DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bilateral pulmonary nodules.
POSTOPERATIVE DIAGNOSIS: Bilateral pulmonary nodules.
OPERATION PERFORMED:
1. Right chest wall skin nodule excision.
2. Right mini thoracotomy with nodule wedge excision x3.
3. Placement of On-Q pain pump.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 50 mL.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female who had left-sided breast cancer 11 years ago. She had fallen recently and by chest x-ray was noted to have new lung masses, the presence of which was confirmed by CT scan. She presents today for excisional biopsy for definitive diagnosis. She understands the risks and possible complications of the procedure and wishes to proceed.
OPERATIVE FINDINGS: On the chest wall, very close to the axilla, was a palpable nodule in the skin. This was wedged out and sent to pathology. The lung parenchyma had numerous pulmonary nodules varying in size from 2 mm to over a centimeter. These were in all three of the lobes on the right side. There was no effusion and no parietal pleural abnormalities. The first nodule was taken from the right lower lobe and this, by frozen section, was consistent with a carcinoid tumor. A second one was taken from the right middle lobe, in the area that had been hypermetabolic by PET scan, and this again was consistent with carcinoid. The third nodule was taken from the right lower lobe and also submitted for pathology.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced without complication. The patient was placed in the left lateral decubitus position and the right chest prepped and draped in the usual sterile fashion.
A 2 cm elliptical nodule was palpated in the skin of the right chest wall just below the axilla. This felt firm and had some discoloration. Wondering if this was a metastatic skin lesion, we wedged it out sharply and sent it for pathology. This wound was closed with a 2-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure.
Following this, a right lateral mini thoracotomy was made in the 5th intercostal space. The multiple nodules were palpated in the lung parenchyma. Using a TA-45 stapler with thick tissue reload, one of the nodules was wedged out from the right lower lobe and sent for frozen section. This appeared consistent with carcinoid tumor. An additional nodule from the right middle lobe was wedged out in a similar fashion and also sent for frozen section, which yielded the same result. An additional third nodule was removed from the right lower lobe, which has also been sent for pathology.
At the completion of this, after checking for adequate hemostasis, a 32-French tube was placed and secured with 0-Vicryl suture. The ribs were approximated with #2 Vicryl stitches. An On-Q pain pump was placed. The muscular layer closure was done with 0-Vicryl suture and an additional pain catheter placed. The subcutaneous tissues were approximated with #2 Vicryl and the skin with 4-0 Monocryl in running subcuticular fashion. Steri-Strips and sterile dressings were applied.
The patient tolerated the procedure well without any complications. The patient was extubated and transferred to the recovery room in stable condition. Sponge and needle count was correct at the end of the case.
