DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Myasthenia gravis.
2. Multiple medical comorbidities.
POSTOPERATIVE DIAGNOSES:
1. Myasthenia gravis.
2. Multiple medical comorbidities.
OPERATIONS PERFORMED:
1. Total thymectomy by median sternotomy, inframammary approach.
2. Placement of Accufuser bupivacaine pump.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. General anesthesia was administered without the use of muscle relaxants. The patient was placed on the operating room table. The previously placed Vas-Cath will be used for venous access. Arterial line was placed. Shoulder roll underneath the scapulae. The neck extended. Arms placed to the side where the neck and chest and abdomen were prepped and draped in usual sterile fashion. The patient has chosen an inframammary approach. Therefore, the patient came to the operating room wearing her brassiere. An outline of the contour of the brassiere was established, and the incision was made to be hidden by the brassiere. It extends from underneath the right breast, across the midline in a curvilinear fashion, bell-shaped curve, to the under surface of the left breast. The incision was carried through the skin and subcutaneous tissues. Hemostasis was achieved with electrocautery. The breasts were elevated off of the chest wall, and the pectoralis fascia was included with the mobilization process. Specifically, the pectoralis fascia remains on the pectoralis muscle. The sternum was identified in the midline. The xiphoid bone was removed. The median sternotomy was performed without difficulty. Entry into the thorax was not complicated. Bleeding from the bone was controlled with bone wax. Of note, the patient had a preoperative coagulation deficit as a result of the plasmapheresis and was transfused cryoprecipitate and fresh frozen plasma at the request of the hematologist and the medical team. During the procedure, the patient also received additional fresh frozen placed, approved by the blood bank director.
The thymus was removed in its entirety. The right and left pleural spaces were not entered. The thymus is boggy, soggy, edematous, thickened, rubbery, and nonhomogenous. The color is a pearly white admixed with areas of gray. The left side of the thymus was mobilized off of the left mediastinum. Additionally, some of the mediastinal fat was taken with the specimen. The left pleural space was not entered. The left phrenic nerve was not disturbed at any time during this procedure. The innominate vein and the branches to the thymus gland had been identified and hemostasis achieved with surgical clips. The left hemithymus extending into the left neck at the level of the thyrothymic ligament was mobilized as far cephalad as could be possible through this approach and confidence is present that the entire thymus gland has been removed. Hemostasis was achieved with surgical clips.
Similarly, the right side of the thymus gland was mobilized off the mediastinum. The right pleural space was not entered. The right phrenic nerve was not disturbed. The innominate vein branches were all identified and ligated with surgical clips. The thyrothymic ligament on the right also was dissected into the neck as far as possible during this approach and hemostasis achieved with surgical clips. The thymus gland was removed in its entirety and sent for permanent pathologic analysis. The patient, as mentioned, had a slight coagulopathic ooze. Hemostasis was absolutely complete from a surgical perspective, as multiple inspections of the mediastinum, the sternum and the operative field revealed no evidence of any active bleeding, just a general ooze from the bone of the sternum that was responsive to the help of bone wax.
The mediastinum was drained with a 24-French Blake drain, placed through a midline approach. Two catheters for bupivacaine Accufuser were used. These were 10 inch long catheters, placed in the subxiphoid region, one to the right side, one to the left side. There catheters ran parallel to the sternum from inferior to superior and were secured with 3-0 chromic sutures. The catheters were secured to the skin with 3-0 Prolene sutures. The presternal fascia was closed with 0 Vicryl. Hemostasis was achieved on all operative sites. Small amounts of fibrin glue were sprayed into the mediastinum prior to closure. The linea alba was closed with #2 Ethibond sutures. The Blake drains in the submammary but prepectoral region are 19-French Blake drains placed through a right and left lateral approach, secured with nylon sutures. The flaps were sprayed with fibrin glue.
The skin was closed with 0 Vicryl deep subcutaneous reapproximation, 2-0 Vicryl superficial subcutaneous and subdermal closure and 3-0 Monocryl skin closure. Sterile dressings have been applied. The sponge, needle and instrument counts were correct. The estimated blood loss was 600 mL. The patient received one unit of packed red blood cells and eight units of fresh frozen plasma and five units of cryoprecipitate. Sterile dressings have been applied. The patient will be transferred to the medical intensive care unit.
