DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Bilateral pneumothoraces, anterior.
POSTOPERATIVE DIAGNOSIS:
Bilateral pneumothoraces, anterior.
PROCEDURE PERFORMED:
Bilateral chest tube placement.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: IV sedation.
ESTIMATED BLOOD LOSS: None.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: The patient is a critically ill young gentleman who has severe ARDS. The patient has been noted to have previous pneumothoraces. His pneumothoraces are currently not adequately drained by his current chest tube placement. The chest tubes on x-ray appear to be posterior and pneumothoraces are anterior. This has affected his saturations, and he is also tachycardic. The patient thus presents for placement of anterior chest tubes.
DESCRIPTION OF PROCEDURE: On the date of the operation, the patient’s bilateral arms were extended over his head, and his bilateral chests were prepped. A time-out was held, and the patient and the planned procedure were confirmed. The patient’s previous posterior chest tubes were removed, and the area was prepped with Betadine and draped in the standard sterile fashion.
The anterior axillary line incisions were extended and tunnels made down to the pleura. There was a rush of air when the pleura was entered on the right side; there was no rush of air on the left side. A finger sweep was made into the space that was anterior. This confirmed nearby adhesions. A 32-French chest tube was then inserted on each side under direct palpation, anteriorly over the top of the lung. It was ensured that these did not go posteriorly. These were directed anteriorly.
They were then secured and placed with 2-0 silk sutures. Sterile dressings were applied. The patient tolerated the procedure well without complications. The patient’s oxygen saturations increased after the procedure, and the patient remained in the surgical intensive care unit in critical condition. No complications were observed as of this time.
