DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left empyema.
POSTOPERATIVE DIAGNOSIS: Left empyema.
PROCEDURE PERFORMED: Drainage of empyema and placement of a left empyema tube.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local, LMA.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman with a history of left-sided lung cancer, status post resection a year ago. He developed a malignant effusion and underwent chest tube drainage for this in the past. He subsequently developed recurrence of the fluid and recently purulent material. He now requires drainage of the residual empyema. He understands the risks and possible complications of the procedure and wishes to proceed.
OPERATIVE FINDINGS: The small wound on the left chest was connected via a small tract to a large collection in the left posterior chest. This fluid was frankly purulent and malodorous. A sample was sent for culture. A large empyema tube was left in place.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the right lateral decubitus position on the OR table. The patient was sedated, and an LMA was placed for control of his airway. The small open area on the left chest was expanded into a 2 cm incision and a 1 cm portion of rib was removed in the base of the wound. The thickened pleura was excised using cautery, and this led into a large posterior cavity with extremely thickened visceral and parietal pleura that was filled with purulent material. This cavity was copiously irrigated with warm antibiotic solution. A 40-French chest tube was then placed into the cavity through the existing small wound. This was secured in place with 0 Vicryl suture and the wound approximated around the tube. The tube was hooked up to a Pleur-evac for optimal drainage. A sterile dressing was applied. The patient tolerated the procedure well without any complications. Estimated blood loss was minimal. The patient was transferred to the recovery room in stable condition. Sponge and needle count was correct at the end of the case.
