DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Multiloculated right-sided pleural effusion with probable empyema with bronchopneumonia and trapped lung.
2. Respiratory compromise.
3. Sepsis.
4. Deep venous thrombosis, on Angiomax.
5. Exogenous obesity.
POSTOPERATIVE DIAGNOSES:
1. Multiloculated right-sided pleural effusion with probable empyema with bronchopneumonia and trapped lung.
2. Respiratory compromise.
3. Sepsis.
4. Deep venous thrombosis, on Angiomax.
5. Exogenous obesity.
OPERATION PERFORMED:
1. Flexible bronchoscopy.
2. Right muscle-sparing lateral thoracotomy with evacuation of multiloculated bloody pleural effusion.
3. Decortication of the right lower lobe.
4. Wedge resection of the right lower lobe.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
INDICATION FOR OPERATION: The patient is a very pleasant (XX)-year-old Hispanic male, who underwent a recent lumbar spine surgery for acute cauda equina syndrome. The patient was admitted with fevers, tachypnea, and signs of sepsis. The patient has been seen by multiple consultants, including General Medicine, Critical Care, Vascular Surgery, as well as Neurosurgery, and Infectious Disease, and the patient was treated with Angiomax for his deep venous thrombosis.
CT of the chest reveals a loculated right-sided pleural effusion with evidence of bronchopneumonia and lung trapping. It was felt that the patient may be harboring an empyema associated with bronchopneumonia. Recommendation was for the patient to undergo the above-named procedure. The entire procedure was fully explained to the patient and his family. All risks, benefits, and options were discussed. The risks included, but were not limited to, bleeding, infection, persistent air leak, and bronchopleural fistula. All of the patient’s questions were answered, and he wished to proceed with the surgery.
OPERATIVE FINDINGS: Revealed 425 mL of bloody right pleural fluid that was loculated. There was evidence of serofibrinous exudate involving the right lower lobe without entrapment of the lung. The basilar segments of the right lower lobe had a purplish discoloration with induration present that was likely secondary to embolic phenomenon. Specimens were sent to microbiology, pathology, as well as chemistries for analysis.
DESCRIPTION OF OPERATION: The patient was brought to the operative suite and placed in the supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal tube visualizing the distal trachea, carina, and right and left mainstem bronchus with their primary and secondary divisions. No evidence of any endobronchial tumor was noted. The scope was then withdrawn.
A double-lumen endotracheal tube was then positioned by the anesthesiologist. The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A right muscle-sparing lateral thoracotomy was made.
We entered via the fourth intercostal space. Careful exploration was carried out, and findings are as stated above. The loculated bloody pleural effusion was evacuated with the specimens being sent to microbiology, pathology, as well as chemistries for analysis.
Further inspection revealed serofibrinous exudate involving the right lower lobe without entrapment of that lobe. Decortication of that lobe was then carried out. Once we had removed the decorticated tissue, we noted that the basilar segments of the right lower lobe had a purplish discoloration and marked induration was noted in these areas. We suspected that the patient had emboli to this region.
Using stapler devices, we wedged out one of these areas and sent it down to both pathology, as well as to microbiology for examination. We copiously irrigated the entire area using several liters of warm antibiotic saline solution.
Initially, the irrigant came back cloudy, but after several liters of irrigation, it came back clear. Good lung expansion was noted postprocedure. There were some minor air leaks from the staple line.
Attention was then directed to closing. Two, 32-French chest tubes were placed, one anteriorly and one posteriorly, and these were brought out through inferior stab wounds. The ribs were approximated using heavy Vicryl sutures.
The chest wall muscles, fascia, skin, and subcutaneous tissues were approximated using the same suture material. Dressings were applied.
Marcaine 0.25% was used as a paravertebral block at the level of T2 through T9 and also placed On-Q pain delivery system underneath the chest wall muscles and brought them out through inferomedial stab wounds in order to deliver local regional analgesia to decrease postoperative narcotic use.
The patient tolerated the procedure and was sent to the cardiovascular intensive care unit in stable condition.
