DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Recurrent right pleural effusion.
POSTOPERATIVE DIAGNOSIS: Recurrent right pleural effusion.
PROCEDURE PERFORMED: Right PleurX catheter placement.
SURGEON: John Doe, MD
ANESTHESIA: Local with IV sedation.
COMPLICATIONS: None.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old female with a complex past medical history, most pertinent for nonalcoholic steatohepatitis (NASH) cirrhosis with associated encephalopathy and coagulopathy. The patient has developed a recurrent right pleural effusion. In an effort to palliate her respiratory symptoms, the patient was referred for a PleurX catheter placement for home drainage. The patient and her family understood the risks and possible complications of the procedure and wished to proceed.
OPERATIVE FINDINGS: The right chest was opacified on preoperative chest x-ray, and 2 liters of serous fluid was withdrawn before clamping the drainage tube. There were no bleeding complications, and the fluid was not blood tinged.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. Intravenous sedation was administered without complications. The patient was then positioned with the head up and a roll under the right shoulder. The right chest and upper abdomen were prepped and draped in the usual sterile fashion. Lidocaine 1% was used to infiltrate two areas; one in the right upper quadrant where the tube would exit and the other along the anterior axillary line in the seventh intercostal space.
A small counterincision was made in the right upper quadrant area. Through the anterior axillary line area, the pleural space was accessed by Seldinger technique. The counterincision was made around the guidewire and then the PleurX catheter was tunneled from the right upper quadrant small incision to the one overlying the ribs. A sheath introducer was then passed over the wire and then the PleurX catheter was placed through the sheath introducer. There was good return of fluid. Two liters of serous fluid was withdrawn slowly as the small counterincision was closed with Monocryl stitch.
The catheter was capped off, and sterile dressings were applied. The patient tolerated the procedure well without any complications. The patient was transferred to the recovery room in stable condition. Sponge and needle count was correct at the end of the case.
