DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Locally recurrent right breast cancer.
POSTOPERATIVE DIAGNOSIS: Locally recurrent right breast cancer.
PROCEDURE PERFORMED: Port-A-Cath insertion via the left subclavian vein.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Local, 11 mL of 0.5% lidocaine with 0.25% Marcaine at final concentration, with monitored anesthesia care.
ESTIMATED BLOOD LOSS: Less than 20 mL.
COMPLICATIONS: There were no complications.
INDICATIONS FOR PROCEDURE: The patient is an (XX)-year-old Hispanic female initially diagnosed with a right breast cancer 13 years ago. For this, she underwent a modified radical mastectomy with immediate reconstruction. At that time, she had no chemotherapy but did take tamoxifen because it was estrogen receptor positive. Eight years ago, the patient developed a mass under her right axilla, which proved to be recurrent cancer, in a lymph node, upon excision. Following this, she did undergo chemotherapy, specifically four cycles of Adriamycin and Cytoxan followed by radiotherapy. More recently, she has developed a new right axillary mass, which was locally painful. She underwent an incisional biopsy at an outside hospital with another surgeon, which again revealed recurrent cancer. The patient’s margins were positive, yet scans for the extent of disease failed to demonstrate any distant metastatic disease. The patient has initiated chemotherapy with gemcitabine and Taxol; however, her peripheral IV access is poor, and she was recommended for consideration of a Port-A-Cath.
INTRAOPERATIVE FINDINGS: The catheter, as inserted, has the tip in the proximal superior vena cava. There was no evidence, on fluoroscopy, intraoperatively, for hemothorax or pneumothorax. Aspiration of the port was easy, and it could be easily flushed as well. Postoperative chest x-ray demonstrated the tip in the superior vena cava as well as no evidence for any complication of hemothorax or pneumothorax.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. Both arms were tucked, a roll between her shoulder blades. She was then placed in the Trendelenburg position. A time-out was called, and the patient’s identity as well as the procedure planned and site and side were confirmed before we proceeded.
The left chest wall as well as the neck was then carefully prepped and draped in the usual aseptic fashion. Local anesthetic was used to raise a wheal of local anesthetic within the dermis at approximately two-thirds the distance between the sternal notch and the clavicle. Once this was inserted, local anesthetic was then used to infiltrate the path between the focal wheal and the clavicle. A cannulation needle was then inserted at the wheal at the skin site. This was passed up to the bone and then under it, aiming at 1 cm above the sternal notch. The subclavian vein was immediately cannulated and the guidewire advanced through the needle. The needle was removed and the guidewire carefully clamped to the adjacent drape while we turned our attention to the development of a Port-A-Cath pocket.
At a point between the expected lie of her bra strap, on the left side, and the expected opening for a V-neck sweater or shirt, a transverse incision was drawn on the skin with a sterile skin marker, approximately 4 cm below the clavicle. Once drawn on the skin, local anesthetic was used to infiltrate the underlying dermis and subcutaneous tissues. The underlying subcutaneous tissues, inferior to the expected incision, were also injected with local anesthetic. The incision was made along the planned line with a 15 blade scalpel. This was then extended through the remainder of the dermis using electrocautery maintaining hemostasis as we progressed. A skin flap was then raised inferiorly for the extent of the expected Port-A-Cath pocket. Once large enough, the development ceased. Excellent hemostasis was obtained throughout that entire port pocket development.
Local anesthetic was then used to infiltrate the underlying subcutaneous tissues between the guidewire insertion site and the Port-A-Cath pocket. The guidewire insertion site was then dilated with the use of an 11 blade to enlarge the opening at the guidewire site. This was then carefully dilated subcutaneously with a mosquito clamp. The clamp was then used to tunnel from the guidewire site to the Port-A-Cath pocket and then used to bring the catheter back through the tunnel to the guidewire site.
The dilator with introducer was placed over the guidewire and the dilator with guidewire removed. The catheter was inserted into the introducer and advanced under fluoroscopic control until the tip lay within the proximal superior vena cava. The peelaway sheath of the introducer was then removed. The additional slack in terms of catheter was then taken up at the Port-A-Cath pocket site and the catheter clamped using a rubber-shod clamp. The catheter was then cut distally to the clamp by approximately 1 cm and the catheter attached to the port on the side of the clamp. Once this was connected, the locking device provided by the manufacturer was then used to lock the two in place. The port was then placed within the pocket and secured to either side of the port catheter connector site using sutures of 2-0 Prolene.
The Port-A-Cath pocket was then carefully irrigated with sterile saline. Excellent hemostasis had been previously obtained. The port was then accessed using heparinized saline in a syringe with the Huber needle. The port was accessed and blood could be easily aspirated and the port easily flushed. Intraoperative fluoroscopy confirmed that there were no kinks along the catheter length, and there did not appear to be any evidence for pneumothorax or hemothorax.
The skin for the Port-A-Cath pocket was then closed in two layers. The deep dermis was approximated using a running simple suture of 3-0 Vicryl and the skin closed with a running subcuticular suture of 4-0 Monocryl. A single inverted suture of 4-0 Monocryl was also used to close the guidewire insertion site.
The skin was then cleansed, dried, then dressed with Dermabond. Once this was dry, the patient who was expected to undergo chemotherapy in two days, was then left accessed using a butterfly Huber needle mechanism. This was then dressed with gauze and Tegaderm. The patient tolerated the procedures well. Sponge, needle, and instrument counts were all correct at the end of the procedure. The patient was then brought back to the same day surgery area at the end of the procedure awake and in good condition. Estimated blood loss was less than 20 mL, and there were no complications.
