DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Lymphocytic colitis.
2. Line sepsis with infected Port-A-Cath.
3. Recent excision, pilonidal abscess.
PROCEDURES PERFORMED:
1. Right internal jugular central venous catheter placement with SonoSite ultrasound guidance.
2. Removal of right infraclavicular Port-A-Cath.
3. Dressing change on intergluteal wound with wound VAC.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Hispanic female diagnosed with lymphocytic colitis, and as part of the treatment for that, has been on total parenteral nutrition for approximately three months and had a Port-A-Cath inserted some time ago in the right subclavian vein. The patient also has had a chronic pilonidal that became infected in the past few weeks and was excised approximately nine days ago. The patient has poor pain tolerance, and dressing changes have been quite difficult, even with use of the vacuum-assisted closure device. The patient has recently presented with fevers and was found to have blood cultures positive for Staphylococcus.
DESCRIPTION OF PROCEDURE: After obtaining informed consent and identification of the patient, the patient was transported to the operating room where she was placed supine and general anesthetic administered. With her supine and the head tilted somewhat to the left, both sides of the neck were imaged first with the Site-Rite ultrasound, noting both internal jugular veins to be widely patent.
The right side was selected and prepped with ChloraPrep. Sterile drapes were placed exposing the right side of the neck. The Site-Rite ultrasound was draped sterilely, and with the Site-Rite imaging over the neck, the internal jugular vein was visualized with the ultrasound. Local anesthetic was infiltrated in the skin and subcutaneous tissue adjacent to the ultrasound transducer.
Then, an 18-gauge thin wall was introduced through the skin and observed under ultrasound to puncture the internal jugular vein with free return of blood. The syringe was removed from the needle and a guidewire passed through the needle without resistance. The needle was withdrawn, and a small incision made adjacent to the guidewire. A vessel dilator was passed over the guidewire and withdrawn, and then a triple lumen central venous catheter, that had been preflushed with heparinized saline, was passed over the guidewire, and the guidewire withdrawn. Aspiration of the lumen noted free return of blood. This lumen was capped and flushed with heparinized saline. The proximal lumen was aspirated again noting free return of blood and then reflushed with heparinized saline. The catheter was secured to the skin with 3-0 silk sutures with approximately 15 cm mark on the catheter at the skin level. Then, a sterile dressing was placed over the catheter entry site.
Next, the right shoulder area was prepped with ChloraPrep and sterile drapes placed exposing the existing subcutaneous port site. An incision was made through the skin, along the previous surgical scar, and dissection of the subcutaneous identified the catheter in the subcutaneous tissue, and this followed to the junction with the port. The capsule around the port was incised and the catheter withdrawn. Then, the port was removed from within its pocket and the wound observed for hemostasis.
Subcutaneous tissue was approximated with 3-0 Vicryl sutures and then the wound dressed with antibiotic ointment and a sterile dressing. The patient was then turned into a right lateral position. The intergluteal wound was approximately 6 x 2.5 x 2 cm deep and appeared clean, with beginnings of granulation tissue starting. The skin around the wound was cleaned and then a GranuFoam wound VAC dressing was cut to fit within the existing wound and then sealed in place and bridged to her left hip area with foam to prevent her laying on the tubing. This was connected to suction and sealed well. The patient was then was awakened from anesthesia and transported to recovery in stable condition.
