DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left liver mass.
2. Lung nodules.
POSTOPERATIVE DIAGNOSES:
1. Left liver mass.
2. Benign lung nodules.
PROCEDURES PERFORMED:
1. Right VATS exploration.
2. Pleural biopsy.
3. Right lower lobe wedge resection.
4. Right upper lobe wedge resection.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old man with a large left liver mass. He is being worked up for resection. A PET scan showed bright uptake in the liver as well as some uptake in the bilateral pulmonary hila as well as in the right supraclavicular region. A CT scan of the chest and abdomen revealed a large left liver mass as well as two very small right lung nodules. There was no enlarged mediastinal adenopathy. There were calcifications in the hilum on the right. There was no palpable supraclavicular adenopathy. In light of these nonspecific PET findings, we felt it would be reasonable to perform a right VATS to obtain wedge resections of the lung and to examine the right hemithorax. The patient agreed and surgery was scheduled.
DESCRIPTION OF PROCEDURE: After the induction of general anesthesia, a double lumen endotracheal tube was inserted. Its position was verified bronchoscopically. The patient was moved into the left lateral decubitus position, and the right chest was prepped and draped for VATS exploration, pleural biopsy, and right lower and upper lobe wedge resection. Heparin had been given subcutaneously, and antibiotics had been administered systemically.
Three 12 mm thoracoscopy ports were inserted; one in the auscultatory triangle, one in the fifth intercostal space at the anterior axillary line, and one in the eighth intercostal space at the midaxillary line. The right hemithorax was examined. There were a number of mildly raised pigmented lesions of the parietal pleura. One of these was biopsied and sent for frozen section and revealed no evidence of malignancy, merely reactive mesothelial cells.
The lung was then examined. There were two visceral pleural nodules corresponding to the two very small nodules seen on the CT. Both were in the major fissure, one in the upper lobe and one in the lower lobe. Both were resected using the Endo-GIA thick tissue stapler and sent for frozen section. Both were without evidence of malignancy. The hilum was examined through the fissure as well as anteriorly and posteriorly, and there were no suspicious masses. There were calcifications, and we were concerned that dissection in the hilum with these calcified nodes would be risky and of low yield considering the absence of masses on a CT or examination.
The upper mediastinum on the right was then examined, and there were no suspicious masses. With benign nodules in the pleura in both the upper lobe and the lower lobe and no visible abnormalities in the hilum or mediastinum, we felt that a thorough explanation of all the potential spread had been performed. Therefore, after assuring hemostasis, a 20-French straight chest tube was inserted, and the right lung was reinflated. The patient was extubated and brought to the postanesthesia care unit hemodynamically stable and breathing spontaneously. There were no intraoperative complications.
