DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Restrictive lung disease.
2. Dyspnea on exertion.
3. History of smoking.
POSTOPERATIVE DIAGNOSES:
1. Restrictive lung disease.
2. Dyspnea on exertion.
3. History of smoking.
OPERATION PERFORMED:
1. Right thoracoscopy with right upper lobe, right middle lobe, and right lower lobe wedge resection biopsies.
2. Right sixth, seventh, and eighth intercostal space intercostal blocks with Marcaine 0.25% with epinephrine.
3. On-Q pain catheter placement.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 25 mL.
COMPLICATIONS: None apparent.
DISPOSITION: To postanesthesia care unit in satisfactory condition.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male with restrictive lung disease and progressive dyspnea on exertion. He had a prior history of smoking, having quit a year ago. Dr. Jane Doe of the pulmonary medicine service requested our assistance in obtaining lung tissue for pathologic evaluation in order to determine the etiology of his pulmonary fibrosis. The risks, benefits, and alternatives to a right thoracoscopy with wedge resection biopsies were discussed with the patient, and informed consent was obtained.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. Following the smooth induction of general anesthesia, a left-sided double lumen endotracheal tube was placed. The position was confirmed. A Foley catheter was placed. The patient was log rolled into the left lateral decubitus position. All pressure points were appropriately padded, and the right chest was prepped and draped in the usual sterile fashion. A timeout was held confirming the correct patient and the correct side for the procedure. Preoperative antibiotics and subcutaneous heparin had been administered. Compression boots and a lower body warmer were in place.
A 12 mm port was placed in the eighth intercostal space in the posterior axillary line after infiltration with Marcaine 0.25% with epinephrine. Under the guidance of a 10 mm 30-degree scope, a 12 mm port was placed in the sixth intercostal space anteriorly, and a 5 mm port was placed in the sixth intercostal space posteriorly. Both of these sites were infiltrated with Marcaine 0.25% with epinephrine. Additional Marcaine injection was performed in the seventh intercostal space.
The pleural space was inspected. There was no pleural effusion. There was no parietal pleural pathology. There was gross thickening and fibrotic changes of the lung, more pronounced in the middle lobe and the lower lobe than the upper lobe, but diffuse. The most grossly normal-looking lung was the apical segment of the right upper lobe of the lung. This was grasped with grasping forceps, and a wedge resection biopsy was performed with serial firings of the Echelon endoscopic stapler. The specimen was placed into a specimen bag and brought out through the anterior port site.
Next, a wedge resection of the medial segment of the right middle lobe of the lung again was performed with the Echelon stapler. The specimen was brought out through the anterior port site. The most grossly abnormal was the superior segment of the right lower lobe of the lung. This was grasped with grasping forceps, and a wedge resection biopsy was performed. The specimen was placed into a specimen bag and brought out through the anterior port site. The specimen was cut on the back table. A portion of the tissue was sent for routine fungal and mycobacterial cultures. The remaining tissue was sent for pathologic evaluation. The staple lines were then treated topically with 5 mL Tisseel fibrin sealant.
An On-Q catheter was tunneled from the costal margin to the eighth intercostal space port site and then tunneled posteriorly up to the fifth intercostal space. It was primed with 5 mL of 0.375% Marcaine. The right lung was ventilated, and with sustained positive pressures to 25 and 30 mmHg, appropriately expanded to fill the right chest. The ports were removed, and the port sites were closed in layers with absorbable suture, with the skin approximated with a 4-0 Monocryl subcuticular skin stitch. These incisions were sealed with Dermabond. A 10 French chest tube had been placed through a separate stab wound incision in the seventh intercostal space and placed posteriorly to the apex of the chest. This was secured at the skin with a #2 silk suture. It was placed to an Atrium chest drainage system. The patient awoke from general anesthesia. He was extubated and transported to the PACU in satisfactory condition.
