DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Rectal cancer, status post resection.
2. Need of adjuvant chemotherapy.
POSTOPERATIVE DIAGNOSES:
1. Rectal cancer, status post resection.
2. Need of adjuvant chemotherapy.
OPERATION PERFORMED: Venous access device implantation.
SURGEON: John Doe, MD
ANESTHESIA: Local with MAC
ESTIMATED BLOOD LOSS: None.
IMPLANT: MediPort.
SPECIMENS: None.
COMPLICATIONS: None.
OPERATIVE FINDINGS: Three attempts were made in the right subclavian vein, ultimately, access was gained in two. In one, the J wire progressed to the right internal jugular. In the second one, a similar event happened; however, under fluoroscopy, it was guided down into the superior vena cava and through the heart to the inferior vena cava.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female recently diagnosed with rectal cancer, who underwent coloanal anastomosis with a protective ileostomy following neoadjuvant chemoradiation. Now, her postoperative adjuvant chemotherapy has been delayed due to some cardiac issues, which have now been resolved. The patient has elected at this time to proceed with adjuvant chemotherapy pending reversal of ileostomy. She presents at this time for MediPort insertion to facilitate chemotherapy.
DESCRIPTION OF OPERATION: After adequate preoperative preparation and counseling to include the risk of bleeding, pneumothorax, and catheter issues such as breakage and infection, the patient expressed understanding of all these risks and agreed to the procedure. The patient was taken to the operating room and placed in the supine position, and IV sedation was given. The right subclavian area was shaved, prepped, and draped in standard fashion. A standard subclavian approach was used, which failed to gain access to the subclavian vein. A second attempt was made on the right side, which did gain entry into the subclavian vein; however, the J wire, under fluoroscopy, was noted to be going up the internal jugular vein. Attempts, while under fluoroscopy, to guide it down into the superior vena cava were unsuccessful.
Therefore, a third attempt was made. Entry into the subclavian vein once again was attained, and once again, the J wire progressed up to the internal jugular vein. However, at this time, we were able to successfully manipulate it down into the superior vena cava and through the heart into the inferior vena cava, under fluoroscopy. At this point, then, additional local anesthesia was injected; this had been used prior to all 3 subclavian attempts.
A pocket was then created in the right upper chest. Incising through skin and subcutaneous tissue down to the fascia, a pocket was made just inferior to the J wire insertion. At this point, the dilator with peel-away sheath was introduced over the J wire using Seldinger technique. The dilator was then removed. A catheter that had previously been fashioned was then placed over the J wire into the peel-away sheath. The peel-away sheath was then peeled away and the J wire was then removed. The catheter was then connected to the port.
The port was then accessed. Good easy return of blood was appreciated, and heparinized saline was then infused into the port and the catheter. At this point, after establishing good hemostasis in the pocket, the port was then placed in the pocket and secured down to the fascia with the use of 2-0 Prolene to opposite sites. Once this was done, under fluoroscopy, we viewed the tip of the catheter to be in the right atrium, which we felt was acceptable.
The incision was then closed using 3-0 Vicryl to approximate the platysma. The skin was then closed with 4-0 Monocryl in a running subcuticular fashion. The port was once again accessed through the skin with good easy return of blood and easy infusion of heparinized saline solution. Benzoin and Steri-Strips were then applied to the incision. Sterile dressing was then applied. The patient was then transported back to recovery room in satisfactory condition. Postoperative chest x-ray is still pending at this time.
