DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Seroma versus abscess of the permanent pacemaker pocket in the left subclavian area, possibly posttraumatic.
POSTOPERATIVE DIAGNOSES:
1. Posttraumatic sterile seroma of the permanent pacemaker pocket.
2. Malfunctioning of the old pacemaker generator.
OPERATION PERFORMED:
1. Explantation of the old pacemaker system generator.
2. Lysis and reduction of the adhesions in the permanent pacemaker implant pocket.
3. Implantation of a new pacemaker generator and creation of a separate pocket.
SURGEON: John Doe, MD
ANESTHESIA: MAC.
DESCRIPTION OF OPERATION: Consent was obtained in the preoperative area. The patient was taken to the operating room, put on her back, and anesthesia was started. Usual sterile prep was performed, preparing left and right subclavian areas. After local anesthesia with 2% lidocaine, the incision was done just in the middle of the pocket. Subcutaneous tissue was separated using sharp and blunt dissection. Electrocautery was utilized for hemostasis. Then, the thick capsule around the pacemaker was identified. It was opened and a small amount of the serosanguineous fluid came out of it, and it was cultured and sent for express Gram staining. The pacemaker generator was taken out of the system. It was noted on the monitor then that the patient was missing the ventricular stimulation. Only atrial impulses were noted, but ventricular stimulation was absent intermittently. We then disconnected the ventricular lead from the pacemaker system and connected it to the external system and interrogated it. It appears the lead was giving very similar thresholds when it was checked, to when it was in vivo through the pacemaker system. Therefore, we decided that the pacemaker generator is malfunctioning and it could be injury from electrocautery or other causes. It will be sent to the company for their investigation. Then, evaluating the area, we did not see any evidence of pus. There were noted very thick adhesions, hypertrophic scar. Thickness of the capsule was in the range of 0.6 to 0.8 cm. The lead was frozen in that scar tissue. Incision was made to free the lead from the adhesions and resect as much as possible the old capsule and then create a separate pocket lower down, just behind the breast over the major pectoralis muscle, in the subfascial space. It was created utilizing sharp and blunt dissection. The adhesions were lysed and cut, and the lead was freed all the way down where it goes into the muscle. Inspection revealed there was no damage done and the plastic coating appears to be intact. The majority of the large pieces of the scar tissue were excised back to normal-appearing tissue. No evidence of infection again noted. Then, we washed the wound with warm normal saline and bacitracin-containing solution, the new pocket as well as old pocket. Then, the new generator was attached to the lead and secured in place in the new pocket. The pocket was closed in layers utilizing Vicryl 3-0 and Monocryl 3-0 with Steri-Strips on top and putting the Tegaderm and pressure dressing. The patient was woken up and taken back to recovery.
Thresholds in the chronic lead were as follows: The threshold was 2.8 volts, resistance 380 ohms and no R-waves were detected. The patient did not have spontaneous ventricular electrode activity.
ESTIMATED BLOOD LOSS: Less than 10 mL.
