PREOPERATIVE DIAGNOSIS: History of resected cholangiocarcinoma.
POSTOPERATIVE DIAGNOSIS: History of resected cholangiocarcinoma.
PROCEDURE PERFORMED: Port-A-Cath insertion via the right internal jugular vein.
SURGEON: John Doe, MD
ANESTHESIA: Local, 18 mL of 0.5% lidocaine with 0.25% Marcaine at final concentration, with monitored anesthesia care.
ESTIMATED BLOOD LOSS: Less than 20 mL.
COMPLICATIONS: None.
INTRAOPERATIVE FINDINGS: Intraoperative fluoroscopy demonstrated that the tip of the catheter was in the proximal superior vena cava. There was no evidence on intraoperative fluoroscopy for a hemothorax or pneumothorax. There were no kinks in the lines. The catheter accessed with a Huber needle, could be easily aspirated as well as flushed with heparinized saline. Postoperative chest x-ray also demonstrated good placement of the tip of the catheter and the port itself with no evidence of pneumothorax or hemothorax.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. His arms were tucked and a small roll placed between his scapulae along his spine. The bed was then adjusted to Trendelenburg position. Right side of the chest, the neck, and upper arm were then prepped and draped in the usual aseptic fashion. A time-out was called, and the patient’s identity as well as the procedure planned, site, and side confirmed before we proceeded. Local anesthetic was used to raise a wheal of local within the dermis under the clavicle on the right side at a distance of approximately two-thirds between that of the sternal notch and the shoulder. Once this wheal was raised, local anesthetic was then extended from that site to the clavicle. Cannulation needle was then inserted under the clavicle, but because of the broadness of his clavicle, we were unable to pass the needle under the clavicle, and therefore, this mode of access was abandoned. We then turned our attention to the performance of cannulation of his internal jugular vein on the right side. A small wheal of local anesthetic was raised at the superior apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle on the right side. With the patient’s head turned slightly to the left, once the wheal was raised, a locator needle consisting of a 25-gauge needle on a syringe was carefully inserted while aiming at a 30-degree angle for the ipsilateral nipple. Having accessed venous blood, the cannulation on a syringe was then inserted adjacent to the locator needle. This was inserted and the internal jugular vein accessed, evidenced by aspiration of venous blood. The locator needle was removed and passed off the field. Guidewire was then passed with the cannulation needle, and under fluoroscopic control, advanced until it was in the proximal superior vena cava. The cannulation needle was then removed and our attention was turned to the formation of a pocket for the port. A transverse incision was drawn on the skin, planned with a sterile skin marker. This was for a length of approximately 3 cm below the clavicle, between the shoulder and the chest, in the midclavicular line, approximately 3-4 cm below the clavicle. Once drawn on the skin, local anesthetic was used to infiltrate the underlying dermis and subcutaneous tissue. The incision was made and extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Local anesthetic was then used to infiltrate the underlying subcutaneous tissues deep and inferior to this for the purpose of development of the Port-A-Cath pocket. A skin flap was then raised inferiorly deep to the investing adipose of the skin for the port itself. Once the pocket was of adequate size to accept the port, local anesthetic was then used to infiltrate subcutaneously the path between the Port-A-Cath pocket and the guidewire insertion site. A #11 blade scalpel was used to slightly enlarge the skin nick in the neck at the site of the guidewire insertion. Once this was performed, a mosquito clamp was then carefully used to dilate the subcutaneous tissues immediately deep to the skin. The catheter itself, which had been previously irrigated with heparinized saline, was connected distally to a syringe of heparinized saline and proximally to a tunneler. The tunneler was then used to tunnel the catheter from the Port-A-Cath pocket site to the guidewire insertion site. Once this was done, the tunneler was removed and again catheter flushed with heparinized saline. The dilator and introducer were placed over the guidewire and introduced into the internal jugular and over the guidewire and into the superior vena cava. This was done under fluoroscopic control and confirmed. The guidewire and the dilator were then removed, the catheter inserted into the introducer, advancing the catheter tip until it was in the proximal superior vena cava. The peel-away introducer was then carefully removed and discarded. The additional length of the catheter at the guidewire insertion site was then pulled back at the Port-A-Cath site to bring the catheter completely subcutaneous. A rubber-shod clamp was then placed over the catheter within the Port-A-Cath pocket site, and the catheter cut approximately 1 cm beyond that distally. The catheter cut site was then attached to the port and the rubber-shod catheter released. The catheter was then more fully advanced over that port catheter connector site and the locking mechanism, as provided by the company, was advanced over the connector site, locking this in place. The port was then placed within the pocket and secured to either side of the port catheter connector site, to the posterior adipose and fascia, using sutures of 2-0 Prolene. The Port-A-Cath pocket was then irrigated with sterile saline and inspected again for hemostasis. Having obtained excellent hemostasis, the port was then accessed using a Huber needle and heparinized saline. The port could be easily aspirated and flushed. Fluoroscopy was then used to ensure that there were no kinks along the catheter path and that the catheter tip was within the proximal superior vena cava. There was no evidence at that time for a hemothorax or pneumothorax. The skin of the port pocket site was then closed in 2 layers. The deep dermis was approximated using a running simple suture of 3-0 Vicryl, and the skin closed with a running subcuticular suture of 4-0 Monocryl. The guidewire insertion site was also closed with a single inverted suture of 4-0 Monocryl. Both sites were then cleansed, dried, and dressed with Steri-Strips before placement of gauze and Tegaderm dressings. The patient tolerated the procedure well. Sponge, needle, and instrument counts were all correct at the end of the procedure. The patient was then brought to the same day surgery area at the end of the procedure, awake, and in good condition. Postoperative chest x-ray failed to demonstrate any pneumothorax or hemothorax, and the catheter was in good position with no evidence for kinks.
