Hurley Medical Center



Name:Click here to enter name.DEPARTMENT OF SURGERYREQUEST FOR SPECIFIC PRIVILEGESGROUP 111.00General Surgery1.01?Abdominal Procedures1.02?Abdominal Perineal Resection1.03?Appendectomy1.04?Hernia Repair, Diaphragmatic1.05?Hernia Repair, Femoral1.06?Hernia Repair, Incisional1.07?Hernia Repair, Inguinal1.08?Hernia Repair, Umbilical1.09?Other Hernia1.10?Staging Laparotomy?1.20?Operations on Biliary Tract1.21?Gallbladder1.22?Intestinal Tract1.23?Pancreas1.24?Peritoneum, Omentum1.25?Spleen1.26?Paracentesis1.27?Stomach1.28?Liver1.29?Vagotomy1.30?Cystotomy1.35Breasts1.36?Excision of Cyst or Tumor1.37?Incision and Drainage of Abscess1.38?Mastectomy, Simple1.39?Mastectomy, Radical1.40?Reduction/Augmentation Mammoplasty1.41?Subcutaneous Mastectomy1.42?Post-Mastectomy Breast Reconstruction1.43?Gynecomastia1.50Esophagus1.51?Repair Trauma of Esophagus1.52?Dilation with Bougies1.53?Esophageal Resection1.54?Trauma & Repair of Lacerations1.55?Esophagectomy1.56?Tracheoesophageal Fistula1.57?Esophageal Atresia Repair, Excise Duplications1.60Blood Vessels - Anastomoses1.61?Aneurysmectomy1.62?Embolectomy1.63?Phlebectomy1.64?Phlebotomy1.65?Thrombectomy1.66?Vein Ligation1.67?Trauma & Repair of Blood Vessel Lacerations1.68?Endarterectomy1.69?Extra-Anatomical Bypass1.70?Carotid Surgery1.71?Surgery for Occlusive Disease1.72?AV Fistulae1.73?Angioplasty; Diagnostic/Catheter Directed Arteriography; Endovascular Stenting1.75Lymph Channels & Nodes1.76?Biopsy1.77?Incision and Drainage1.78?Excision1.79?Regional Node Dissection1.80Skin and Subcutaneous Tissue1.81?Biopsy1.82?Burns, First1.83?Burns, Second and Third Degree1.84?Excision Lesion (Cyst, Lipomata, Polyps, etc.)1.85?Graft, Pedicle1.86?Graft, Tubular1.87?Incision and Drainage (Abscesses, Paronychia)1.88?Deep Abscess (Thyroglossal Cyst, etc.)1.89?Suture, Uncomplicated Wounds1.90?Repair Complicated Wounds1.91?Myocutaneous Flaps1.95Thyroid1.96?Reopening of Wound for Hemorrhage Control1.97?Thyroidectomy1.98?Parathyroid Surgery2.00Chest Surgery2.01?Cardiovascular Surgery2.02?Collapse Therapy2.03?Drainage, Closed2.04?Drainage, Open2.05?Lobectomy2.06?Phrenic Nerve Surgery2.07?Pneumonectomy2.08?Scalenotomy2.09?Thoracentesis2.10?Thoracic-Abdominal Incision2.11?Major Chest Surgery2.12?Emergency Thoracotomy (Open/Closed)2.13?Major Chest Surgery for Trauma2.14?Ligation of Ductus Arteriosus2.15?Median Sternotomy2.16?Pericardiotomy2.17?Repair Heart Wound2.18?Resection of Lump2.19?Varicocele2.20?Vesicotomy2.21?Thorascopy2.22?Video Assisted Thoracic Surgery3.00Ears, Nose and Throat Surgery3.01?Adenoidectomy3.02?Excision Lesions, Local (Brachial, Thyroglossal Cysts, Polyps, etc.)3.03?Major Lesions3.04?Laryngectomy3.05?Mastoidectomy, Simple3.06?Mastoidectomy, Radical3.07?Rhinoplasty3.08?Sinus - Incision3.09?Sinus - Excision (Submucous Resection)3.10?Tonsillectomy3.11?Otoscopy3.12?Otoplasty3.13?Tympanoplasty3.14?Stapedectomy3.15?Audio Meatoplasty3.16?Otolaryngological Facial Nerve Surgery3.17?Blepharoplasty3.18?Rhytidectomy3.19?Nasal and Nasal/Septal Reconstruction3.20?Microtia & Traumatic Ear Defects3.21?Eyelid Reconstruction3.22?Radical Neck Dissection3.23?Laryngectomy, Partial or Total3.24?Functional Endoscopic Sinus Surgery3.25?Myringotomy3.26?Tracheotomy3.27?Trauma and Repair of Blood Vessel Lacerations – Neck3.28?Deep Abscess - Neck3.29?Tracheal Reconstruction4.00Maxillofacial and Oral Surgery4.01?All Oral Surgery Including Excision of Lesions4.02?Fractures Reduction4.03?Tongue Tie Release5.00Eye5.01?Enucleation5.02?Extraocular - Excision of Lesion (Pterygium, Nevus, etc.)5.03?Removal of Foreign Body5.04?Suture5.05?Eyelid - Excision of Lesion (Chalazion, Xanthoma, etc.)5.06?Plastic Repair of Eyelid5.07?Orbit, Excision Lesion5.08?Evisceration5.09?Plastic Repair5.10?Cataract, Glaucoma, Retinal Detachment; Intraocular Lens Implant5.11?Intraocular & Extraocular Eye Surgery5.12?Laser Procedures, Retinal6.00Gynecological Surgery(6)1.00?Amputation, Cervix(6)1.01?Cauterization Cervix(6)1.02?Closure - Rectovaginal Fistula(6)1.03?Closure - Vesicovaginal Fistula(6)1.06?Dilation and Curettage(6)1.08?Excision of Glands (Bartholin’s, Skene’s)(6)1.09?Hymenotomy(6)1.10?Hysterectomy - Total(6)1.11?Hysterectomy - Subtotal (Paracervical)(6)1.12?Hysterectomy, Vaginal(6)1.17?Repair - Cystocele(6)1.19?Repair - Rectocele(6)1.20?Salpingectomy (Ectopic Pregnancy)(6)1.21?Salpingo-oophorectomy(6)1.25?Abdominal Sterilization(6)1.26?Hysteropexy(6)1.28?Hysteroscopy7.00Neurosurgery7.01?Craniectomy7.02?Craniotomy7.03?Laminectomy7.04?Neurotomy7.05?Peripheral Nerve Surgery7.06?Sympathectomy, Cervical7.07?Sympathectomy, Lumbar7.08?Sympathectomy, Thoracic7.09?Carpal Tunnel Decompression7.10?Stereotaxis Surgery on Brain7.11?Percutaneous Cordotomy7.12?Extracranial Carotid and Vertebral Surgery7.13?Trans-Sphenoidal Surgery7.14?Extracranial/Intracranial Bypass7.15?Percutaneous Radiofrequency for Trigeminal Neuralgia8.00Orthopedic Surgery8.01?Amputations, Simple (Fingers, Toes)8.02?Amputations, Major8.03?Arthrodesis8.04?Arthroplasty8.05?Drainage, Bone8.06?Graft, Bone8.07?Reduction Dislocation or Fracture – Dislocation Closed8.08?Dislocation Open with Suture8.09?Dislocation Open with Metal Screw, Nail, Pin, Band, Plate, etc.8.10?Repair Tendons - Primary8.11?Repair Tendons - Secondary8.12?Spinal Fusion8.13?Tenotomy8.14?Wounds Sufficient to Result in Permanent Disability or Death8.15?Hip Replacement/Reconstruction8.16?Arthroscopic Surgery8.17?Laminectomy8.18?The Ilizarov Method8.19?Knee Anterior Cruciate Ligament8.20?Radial Shortening Osteotomy Wrist8.21?Graft, Skin8.22?Lumbar Disc Replacement9.00Rectal Surgery9.01?Anal Fissure9.02?Anal Fistula9.03?Anoscopy, Proctoscopy, Sigmoidoscopy9.04?Excision Lesion, Local9.05?Excision Lesion, Malignant9.06?Hemorrhoidectomy, Internal9.07?Hemorrhoidectomy, External9.08?Incision and Drainage9.09?Pilonidal Cyst9.10?Pull-through Operation for Hirschsprung's Disease in Imperforate Anus9.11?Colectomy10.00Urological Surgery10.01?Adrenalectomy10.02?Anterior Urethropexy10.03?Augmentation Cecal Cystoplasty10.04?Cavernosum10.05?Circumcision10.06?Continent Diversion with Colon Loop or Ileal Loop10.07?Cutaneous Ureterostomy10.08?Cystectomy10.09?Cystolithotomy10.10?Cystoscopy, Ureteroscopy10.11?Cystostomy10.12?Cystolithotripsy10.13?Epididymectomy10.14?Exploration of Testis10.15?Hydrocele10.16?Hydrocelectomy10.17?Hypospadias Repair10.18?Ileal & Colon Urinary Conduits10.19?Ileal Loop10.20?Insertion of Artificial Sphincter10.21?Meatoplasty10.22?Microscopic Vasovasotomy10.23?Needle Bladder Suspension, Stamey Procedure, etc.10.24?Nephrectomy, Donor10.25?Nephrectomy, Harvest for Transplant10.26?Nephrectomy, Partial10.27?Nephrectomy, Total10.28?Nephrectomy, Transplant10.29?Nephrolithotomy10.30?Nephroureterectomy10.31?Orchidectomy10.32?Orchiopexy10.33?Percutaneous Nephrolithotomy10.34?Percutaneous Nephrolithotripsy10.35?Penile Insert10.36?Penile Prosthesis Insertion10.37?Plastic Operations on Kidney10.38?Plastic Surgery of Penis10.39?Prostatectomy10.40?Pyeloplasty10.41?Radical Prostatectomy10.42?Renal Autotransplantation10.43?Renal Trauma & Repair of Lacerations10.44?Renal Vascular Surgery10.45?Retroperitoneal & Pelvic Lymphadenectomy10.46?Revascularization of the Corpora10.47?Spermatocelectomy10.48?Testicular Autotransplantation10.49?Thoracoabdominal Approach to the Adrenal Gland/Kidney10.50?Total & Partial Adrenalectomy10.51?Total Cystectomy10.52?Transurethral Resection10.53?Ureteroscopy10.54?Ureterolithotomy10.55?Ureterolithotripsy10.56?Urethral Surgery10.57?Urethrectomy10.58?Urethrotomy, External10.59?Urethrotomy, Internal10.60?Varicocele/Varicocelectomy10.61?Vesicotomy10.62?Vasectomy10.63?Ureterectomy10.64?Renal Cyst Drainage10.65?ESWL10.66?Vasectomy Reversal10.67?Prostatic Seeding Procedure11.00Other Procedures11.01?Reimplantation11.02?Free Tissue Transfer11.03?Translumbar Aortography11.04?Peripheral Vascular System Operative Procedures11.05?Femoral Arteriography11.06?Brachial Arteriography11.07?Angiography11.08?Venogram11.09?Microvascular Tissue Transplant11.10?Implantation Alloplastic Material; Soft Tissue & Bone11.11?Head and Neck Reconstruction11.12?Repair of Congenital Deformities11.13?Reconstruction of Scalp, Forehead, Calvaria11.14?Cosmetic Surgery of the Aging Face11.15?Abdominoplasty11.16?Suction Assisted Lipectomy11.17?Orbital Exenteration for Malignancy11.18?Pelvic Exenterations (Total, Anterior, Posterior)11.19?Hemipelvectomy & Forequarter Amputation11.20?Infusaid Pump, Hepatic Artery Cath for Long Term Chemo11.21?Chemical Peeling11.22?Microsurgery11.23?Liposuction of the Abdomen, Thighs, and Hips Only11.24?Excision of Superficial Cutaneous Lesions Anywhere on the Body11.25?Muscle Flap Harvesting11.26?Deep Abscess (Pelvic, etc.)11.27?Endovascular Deployment of Aortic Grafts for Treatment of Abdominal Aortic Aneurysm11.28?Septoplasty13.00?CRITICAL CARE MANAGEMENT (includes Bronchoscopy, Laryngoscopy, Ventilator Care, TPN, etc.)Special Privileges *(12)1.00?Culdoscopy(12)1.01?Gastroscopy(12)1.02?Peritoneoscopy(12)1.03?Bronchoscopy(12)1.04?Laryngoscopy (Flexible/Rigid)(12)1.05?Tracheoscopy(12)1.06?Sigmoid, Flexible Diagnostic(12)1.07?Sigmoid, Rigid Diagnostic(12)1.08?Laparoscopy(12)1.09?Colonoscopy(12)1.10?GI Endoscopy with Gen. Anesthesia(12)1.11?Colonoscopy with Polypectomy(12)1.12?Sigmoid, Flexible With Biopsy and Polypectomy(12)1.13?Sigmoid, Rigid With Biopsy and Polypectomy(12)1.14?Laparoscopic Cholecystectomy(12)1.15?Laparoscopic Appendectomy(12)1.16?Laparoscopic Hysterectomy(12)1.17?Laparoscopic Lysis of Adhesions(12)1.18?Laparoscopic Exam. of Abdominal Cavity/Common Duct Exploration(12)1.19?Laparoscopic Inguinal Herniorrhaphy(12)1.20?Laparoscopic Suturing Techniques(12)1.23?Laparoscopic Bowel/Hernia Repair(12)1.24?Laparoscopic Stapling(12)1.25?Laparoscopic Inguinal Hernia Repair(12)2.00?TPN/PPN*(12)3.00?Yag Laser*(12)3.01?CO 2 Laser*(12)3.02?Colposcopy(12)3.03?Anoscopy(12)3.04?Proctoscopy(12)3.05?Midas Rex Bone Scalpel(12)3.06?Esophagoscopy(12)3.07?Myelogram(12)3.08?Admin. of IV Anesthesia/Analgesia When Loss of Reflex May Occur (12)3.09?Lithotripsy(12)3.10?Endoscopic Carpal Tunnel Release(12)3.11?Automated Percutaneous Lumbar Discectomy(12)3.12?Arteriovenous Fistula for Renal Access(12)3.13?Tissue Welding (Skin Lesions)*(12)3.14?Repair of Uncomplicated Bowel Perforation(12)3.15?Repair of Bladder Perforation(12)3.16?Laparoscopic Pelvic Lymph Node Dissection(12)3.17?KTP/Yag Laser*(12)3.18?Resectoscope(12)3.19?Hysteroscopy(12)3.20?Laser of Cervix, Vagina, Vulva, Abdomen(12)3.21?Laparoscopic Ovarian Cystectomy(12)3.27?Diagnostic Laparoscopy(12)3.42?Laparoscopic Bowel Resection(12)3.43?Laparoscopic Vagotomy(12)3.44?Laparoscopic Fundoplication(12)3.45?Laparoscopic Colon Resection(12)3.46?Sigmoid, Flexible with Biopsy(12)3.47?Sigmoid, Rigid with Biopsy(12)3.48?PEG(12)3.49?Cystoscopy(12)3.52?Laparoscopic Examination of Abdominal Cavity with Varicocele Treatment(12)3.54?Laparoscopic Nissen Fundoplication(12)3.55?Trans-Abdominal Preperitoneal (TAPP) Herniorrhaphy(12)3.56?Properitoneal Herniorrhaphy(12)3.57?Sigmoid Colon Resection(12)3.58?Laparoscopic Colectomy(12)3.61?Laser Assisted Uvulopalatoplasty(12)3.62?Laser Urological Surgery(12)3.64?Interstitial Laser Ablation of the Prostate(12)3.65?Upper GI Endoscopy (incl wall stents)(12)3.66?Endoscopic, FAST & Abdominal/Ultrasonography(12)3.67?Photodynamic Therapy for Cancer(12)3.68?Distal Esophagectomy (for distal esophageal tumors with esophagogastrectomy)(12)3.69?Radiofrequency Ablation of Liver Tumors(12)3.70?Thoracoscopic Sympathectomy(12)3.71?PEJ(12)3.72?Bronchoscopy, Flexible for Traumatic Diagnosis(12)3.73?Extracorporeal Lithotripsy(12)3.75?Intradiscal Electrothermal Therapy(12)3.79?Inferior Vena Cava Filter Placement(12)3.80?Vertebroplasty(12)3.81?Kyphoplasty(12)3.82?Laparoscopic Bariatric Surgery(12)3.83?Roux-en-Y Gastric Bypass Surgery(12)3.88?Bariatric Lap-Banding Surgery(12)3.89?Nucleoplasty/Plasma Disc Decompression(12)3.90?Open Roux-en-Y Gastric Bypass Surgery(12)3.91?Laparoscopic Gastric Roux-en-Y(12)3.92?Adjustable Laparoscopic Gastric Banding(5)1.04?Placement of Swan-Ganz Catheters(5)1.11?Intra-aortic Balloon Pump(5)3.04?ERCP(5)3.05?Sphincterotomy(5)3.07?Endoscopic Sphincterotomy w/biliary drainage & stone removal(5)3.11?Endoscopic Sphincterotomy w/Stone Removal(5)5.07?Placement of CVP Lines(5)5.08?Placement of Art Lines(5)5.10?Placement/Removal of Tenckhoff Catheter(5)5.11?Placement/Removal Double Lumen Medi-Port(5)8.08?Ventilator Care*_____________________________________________________________________________________________SignatureDate********************************************************************************************Department:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed, but not recommended:________________________________________________________________________________________________ChairpersonDateMedical Staff Executive Committee:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed, but not recommended:_____Date____________________Board of Hospital Managers:Reviewed and approved, as requested:_____Reviewed and approved, with exception:_____Reviewed but not approved:_____Date____________________ * Requires written documentation of training and demonstrated competency. Note: If privileges are denied, limited, or granted other than as requested, documentation must be provided. ................
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