DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. History of tuberculosis of the left upper lobe of lung.
2. History of bronchoalveolar carcinoma of the right upper lobe of the lung.
3. Nonsmoker.
4. Cleared by Cardiology for surgery.
OPERATION PERFORMED:
1. Right upper lobectomy.
2. Mediastinal lymph node dissection.
3. Accufuser bupivacaine pump insertion.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This (XX)-year-old female has a biopsy-proven non-small cell bronchoalveolar variant in the right upper lobe of lung. During her staging workup, a left lung nodule was identified, which was hypermetabolic on PET scan. She had a left video thoracoscopy performed approximately three weeks ago revealing that that was a granuloma.
Last week, the information came back from the laboratory that acid-fast growth is consistent with tuberculosis, and therefore, she is returned to the operating room with respiratory isolation. She was not on respiratory isolation before because her sputum was negative for AFB x3, and therefore, she is not considered contagious.
Dr. Jane Doe informed me that she was safe to have surgery on her right lung, even with her history of left microbiology consistent tuberculosis and she approved surgery. She will see her postoperatively and requested three more sputum samples from the operating room through the endotracheal tube that have been performed and submitted for culture for AFB.
Informed consent was obtained for right upper lobectomy, mediastinal lymph node dissection, and Accufuser bupivacaine pump insertion. Risks and benefits of the lobectomy and other procedures were explained. A preprocedure time-out was accomplished.
DESCRIPTION OF OPERATION: Double-lumen endotracheal anesthesia was utilized. The patient has an arterial line and central venous catheter. The patient is on respiratory isolation. In left lateral decubitus position, the right chest was prepped and draped in the usual sterile fashion.
A standard posterolateral thoracotomy incision was created. The latissimus dorsi muscle was transected with electrocautery. The serratus anterior muscle was spared. The thorax was entered above the 5th rib in the 4th intercostal space. Entry into the thorax was not difficult. There was no pleural effusion and no pleural studding to report. The right middle lobe and right lower lobe were carefully inspected and had no visible or palpable abnormalities. The right upper lobe has the cancer as described by CAT scan, and it appears resectable.
The truncus anterior branch of the right upper lobe of the pulmonary artery was individually ligated with 2-0 silk ties, 3-0 silk suture ligatures, and then it was transected. The posterior ascending branch of the right upper lobe pulmonary artery was identified within the fissure, and it was also ligated and transected. Hemostasis was achieved with 3-0 silk ties and surgical clips and 3-0 silk suture ligatures. On the truncus anterior branch are 2-0 silk ties and 3-0 silk suture ligatures.
The pulmonary venous branches of the right superior pulmonary vein to the right upper lobe were identified and individually identified and ligated with 2-0 silk ties, 3-0 silk suture ligatures, and surgical clips. The pulmonary artery and pulmonary veins to the right middle lower lobe were identified and preserved. The major and minor fissures were completed with GIA stapling device, Ethicon Echelon 60 mm staplers with green staple line cartridges. The fibrolymphatic tissue around the bronchus was mobilized onto the bronchus itself, and the bronchus was occluded with a TA30 stapler. The lung was inflated to prove that the right lower lobe and right middle lobe inflate normally and the right upper lobe does not; the stapler was fired.
The specimen was transected and sent for pathology analysis. There is no evidence of any obvious granulomatous process in this right upper lobe. Biopsies were all consistent with cancer, and the bronchus margin is clear on frozen section. The right middle lobe is not adherent to the right lower lobe, and therefore, after full inflation and anatomic reorientation, the right middle lobe was plicated to the right upper lobe, and eventually, this was completed with a felt strip and 3-0 Prolene sutures as well as the previously applied TA30 staple line.
The chest was irrigated with normal saline. There was no evidence of any air leak from the bronchus stump at 25 to 30 cm of inspiratory pressures. There was no active bleeding to report. The lymph nodes have been sampled from the right paratracheal R4 distribution, right paratracheal R10 distribution. Inferior pulmonary ligament lymph node was harvested during the mobilization of the inferior pulmonary ligament, and the subcarinal lymph nodes were also harvested. Hemostasis was achieved with surgical clips. Once again irrigation has been accomplished, and there is no active bleeding to report.
The chest was drained with 36-French chest tubes anteriorly and posteriorly, each secured with nylon sutures. Intercostal nerve block of 0.25% Marcaine with epinephrine, two interspaces below the incision, two interspaces above the incision, as well as the incision itself at the interspace. The ribs were closed with #2 Vicryl pericostal sutures and a rib punch.
The first Accufuser bupivacaine catheter was a 10 inch long catheter from a posterior approach running underneath the inferior aspect of the 6th rib from anterior to posterior where it is curved and incorporated into the paraspinal musculature, which was previously mobilized, secured to the soft tissue with 3-0 chromic, secured to the skin with 3-0 Prolene. Serratus anterior muscle was closed with 0 Vicryl. The second Accufuser bupivacaine pump was a 5 inch long catheter from a posterior approach, residing between the latissimus dorsi and the serratus anterior. It also was secured to the soft tissues with 3-0 chromic and secured to the skin with 3-0 Prolene.
Latissimus dorsi was closed with 0 Vicryl, subcutaneous tissues closed with 2-0 Vicryl. The skin was closed with a running 3-0 Monocryl subcuticular closure. Sterile dressings were applied. Accufuser pumps secured with Prolene. Per patient request, no adhesive tape was used, so all of her bandages were utilized with a fluff dressing, Telfa dressing, and paper tape. The sponge, needle, and instrument counts were correct. The estimated blood loss was less than 100 mL. The patient tolerated the lobectomy and other procedures well and was transferred to the intensive care unit under respiratory isolation.
