DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Metastatic carcinoma of the breast along with small bowel fistula requiring long-term IV access for hyperalimentation.
POSTOPERATIVE DIAGNOSIS: Metastatic carcinoma of the breast along with small bowel fistula requiring long-term IV access for hyperalimentation with poor peripheral access.
OPERATION PERFORMED: Insertion of a 9.5-French dual/double-lumen Groshong catheter via right subclavian.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: LMA with 0.25% Marcaine.
ESTIMATED BLOOD LOSS: Minimal. No transfusions.
DRAINS: None.
SPECIMEN: None.
DESCRIPTION OF OPERATION: The patient was in the main operating room under adequate LMA anesthesia. She had already been on multiple antibiotics, including vancomycin and clindamycin. A small towel was placed in the infrascapular area. Both arms were tucked to the sides and adequately padded. The entire upper chest, including the shoulder and neck area, was prepped with iodoform and draped in the usual sterile fashion.
Knowing that the patient had a right mastectomy, we opted to go on the left side where the infraclavicular region on the left side was anesthetized using 0.25% Marcaine. Using a standard percutaneous Seldinger technique, despite multiple attempts, we were never able to identify the left subclavian vein. The patient remained very stable with saturations up to 100.
For that reason, we opted to go on the right side. At this point, attention was directed to the right infraclavicular region. It was well anesthetized using 0.25% Marcaine. Using a standard percutaneous Seldinger technique, the right subclavian was identified on the first pass with absolutely no difficulty. Blood was aspirated. A guidewire was then placed through the needle guide into the subclavian vein, superior vena cava, and right atrial junction, as confirmed by fluoroscopy.
Next, a small tunnel was then fashioned where at this point a 9.5-French dual-lumen Groshong catheter was then placed through this tunnel. This was then cut to appropriate length and flushed using saline. Next, a dilator with a peel-away sheath was placed over the guidewire. The guidewire along with the dilator were subsequently removed. The catheter tube was then placed through this peel-away sheath. The catheter was then guided down the subclavian vein to the superior vena and right atrial junction, as confirmed by fluoroscopy.
Blood was aspirated from both lumens. This then flushed using saline with no difficulty. At this point, the small incisions were approximated using 4-0 Vicryl. The small butterfly Luer-Lok was then secured to the Groshong catheter using interrupted 2-0 Prolene. The catheter was flushed again one more time with no difficulty.
Sterile dressing was applied to the wound. The estimated blood loss was minimal; none was transfused. No drains were placed. Sponge, needle and instrument counts were correct on three occasions. The patient subsequently tolerated the procedure well, and she was then returned to the recovery room in very stable condition.
