For the morbidly obsessed wannabe doctors out there.

Procedure:​
Surgery was covered with intravenous Cefuroxime, intravenous Gentamicin, Flowtron Boots, pre-preparation of skin with alcoholic chlorhexidine.

Position: Supine with left-sided raised 20° on beanbag.

Incision Approach:

Approached Mr Agu. Left oblique incision. Two window approach. L4-L5 L4-3 rector sheath opened obliquely with external and internal oblique split in line of fibre. Transversus abdominis split and retroperitoneal space entered. Peritoneum pulled to the right hand psoas exposed with the vessels retracted to the right hand side. Excellent exposure of the L4-L5 disc. Segmental vessel over the L4 body ligated with Liga-clip. Good exposure of the L3-L4 disc space and the proximal one half to two thirds of the body of L3. Two separate window for the L5-S1 space with opening of the rectus sheath with a retroperitoneal approach. Iliac vessels identified and the bifurcation identified. The bifurcation retracted both to the right into the left to give exposure of the L5-S1 space. Median sacral artery divided.

Procedure Findings: L5-S1 anterior lumbar interbody fusion undertaken. L5-S1 discectomy with elevation of the end plates with good exposure with the end plate. Good removal of the disc material. Disc was normal. A size 18x38x28 12° cage was placed. Excellent hold. Position checked on imaging intensifier. Two screws placed in L5 and S1 27.5mm. Excellent fix and screw satisfactory on AP and lateral imaging intensifier. Exposure facilitated with the SIN frame. Two L4 corpectomy. Good exposure of the L4 and L3 bodies with the SIN frame. L4 and L5 discectomy. L3 L4 discectomy. The L3 L4 disc was very degenerate and destroyed. No overt parcel evidence of sepsis but a very abnormal disc. L4 corpectomy was undertaken with a combination of rongeurs and Burr. Complete removal of the L4-5 disc and the L3-4 disc with one third removal of the body of L3 down to normal bleeding bone. Burr used to get posterior wall of L4 removed to approximately 3-4mm of the back of the spine. Thorough washout of the space with approximately 1.5L of normal saline over the procedure. Combination of curette used to remove all the disc material which was sent for histology and microbiology. A VLIFT cage was placed. 22×32 with endplates of 3° and 8°. Expanded satisfactory. Excellent hold. Rock solid within the L3 L5 space. The cage was packed with allograft and DBX. Good haemostasis at the end of this procedure]

Closure: Closure Mr Agu. Closure was in layers for transversus abdominus internal oblique and external oblique with one Vicryl. A one PDS loop to the rectus sheath. 2-0 Vicryl to the subcutaneous fat and 3-0 Monocryl to the skin.

Post-Operatively: The surgery is covered with 48 hours of IV Cefuroxime and Gentamicin. Clexane to be started at 1800hr on 17.09.2016. Postoperatively there was good perfusion of both feet but dorsalis pedis and posterior tibial pulses present with both femoral pulses present too. Both feet were warm and well perfused. He can sit up and mobilise into his wheelchair as his symptoms allow.

Many thanks.

Yours sincerely

Dictated but not signed to avoid delay

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