Pulmonary / Thoracic Surgery Operative Sample Reports for Medical Transcriptionists:
OPERATIONS PERFORMED: Right upper lobectomy, harvesting of hilar and inferior pulmonary ligament mediastinal lymph node, and Accufuser bupivacaine anesthesia pump insertion.
DESCRIPTION OF OPERATION: The procedure was performed with lung ventilation, intermittent periods of apnea, and the maintenance of oxygen and carbon dioxide parameters within anesthetic norms. Arterial line central venous catheter was placed. The patient was placed in the left lateral decubitus position for a right thoracotomy and the right chest was prepped and draped in the usual sterile fashion. A standard posterolateral thoracotomy incision was created. The latissimus dorsi muscle was transected with electrocautery. The serratus anterior muscle was spared. The thorax was entered above the fifth rib in fourth intercostal space. The right upper lobe had a mass in it, about 2.5 or 3 cm in size, located in the mid portion of the parenchyma of the apical segment and not amenable to a wedge resection because of its anatomical constraints. Likewise, the inability to provide single-lung ventilation absolutely contraindicated the chance of doing a wedge resection. The right middle lobe and right lower lobe were carefully inspected and palpated and were without any obvious palpable or visible abnormalities. Once again, with intermittent ventilatory technique, the right upper lobe truncus anterior branches of the pulmonary artery were individually identified, ligated with 2-0 silk ties, 3-0 silk suture ligatures and then it was transected. The completion of the fissure was quite challenging with the ventilatory status as discussed above, but nonetheless, a bridging vein of the interlobar system required ligation with 2-0 silk ties and 3-0 silk suture ligatures prior to the ligation of the posterior ascending branch of the right upper lobe pulmonary artery. The inferior pulmonary ligament was mobilized and the inferior pulmonary ligament lymph node was harvested. The right inferior pulmonary vein had venous drainage pattern of the right lower lobe. The right middle lobe had venous drainage from the right superior pulmonary vein and that was preserved. The right upper lobe branches to the right superior pulmonary vein were individually identified and ligated with 2-0 silk ties, 3-0 silk suture ligatures, and/or surgical clips. The sutures were completed with GIA 75 mm stapling device. The right upper lobe bronchus was cleared of its surrounding fibrolymphatic tissue. Occasional hilar lymph nodes were sent separately to the Department of Pathology. The right upper lobe bronchus was cleared of its surrounding fibrolymphatic tissue, was occluded with a TA 30 stapling device. The lung was inflated to prove the middle lobe and lower lobe inflate normally. The right upper lobe did not. The stapler was fired. The specimen was transected and sent for pathologic analysis. The frozen section confirmed metastatic colon cancer; therefore, a full mediastinal lymph node dissection was not necessary. The lung was inspected. There were a few air leaks from the dissection of the fissure. There was no air leak from the bronchus at 25 cm of inspiratory pressure. Fibrin glue was placed over the operative sites in the standard fashion. The chest had been irrigated with normal saline. There was no active bleeding to report and #36 French chest tubes were placed anteriorly and posteriorly and secured with nylon sutures. The ribs were closed with #2 Vicryl pericostal sutures and a rib punch. The first Accufuser bupivacaine pump was placed from an anterior approach; it is 10 inches long. It resides under the undersurface of the fifth rib. It curves posteriorly to be incorporated within the paraspinal musculature and it is shaped like a hockey stick. The tube was secured with chromic internally and Prolene externally. The serratus anterior muscle was closed with 0 Vicryl. The next Accufuser bupivacaine pump placed is a 5 inch long catheter from an anterior approach secured to the skin with Prolene, secured to the soft tissues with chromic 4-0 sutures. The latissimus dorsi was closed with 0 Vicryl. The subcutaneous tissues were irrigated and closed with 2-0 Vicryl. Skin was closed with staples. Sterile dressings were applied. The sponge, needle, and instrument counts were correct at cavity closure. The sponge, needle, and instrument counts were correct at skin closure. The patient tolerated the procedure well. The estimated blood loss was 200 mL. The patient will be returned to the intensive care unit for postoperative monitoring.
PREOPERATIVE DIAGNOSIS: Pulmonary alveolar proteinosis.
POSTOPERATIVE DIAGNOSIS: Pulmonary alveolar proteinosis.
1. Right total lung lavage.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: After the induction of general anesthesia, a double lumen endotracheal tube was inserted and its position was verified bronchoscopically. Heparin had been given subcutaneously. No antibiotics were given due to the endoscopic nature of the procedure. With the patient in the supine position, we then began the right lower lobe lavage. We irrigated 10 L of warm saline into the right chest, 1 L at a time, and draining approximately 1 L at a time. Initially, the effluent was quite murky and dark. By the end, it had cleared significantly. We therefore rolled the patient into the prone position. The tube position was verified bronchoscopically.
We then lavaged with 10 L of saline in the prone position, initially seeing it quite cloudy, and then gradually clearing. The patient was then moved into the supine position again and bronchoscopy was performed to ensure appropriate placement of the double lumen tube. Ten liters of saline was then used to lavage the right lung.
The patient was then returned to the prone position. Ten liters of saline was lavaged and it appeared that the effluent remained somewhat murky. We then continued up to a total of 25 L in the prone position this time. The patient was then moved into the supine position and another 8 L of fluid was lavaged until it became reasonably clear. Therefore, a total of 63 L of fluid was utilized for the lavage. I performed bronchoscopy on a number of occasions to assure endotracheal tube positioning and to suction residual lavage fluid. In addition, a sample was taken from the first liter of effluent and sent for microbiologic studies. The remainder of the fluid was sent to the lab for further studies.
After the patient was breathing spontaneously, he was extubated and brought to the postanesthesia care unit hemodynamically stable and breathing reasonably comfortably. There were no intraoperative complications.
OPERATION PERFORMED: Left video thoracoscopy with biopsy of AP window lymph node.
DESCRIPTION OF OPERATION: The patient was placed on the operating room table in the supine position. A pre-procedure time-out was performed. A central venous catheter arterial line was placed. The patient was placed in the right lateral decubitus position for a left video thoracoscopy, and the left chest was prepped and draped in the usual sterile fashion. The first thoracoscopic trocar entry site created was approximately at the level of the sixth rib in the posterior axillary line. Local anesthesia was provided with 0.25% Marcaine with epinephrine. The thorax was entered with a muscle-sparing technique after a satisfactory prep and drape and the induction of general anesthesia. Digital palpation with the index finger of the operating surgeon failed to reveal any adhesions within the region and video thoracoscopy was undertaken. The lungs were diffusely emphysematous and diffusely anthracotic. The left lower lobe had no obvious suspicious visible masses. The visceral and parietal pleurae had no obvious satellite studding. The left upper lobe had the mass corresponding to the CT scan findings with a dimpling of the pleura, making this a clinical T2 neoplasm. The laparoscopic peanut clamp was used to provide retraction to the left upper lobe of the lung and provide exposure to the aorticopulmonary window. There was a rock-hard mass measuring about 3 cm in size in the AP window, visually, and palpably consistent with malignancy. A second trocar entry site created was approximately at the level of the third rib in the mid to posterior axillary line, where local anesthesia was utilized for localization purposes as well as for analgesic purposes. The thorax was entered without difficulty. Digital palpation with the index finger of the operating surgeon was able to confirm a rock-hard mass in the AP window. There was some neovascularity of the mediastinal pleura. After discussions with the attending pathologist, we decided to provide a fine-needle aspiration, which was performed with the mediastinoscopy instrument called the needle aspirating device, which is a 25-gauge needle attached to a long laparoscopic cylinder. Fine-needle aspiration was performed x1. The results of that investigation revealed scant cellularity with atypia. A second and a third fine-needle aspiration from this rock-hard mass were performed. There was no active bleeding to report. The needle aspiration device was used to confirm presence within a neoplasm, but not presence within a major blood vessel. The fine-needle aspirate of the second attempt revealed poorly differentiated, metastatic, malignant, non-small cell lung cancer; therefore, the procedure was completed at this juncture. There was no bleeding from the biopsy site. There was no bleeding from the chest wall at the trocar sites. We did not enter the lung, so we did not need to use fibrin glue. We drained the thorax with a #36 French chest tube placed two fingerbreadths below the first trocar entry site, tunneled subcutaneously to enter the chest at the interspace of the first trocar site. The chest tube was directed cephalad and confirmed with video thoracoscopy. The chest tube was secured to the skin with 2-0 nylon sutures x2. Next, the placement of an Accufuser bupivacaine pump was performed from a trajectory of an anterior approach. The catheter is a 5-inch long catheter. It was tunneled subcutaneously and submuscularly. The proximal aspect of the 5 inch long bupivacaine infusion device resides at the first trocar entry site in a submuscular, extrathoracic position. A submuscular tunnel was created with a tonsil clamp to connect this catheter up to the more cephalad second trocar site, where it remains in a submuscular position. The Accufuser was secured to the skin with 3-0 Prolene suture. The trocar sites were inspected and found to be hemostatic. Subcutaneous tissues were closed with 2-0 Vicryl. Subdermal tissues were closed with 2-0 Vicryl. Skin was closed with 4-0 Monocryl. Sterile dressings were applied. Sponge, needle, and instrument counts were correct. The estimated blood loss was minimal. The patient tolerated the procedure well and will be transferred to the recovery room.