DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right neck mass.
2. Airway obstruction.
3. Bilateral vocal fold paralysis.
POSTOPERATIVE DIAGNOSES:
1. Metastatic adenocarcinoma to the right neck.
2. Bilateral vocal fold paralysis.
3. Airway obstruction.
OPERATIONS PERFORMED:
1. Microsuspension direct laryngoscopy with CO2 laser cordectomy with an operating microscope.
2. Tracheostomy.
3. Incisional biopsy of the right neck mass.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 10 mL.
SPECIMENS: Incisional biopsy, right neck mass.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with a history of lung carcinoma, who is being treated for a left vocal fold paralysis. The patient has a new onset right vocal fold paralysis, resulting in bilateral vocal fold paralysis and airway obstruction. The patient also has had a recent PET CT scan, which showed a supraclavicular lymph node in the right neck. In light of the patient’s breathing difficulty and history of lung cancer, the decision was made to take the patient to the operating room for an excisional biopsy of the right neck mass, tracheostomy, and right laser cordectomy.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the ENT service without difficulty. The patient was then prepped and draped in the usual sterile fashion.
An approximately 3 cm horizontal incision was made over the right supraclavicular region. The underlying tissues had a palpable lymph node. Bovie cautery was used to incise the skin and the deep subcutaneous tissues. An incision was made through the platysma muscle and part of the sternocleidomastoid muscle. There was evidence of multiple matted lymph nodes in the right supraclavicular area. An excisional biopsy was performed and sent for frozen pathology. The frozen pathology was positive for adenocarcinoma. Bovie cautery was used for hemostasis. The 3-0 Vicryl stitch was used to reapproximate the deep tissues. The 5-0 nylon was used to reapproximate the skin edges.
Attention was then turned towards the tracheostomy. Bovie cautery was used to incise the skin in a horizontal fashion approximately two fingerbreadths above the clavicle. The incision was made in a horizontal fashion approximately 4 cm in length. The incision was carried horizontally through the deep subcutaneous fat and platysma muscle. The incision was then carried in a vertical fashion from the level of the cricoid down to the fourth tracheal ring. The thyroid isthmus was transected with Bovie cautery. Hemostasis again was obtained with Bovie cautery.
The anterior tracheal wall was identified. The space between the second and third tracheal ring superficial tissues were cauterized. At that point, a 15 blade was used to enter the airway. At that point, the endotracheal tube was removed. A #8 Shiley cuffed tube was then placed into the airway. There was good CO2 return. Prior to placement of the Shiley tracheostomy tube stay sutures were placed around the second and third tracheal ring. The stay sutures consisted of 2-0 silk. At that point, the tracheostomy tube was sewn to the anterior neck wall with 2-0 nylon sutures. A soft Velcro collar was placed around the neck.
The patient was then prepared for the microsuspension direct laryngoscopy with CO2 laser cordectomy. A Dedo laryngoscope was used to visualize the right vocal cord. Suspension was used to maintain apposition. An operating microscope with CO2 laser was then brought into the field to visualize the right vocal cord. After protection of the patient with wet towels, the CO2 laser was used on three watts continuous setting to perform a vertical cordectomy just anterior to the vocal process. There was no bleeding during the procedure. The entire vocalis muscle was transected with this technique.
At that point, the operating microscope was removed. The Dedo laryngoscope was removed. The patient was then awoken from general anesthesia and sent to the postanesthesia care unit in stable condition. There were no complications during the procedure.
