DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left lung cancer.
POSTOPERATIVE DIAGNOSIS: Left lung cancer.
PROCEDURE PERFORMED: Left pneumonectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 300 mL.
COMPLICATIONS: None apparent.
DRAINS: None.
SPECIMENS: Left pneumonectomy, most inferior mediastinal node, multiple other mediastinal nodes.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room and placed on the operating table in the supine position. Anesthesia was induced. He was endotracheally intubated with a double lumen tube. He was then positioned in the lateral decubitus position and the left chest was prepped and draped sterilely. The left chest was entered through a standard left posterolateral thoracotomy incision. The patient’s previous surgical scar from prior left thoracotomy was utilized. The incision was deepened with electrocautery. The fifth intercostal space was entered and multiple pulmonary adhesions to pleura were identified. These were taken down with sharp dissection and electrocautery. Approximately 45 minutes was spent in lysing adhesions to gain full access to the thoracic cavity. There were multiple adhesions in the region of the hilum as well. There was an obvious mass at the left chest that was adherent posteriorly. This was noted to be densely adherent to the pleura and was mobilized from this with some difficulty. There was thought to be likely microscopic tumor disease left behind at the chest wall and this was clipped with clips for postoperative radiotherapy to the area. More adhesions were taken down in the hilum to allow for better exposure.
It was initially attempted to do a left upper lobectomy, preserving the left lower lobe. Multiple branches of the left main pulmonary artery to the left upper lobe were divided and suture ligated with excellent hemostasis. The left superior pulmonary vein was divided with a vascular stapler. It was then attempted to isolate the left upper lobe bronchus and there was significant difficulty due to scarring and calcified adenopathy in the hilar area. The adhesions precluded appropriate mobilization of the left upper lobe bronchus from the left lower lobe bronchus, and given the patient’s disease, adenopathy and adhesions, it was thought most appropriate to simply proceed with pneumonectomy. The remaining vasculature to the lung including the main branch of the artery to the left lower lobe and the left inferior pulmonary vein were both divided with vascular staplers. Multiple adhesions and lymphatics were divided, dividing the lymphatics between clips and this allowed full exposure to the left main stem bronchus which was divided after closure with TA stapler. This freed the specimen which was forwarded to pathology.
The wound was inspected for hemostasis, which was excellent. Additional nodes were dissected. The inferior-most node was sent separately. The more superior mediastinal nodes were sent together. No residual adenopathy remained within the chest. No residual tumor remained on the chest wall; although, there was irregularity to the pleural surface at the site of tumor adherent, thought to likely represent microscopic disease. The wound was irrigated, and before suctioning the irrigant out, the bronchial stump was tested and noted to be watertight. The irrigant was suctioned out. The bronchial stump was sprayed with Tisseel. Sponge, needle and instrument counts were correct. Hemostasis was excellent. The ribs were approximated with interrupted double looped #2 chromic sutures. Chest wall musculature was reapproximated with running #1 Vicryl. Subcutaneous tissues were irrigated and the skin edges were approximated with skin staples. Using a spinal needle and a 60 mL syringe, approximately 400 mL of air was then aspirated out of the thoracic cavity to facilitate a mild mediastinal shift. Sterile dressings were applied. The patient was extubated and returned to the intensive care unit.
