DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Mediastinal and right hilar mass.
POSTOPERATIVE DIAGNOSIS: Mediastinal and right hilar mass.
PROCEDURES PERFORMED:
1. Flexible bronchoscopy.
2. Cervical mediastinoscopy with biopsy and thyroid isthmusectomy.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local regional using 1% Xylocaine and general.
INDICATIONS FOR PROCEDURE: The patient is a very pleasant (XX)-year-old Hispanic female who has mediastinal and right hilar mass, who was brought to the office today for the above-mentioned procedure. The procedures were explained to the patient. All risks, benefits, and options were discussed. The risks include but were not limited to bleeding, infection, and pneumothorax. All of her questions were answered, and she wished for us to proceed with the surgery.
OPERATIVE FINDINGS: Flexible bronchoscopy revealed blunting of the carina. No evidence of any endobronchial mass was noted. Mediastinoscopy revealed several firm pretracheal and right paratracheal masses. Frozen section analysis revealed this to be a non-small cell carcinoma, most likely squamous cell carcinoma.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite and placed in the supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal tube visualizing the distal trachea, carina, and right and left main stem bronchus with the primary and secondary divisions. No evidence of any endobronchial tumor was noted. We did see some blunting of the carina. The scope was then withdrawn.
The patient was then prepped and draped in the usual sterile fashion. A small curvilinear incision was made above the suprasternal notch in the line of the skin crease. Dissection was carried down through the subcutaneous tissue down through the platysmal muscle. The strap muscles were next identified and laterally retracted. We continued our dissection down to the pretracheal fascia. A thyroid isthmusectomy was done without any problems with excellent hemostasis being obtained. A pretracheal plane was next developed. A mediastinoscope was then placed. Careful exploration was carried out, and findings were as stated above. Multiple right paratracheal and pretracheal lymph nodes were encountered after first aspirating these nodes to make sure they were not vascular in nature. Generous biopsies were taken and sent to pathology for examination. Frozen section analysis revealed this to be a non-small cell carcinoma, most likely squamous cell.
Excellent hemostasis was obtained. The wound was then closed in layers using Vicryl sutures. Dressings were applied. The patient tolerated the procedure and was sent to the recovery room in stable condition.
