia was closed with a similar suture, and the skin with a running absorbable suture. Sterile dressings were applied. The scrotal incision was closed in layers with absorbable material, with chromic in the skin. Antibiotic ointment was applied to the site. At the conclusion of the operation, both testicles were present in the scrotum in their normal anatomic position. He left in satisfactory condition.

CPT 49605
Preoperative Diagnosis: Omphalocele.
Postoperative Diagnosis: Same
OPERATIVE PROCEDURE: Omphalocele repair - primary closure
SURGEON: Charles Snyder, MD
FELLOW:
ANESTHESIA: General
ESTIMATED BLOOD LOSS: Less than 5 mL.

INDICATIONS:
The patient is a infant was born with an abdominal wall defect covered by an amniotic sac. Preoperative evaluation including echocardiogram, renal bladder ultrasound were done. Risks and benefits of operation and potential complications and alternative treatment modalities were reviewed with the family.

DESCRIPTION OF PROCEDURE:
Under adequate general endotracheal anesthetic, the patient's abdomen and chest were prepped and draped in a standard surgical fashion. A curvilinear incision was used to excise the amniotic sac. We encountered umbilical vessels and the umbilical vein was ligated between 2-0 silk ties and divided. We were able to maintain the umbilical stalk. This was ligated with a 2-0 silk suture and held in place inferiorly to the wound. The skin and subcutaneous tissue were dissected free from the fascia circumferentially. The defect was actually quite large. The fascia was approximated using multiple interrupted 2-0 PDS sutures in a figure-of-eight fashion. The sutures near the umbilical stalk actually incorporated the umbilical stalk to hold it in place. The skin needed to be divided superiorly in the midline in order to accomplish the repair. This small area was approximated with a running 5-0 Monocryl. The remaining defect surrounding the umbilical stalk was approximated in a running fashion using a pursestring type suture incorporating the skin as well as the fascia. Upon completion of the procedure there was some excess skin which was left in place. A dressing was applied. Hemostasis appeared to be adequate. Dr. Snyder was present for the entire procedure. The patient was taken to the recovery room in satisfactory condition.

Preoperative Diagnosis:
Postoperative Diagnosis: Same
Procedure: Port a cath placement
Surgeon: Charles L. Snyder MD
Asst:

Indications for Operation:
The family wished to have a central line placed. Risk and benefits and alternatives were extensively reviewed with them prior to the procedure, and they agreed to proceed.
Description of Procedure:
The child was given a general anesthetic, prepped and draped in the usual sterile fashion. The child was rotated into the Trendelenburg position and the left subclavian accessed on the first pass. A guide wire was advanced under fluoroscopic control, a pocket made on the left anterior chest wall. The port was a 6 French double lumen port. It was brought to the field; subcutaneously tunneled and secured into place with Prolene sutures. The port had been flushed. The introducer and peel-away sheath were fluoroscopically positioned and the catheter was cut to the appropriate size and was advanced through the peel-away sheath, which was then removed. Good position of the catheter tip was verified in the RA/SVC junction. Good back and forth flow was obtained through the port, which was flushed with heparinized saline solution. The wounds were then closed in layer of absorbable suture. Sterile dressings were applied. Confirmation fluoroscopy at the conclusion of the procedure confirmed good position of the catheter tip with no other abnormalities. The child tolerated the procedure well and left in satisfactory condition.

Procedure: Port a cath removal
Anesthetic: General
Surgeon: Charles L. Snyder MD
Complications: None
Preoperative diagnosis:
Postoperative diagnosis: Same

Indications for procedure:
This child had a port-a-cath previously inserted which was to be electively removed today. Risk and benefits, alternative modes of treatment, and possible complications were all exhaustively reviewed with the family who agreed to proceed.

Description of procedure:
The patient was given a general anesthetic, and prepped and draped in the usual sterile fashion. The old incision was reopened, and dissection carried down to the port. The port and attached catheter were freed up and removed in their entireity. Hemostasis was excellent. The tissues were closed in layers with absorbable suture. Marcaine was injected for Postoperative analgesia. A sterile dressing was applied. The patient tolerated everything quite well, and left in satisfactory condition.

Procedure: Pyloromyotomy, Open
Anesthetic: General
Surgeon: Charles L. Snyder MD
Asst:
Complications: None
Preoperative diagnosis: Pyloric Stenosis
Postoperative diagnosis: Same

Indications for procedure:
This child had a history of projectile nonbilious emesis. There was no history of diarrhea, fever, or any systemic symptoms. US confirmed the diagnosis. Risks and benefits, alternative modes of treatment, and possible complications were all exhaustively reviewed with the family who agreed to proceed.

Description of procedure:
The patient was given a general anesthetic, and prepped and draped in the usual sterile fashion. A small transverse upper midline incision was made, and the fascia split vertically. The hypertrophic pylorus was delivered through the wound, and a serosal incision made from the white line well up onto the antrum.. Blunt dissection was used to clearly split the muscle into 2 halves. The mucosa was intact. The pylorus was returned to its normal location, and hemostasis checked for as Marcaine was injected into the subQ. The fascia was closed in one layer, and the skin with a running subcuticular suture. A sterile dressing was applied. The patient tolerated everything quite well, and left in satisfactory condition.

Preoperative diagnosis: Pyloric Stenosis
Postoperative diagnosis: same
Procedure: Laparoscopic Pyloromyotomy
Anesthetic: General Endotracheal
Surgeon: Snyder, Charles L.
Fellow:
Complications: none
Estimated Blood Loss: minimal
Specimens: none

Indications for operation:
This child had a history of non-bilious, projectile emesis and physical examination consistent with pyloric stenosis.
A preoperative ultrasound examination revealed a XX x XX mm pylorus consistent with pyloric stenosis. We recommended laparoscopic pyloromytomy. The risks and benefits of the procedure, including but not limited to: perforation, bleeding, infection, incomplete pyloromyotomy, were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, HeShe was prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure were confirmed by the entire OR staff.
A small vertical midline incision through the umbilical skin was created. A 5 mm Step trochar placed through the natural fascia defect of the umbilical fascia. Pneumoperitoneum was established with carbon dioxide to a pressure of 12 mmHg. Two stab incisions were placed in the following locations under direct vision: right upper quadrant and left upper quadrant. The liver was retracted and the proximal duodenum grasped to allow for stabilization of the pylorus which was obviously hypertrophied. A longitudinal incision along the anterior aspect of the pylorus was created with an arthroscopy knife deployed to create a 2 mm depth incision from the vein of mayo onto the proximal stomach. The muscle was further split with blunt dissection until the mucosa was visualized. The stomach was insufflated with air and there was no evidence of leak. The two portions of the pyloric muscle were grasped and moved independently. A tongue of omentum was laid over the myotomy. The ports were withdrawn under direct vision. Each port site was instilled with 1/4 % Marcaine under direct vision. The umbilical trochar was removed and the pneumoperitoneum was abolished. The fascia at the umbilicus was re-approximated with 3-0 Vicryl and this area infiltrated with 1/4 % Marcaine. The umbilical skin was closed with 5-0 plain gut sutures in an interrupted fashion. The stab wounds were closed with Benzoin and steri-strips. A compressive dressing utilizing a gauze ball and tegaderm was applied to the umbilicus. Blood loss was minimal.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
Dr. Snyder was present for this case and directed this operation.

Preoperative diagnosis: Delayed gastric emptying
Postoperative diagnosis: Same
Procedure: Laparoscopic Pyloroplasty
Surgeon: Charles Snyder, MD
Fellow:
Indications for operation:
This child had delayed gastric emptying. The risks and benefits of laparoscopic pyloroplasty, including but not limited to: stricture, leak, infection or bleeding, bowel obstruction, incomplete pyloroplasty, and need for an open procedure were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure were confirmed by the entire OR staff. A vertical mid line incision through the umbilicus was created and a
5 mm Step cannula placed thru the natural umbilical fascial defect. Pneumoperitoneum was established and small stab incisions were placed in the
following locations under direct vision: right upper quadrant, right epigastrium, left epigastrium, and left mid abdomen. The liver was placed on traction using a c-retractor attached to a Ferguson post. The pylorus was identified and was divided using electrocautery. The enterotomy was extended
proximally and distally using electrocautery. A standard Heineke-Mikulicz pyloroplasty was performed using interrupted 4-0 silk sutures. Once complete,
the omentum was placed over the pyloroplasty. The liver retractor was removed under direct visualization. The other instruments were removed under direct visualization and hemostasis was ensured. The 5 mm umbilical port was removed
and the pneumoperitoneum was released. The fascia at the umbilicus was reapproximated with 3.0 vicryl and this area was infiltrated with Marcaine. The
umbilical skin was closed with 5.0 plain gut suture. The stab wounds were closed with steri strips following instillation of Marcaine. A compressive
dressing was applied to the umbilicus and sterile dressings placed overlying the stab wound incisions.

The sponge and needle counts were correct following the completion of the
procedure. At the end of the case, the patient was awoken from general
anesthesia and transported to the post-anesthesia care unit for recovery.

Preoperative Diagnosis: Pectus Excavatum
Postoperative Diagnosis: Same
Procedure: Nuss Bar placement
Surgeon: Charles L. Snyder MD
Asst:
Anesthetic: General
Complications none.

Indication for procedure:
This patient had a significant pectus defect. Risks and benefits of operation, alternative modes of treatment, and possible complications were extensively reviewed withthe patient and family, and they agreed to proceed today.

Description of procedure:
After a general anesthetic, the patient was positioned, prepped and draped supine under sterile conditions. The deepest portion of the pectus was ascertained and the interspace just
slightly above this was selected. The lateral incisions were made parallel to this interspace marking. The lateral incisions were
carried down to the chest wall fascia and a midline incision was made just below the xiphoid. The retrosternal space was bluntly dissected
to protect the cardiac structures as the bar was being passed. Blunt dissection bilaterally over the chest wall musculature to the costosternal junction was performed, and with a digit in the retrosternal space, a passer was advanced from lateral to the midline retrosternal space. Sterile tapes were passed times 2, so that they
ran through the future path of the Nuss bar. We selected a bar of appropriate length and bent it to the proper configuration and then carefully inserted the bar using the pull through tapes in an upside down position. Once we rolled the bar over it corrected her pectus
nicely. The tips were then bent in so they fit the chest wall more closely and then horizontal stabilizers placed on either side and fixed with #5 Tevdek with three-point fixation. The incisions were
then closed in layers with Vicryl suture after antibiotic irrigation carried out. The midline incision was closed. The incisions were dressed.
Blood loss was minimal. Condition to recovery was satisfactory.

Preoperative diagnosis:
Postoperative diagnosis: same
Procedure: Laparoscopic Splenectomy
Anesthetic: General Endotracheal
Surgeon:
Fellow:
Complications: none
Anesthesia: General endotracheal
Estimated Blood Loss: minimal
Specimen: spleen

Indications for operation:
There were no symptoms of biliary colic and a preoperative ultrasound of the gallbladder revealed no evidence of cholelithiasis. The risks and benefits of Laparoscopic Splenectomy, including but not limited to: infection or bleeding, pancreatic injury, and need for an open procedure were reviewed with the family. They understood and gave written consent to proceed.

Description of procedure:
The child was brought into the operating room. After successful general endotracheal anesthesia, HeShe was prepped and draped in the standard surgical fashion. The patient's name, medical record number, and procedure was confirmed by the entire OR staff.
The child was placed in a semi-right lateral decubitus position with a roll placed under the left flank. The arms and legs were padded appropriately, and the abdomen was then prepped and draped in the usual sterile fashion. A vertical mid line incision through the umbilicus was created and a 10 mm step troca was placed thru the natural defect within the umbilical fascia. Pneumoperitoneum was established and small midline stab incisions were placed in the following locations under direct vision: upper epigastrium and approximately 5 cm above the umbilicus. Between these sites a 5 mm cannula was placed to accommodate the 5 mm, 70 degree laparoscope. An additional 3 mm instrument was inserted through a stab incision in the left lower quadrant to allow for retraction of the spleen. The lesser sac was opened. There was no evidence of accessory splenic tissue. The spleen was retracted cephalad and the lienocolic ligaments taken down using a harmonic scalpel. The spleen was then retracted caudad, the stomach retracted medially and the short gastric vessels and attatchments to the left hemi-diaphragm were taken down using the harmonic scalpel. The splenic artery was skeletonized and clipped with a 5 mm clip applier and divided between clips. A window behind the splenic hilum was then created to accommodate an endo-GIA stapler with a vascular load introduced through the umbilical port. This was fired accross the hilum taking care not to injure the pancreas. Hemostasis was complete. The remaining splenic attatchments were then taken down, and the spleen was then inserted into an endo-catch bag inserted through the umbilical port site. The neck of the bag was then exteriorized through the umbilical port site. The pneumoperitoneum was abolished and the spleen removed piecemeal from the abdomen by morsilization. The bag was then removed intact and the splenic tissue sent to pathology for examination. The pneumoperitoneum was then reestablished and the staple line examined for adequate hemostasis. The distal pancreas appeared normal. The left upper quadrant was irrigated and the clear irrigant was suctioned from the abdomen. Each port site was instilled with �% marcaine, the ports were withdrawn, and the pneumoperitoneum was abolished. The fascia at the umbilicus was reapproximated with 0 Vicryl and this area was infiltrated with �% marcaine. The umbilical skin was closed with 5-0 plain gut suture. The stab wounds were closed with steri strips. The fascia at the 5 mm port site was closed with 3-0 Vicryl and the skin reapproximated using 5-0 Vicryl. A compressive dressing was applied to the umbilicus and sterile dressings placed overlying the stab wound incisions.
The sponge and needle counts were correct following the completion of the procedure. At the end of the case, the patient was awoken from general anesthesia and transported to the post-anesthesia care unit for recovery.
Dr. Snyder was present for this case and directed this operation.

Preoperative diagnosis: Abnormal Stooling Pattern
Postoperative diagnosis: same
Procedure: Suction Rectal Biopsy
Surgeon: Snyder, Charles L.
Fellow:
Complications: none
Estimated Blood Loss: minimal
Specimens: rectal biopsies

Indications for operation:
This child has an abnormal stooling pattern. There is concern for Hirschprung's Disease. We recommended suction rectal biopsy. The risks and benefits of the procedure, including but not limited to inadequate tissue sampling and bleeding were reviewed with the patients and/or legal guardians. They understood and accepted these risks, and wished to proceed.

Description of procedure:
The procedure was performed at the bedside. With the patient in the lithotomy position, mucosal samples were taken in sequential quadrants of the rectum with the suction biopsy device at the left, right, anterior, and posterior positions. They appeared grossly adequate and were placed in a container containing formalin labeled with the patient's name. The specimen was then hand delivered to the department of pathology for examination. The patient tolerated the procedure well without complications.

Codes: ICD CPT
Preoperative Diagnosis: Nonpalpable undescended testicle.
Postoperative Diagnosis: Atrophic testicular remnant.
Procedure: Laparoscopy and excision of atrophic testicular remnant
Affected Side:
Complications: None
Surgeon: Charles L. Snyder MD

Indications for Operation:
This child had a nonpalpable undescended testicle, and he was brought in for elective repair of this. The risks, benefits, and alternative modes of treatment, fertility, malignancy issues were all reviewed with the family, who understood and accepted and wished to proceed.

Description of Operation:
The child was given a general anesthetic and prepped and draped in the usual sterile fashion. We examined him again under anesthesia, but could not feel any sign of a testicle. There was questionable evidence of compensatory enlargement on the right
side. The scope was placed within the abdomen through a 5 mm port in the umbilicus in an open technique. The abdomen was insufflated to a pressure of 12 and we did identify the vas and vessels on both sides
with no sign of any intraabdominal testicle. The scope was withdrawn. The fascial defect was closed with Vicryl. The area was infiltrated with Marcaine and the skin was closed with plain gut.

Attention was turned to the left inguinal area where an incision was made and dissected carried down to what appeared to be an atrophic
remnant, which was removed in its entirety. No hernia had been visualized on either side. The right side looked entirely normal. The
wound was closed in layers with absorbable sutures and Marcaine injected for postoperative analgesia and left in satisfactory condition.

Preoperative Diagnosis: Nonpalpable undescended testicle.
Postoperative Diagnosis: Atrophic testicular remnant.
Procedure: Laparoscopy and excision of atrophic testicular remnant
Complications: None
Affected side:
Surgeon: Charles L. Snyder, MD
Assistant:

Indications for Operation:
This child had a non-palpable undescended testicle, and he was brought in for elective repair of this. The risks, benefits, and alternative modes of treatment, fertility, malignancy issues were all reviewed with the family, who understood and accepted and wished to proceed.
Description of Operation: The child was given a general anesthetic and prepped and draped in the usual sterile fashion. We examined him again under anesthesia, but could not feel any sign of a testicle. There was questionable evidence of compensatory enlargement on the contralateral side. The scope was placed within the abdomen through a 5 mm port in the umbilicus in an open technique. The abdomen was insufflated to a pressure of 12 mm Hg and we did identify the vas and vessels on both sides with no sign of any intraabdominal testicle. The scope was withdrawn. The fascial defect was closed with Vicryl. The area was infiltrated with Marcaine and the skin was closed with plain gut.
Attention was turned to the inguinal area where an incision was made and dissected carried down to what appeared to be an atrophic remnant, which was removed in its entirety. No hernia had been visualized on either side. The contralateral side looked entirely normal. The wound was closed in layers with absorbable sutures and Marcaine injected for Postoperative analgesia and left in satisfactory condition.
Dr. Snyder was present for the entire operation.

Procedure: Umbilical Hernia Repair
Anesthetic: General
Surgeon: Charles L. Snyder MD
Complications: None
Preoperative diagnosis: Umbilical Hernia
Postoperative diagnosis: Same

Indications for procedure:
This child had a history a reducible umbilical hernia which had filed to close. Risk and benefits, alternative modes of treatment, and possible complications were all exhaustively reviewed with the family who agreed to proceed.

Description of procedure:
The patient was given a general anesthetic, and prepped and draped in the usual sterile fashion. An infra-umbilical incision was made, and the defect skeletonized to healthy fascial edges. PDS sutures were laid in place in a figure of 8 fashion under direct visualization, and then closed. There was no tension and excellent hemostasis. Marcaine was injected into the subQ. The wound was closed in layers with absorbable suture. A sterile dressing was applied. The patient tolerated everything quite well, and left in satisfactory condition.