DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right chest postpneumonic empyema and fluid collection with entrapment of right lower lobe.
POSTOPERATIVE DIAGNOSIS: Right chest postpneumonic empyema and fluid collection with entrapment of right lower lobe.
OPERATION PERFORMED: Right mini thoracotomy x2 with drainage of empyema contents and decortication of right lower and portion of right upper lobe, intercostal nerve blocks x5.
SURGEON: John Doe, MD
ANESTHESIA: Double-lumen general endotracheal.
INDICATION FOR OPERATION: The patient is a (XX)-year-old woman who had originally been admitted with pneumonia. Subsequent to this, she developed a reactive fluid collection in the chest that has been resistant to less invasive maneuvers and drainage. She has been brought to the operating room today on elective basis for right lung decortication and removal of the products of the empyema process.
OPERATIVE FINDINGS: The right lung was fairly densely adherent to the chest cavity in general from inflammatory adhesions. The anterior aspects of the lung were easily mobilized. Along the diaphragm and posterior along the back and near the spine, the adhesions were fairly dense and firm. With time and care, ultimately the lung was able to be fully mobilized circumferentially. The most intense area of the inflammatory reaction and also the largest collection of fibrinous material was posteriorly near the spine. The surface of the lung was also removed of all fibrinous contents. At the conclusion of the procedure, all above three lobes of the right lung were discrete and able to inflate fully.
DESCRIPTION OF OPERATION: After obtaining adequate double-lumen general endotracheal anesthesia, the patient was placed in the left lateral decubitus position with all appropriate pressure points padded. An axillary roll was put in place. A beanbag device with a gel pad was used to hold her in position. The patient’s right chest was prepped and draped in a sterile manner. Initially, a small incision was made at about the tenth intercostal space. We placed this incision over the point of what appeared to be maximal fluid collection. In entering the chest cavity, there was a bunch of gelatinous material that was removed both digitally and with a suction device. At this level, the lung was intensely welded to the diaphragm along the posterolateral edge of the lung. We did not try to mobilize this more than once or twice, as the lung would yield before anything else wound. Once we did everything we could from this incision, it was clear that we needed to move above that.
We made another small incision two interspaces higher. This proved to be all that was necessary to fully mobilize the lung. We were able to mobilize the upper, then middle, then lower lobes anteriorly completely. Ultimately, with a little bit more time and patience, the entirety of the lung was able to be mobilized posteriorly as well. We broke into a couple of loculations posteriorly back near the spine. These were filled with fibrinous material as well that was quietly densely organized. Various adhesions were present that were all taken down.
We were able to define the fissure between the lower and middle lobe first. This was readily separated. The fissure between the upper and middle lobe was a bit more densely adherent, but nonetheless, it readily separated. In working forward and inferiorly, we were able to get between the lung and the diaphragm anteriorly and laterally. We were able then to carry this dissection plane posteriorly all the way and ultimately free the lung off the diaphragm entirely.
All fibrinous debris was then removed from the surface of the lung and also from the lateral chest wall. Once all this had been completed, the chest was copiously irrigated with a warm antibiotic-containing saline solution. A single 36-French chest tube was placed posteriorly and inferiorly in the chest through a small separate stab wound through the eleventh intercostal space. Each of the mini thoracotomy was closed in usual fashion with absorbable sutures. Prior to closing the incisions, a five-level intercostal block with 100% plain Marcaine was done to aid in postoperative analgesia. Additionally, each wound was injected with 1.5% plain Marcaine to help keep her comfortable postoperatively.
Dry sterile dressings were applied to each closed incision. The patient was awakened and extubated and transferred to the postanesthesia care unit in stable condition from my care.
