DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left malignant pleural effusion.
POSTOPERATIVE DIAGNOSIS: Left malignant pleural effusion.
OPERATION PERFORMED: Left video thoracoscopy, drainage of pleural effusion and talc poudrage.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Double-lumen general endotracheal.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
PATHOLOGIC SPECIMEN: None.
DRAINS: A 32 French chest tube to the apex.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female with a recently diagnosed left-sided malignant pleural effusion secondary to a left lung adenocarcinoma. The patient has had a transbronchial biopsy of the left lung consistent with an adenocarcinoma and adenocarcinoma was found in the pleural effusion. The patient has rapid reaccumulation of the left-sided pleural effusion with symptoms, and after discussion of options, the patient elected to proceed with video thoracoscopy and talc pleurodesis.
OPERATIVE FINDINGS: Of 1700 mL of thin serosanguineous left-sided pleural effusion, the last 500 mL of which was much more sanguineous, incomplete re-expansion of the left lower lobe with apparent entrapment by a malignant process. There was also fairly diffuse pleural-based malignant disease. Five grams of aerosolized talc instilled under direct visualization.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. After uneventful induction of double-lumen general endotracheal anesthesia and placement of a right radial arterial catheter, the patient was placed in the right lateral decubitus position. All pressure points were appropriately padded and protected. The patient’s left chest was then prepped and draped in the usual sterile fashion utilizing ChloraPrep.
Beginning over the underlying seventh rib, the skin was infiltrated with 0.5% Marcaine with epinephrine and then an oblique skin incision was made with a #15 blade. This was carried down through the subcutaneous tissues utilizing electrocautery. The pleural space overlying the seventh rib was then meticulously dissected and serially expanded utilizing a curved hemostat. Upon entry into the pleural space, a thin serosanguineous effusion was encountered. The thoracostomy was then dilated using a curved Kelly hemostat and a Yankauer suction tip was introduced and 1700 mL of mostly thin serosanguineous to sanguineous effusion was drained.
Following near complete evacuation of the pleural space, a 12 mm thoracoscopic trocar was then inserted. A survey of the pleural space was performed utilizing a 0 degree thoracoscope. Upon entry into the pleural cavity, there was obvious malignant disease involving the left lower lobe. There was no visualizable normal lung parenchyma. The left upper lobe had a single adhesion from the apex of the lung to the cupola over the left hemithorax. The left costophrenic recess had a more sanguineous effusion that was drained utilizing a Yankauer suction tip. The diaphragmatic surface as well as the pericardial surface and the pericardial fat pad were chronically thickened and coated with a pearlescent material consistent with metastatic disease.
At this point, 5 grams of aerosolized talc was instilled under direct visualization utilizing the 0 degree thoracoscope. After complete coverage of the left lung and the pleural surfaces, a 32 French chest tube was placed to the apex through the existing single port site and secured with 2-0 silk sutures x2. This was connected to the Thora-Seal drain and attempts were made on expanding the left lung utilizing left lung isolation with the ventilator circuit. However, at the high airway pressures, only 150 to 185 mL of tidal volume was able to be delivered. The patient was then placed on standard two-lung ventilation, allowed to awaken from anesthesia, extubated and transported in a hemodynamically stable condition to the postanesthesia recovery room. Sponge, lap and needle counts were correct x2 at the end of the case.
