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Upper Lobectomy Mediastinal Dissection Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left upper lobe lung cancer.
2.  History of cigarette smoking.
3.  Cleared for surgery by primary care and Pulmonary Medicine.
4.  PET scan does not reveal evidence of metastatic mediastinal or distant disease.

POSTOPERATIVE DIAGNOSES:
1.  Left upper lobe lung cancer.
2.  History of cigarette smoking.
3.  Cleared for surgery by primary care and Pulmonary Medicine.
4.  PET scan does not reveal evidence of metastatic mediastinal or distant disease.

OPERATION PERFORMED:
1.  Left upper lobectomy.
2.  Mediastinal dissection, lymph node dissection.
3.  Accufuser bupivacaine pump insertion.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS FOR OPERATION:  This (XX)-year-old gentleman has a biopsy-proven non-small-cell lung cancer. He was brought to the operating room today for elective resection. Informed consent was obtained. Risks and benefits were explained. A preprocedure time-out was accomplished.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in the supine position. Double-lumen endotracheal anesthesia was administered. Central venous catheter and arterial line were in place as well as a urinary catheter. The patient was placed into the right lateral decubitus position for a left thoracotomy and the left 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 fifth rib in the fourth intercostal space. The left upper lobe, near the border of the anterior segment and the lingular subdivision, is the site of the malignancy, very close to the major fissure. The neoplasm did not cross the major fissure. The neoplasm corresponds quite nicely to the CT scan findings. The fissure was essentially complete, facilitating the anatomic and arterial dissection. The left lower lobe was carefully palpated and found to be without any dominant or suspicious masses. There is no pleural effusion, no pleural studding.

Attention was turned to the left hilum where the arterial supply to the left upper lobe was individually identified and ligated with 2-0 silk ties, 3-0 silk suture ligatures and then it was transected. The arterial anatomy was then traced into the major fissure where the lingular subdivision arteries were identified and ligated with 2-0 silk ties and 3-0 silk suture ligatures. There is a very large and presumed to be malignant lymph node in the N1 distribution of the hilum of the left lung that was mobilized off of the bifurcation between the lingular artery and the left lower lobe pulmonary artery, and this lymph node was removed in its entirety with clear margins and sent for permanent pathologic analysis. The lingular artery was identified and ligated accordingly. The left superior pulmonary vein was taken with individual branches, as a vascular stapler could not be put around the circumference of the left superior pulmonary vein. Therefore, each branch was individually ligated with 2-0 silk ties and 3-0 silk suture ligatures and then it was transected.

Attention was turned to the bronchus where a fibro-lymphatic tissue was mobilized off of the edge of the bronchus and the left upper lobe bronchus was occluded with a TA-30 stapling device. The left lung was inflated to prove that the left lower lobe inflates normally and the left upper lobe does not. The double lumen and tube including the blue balloon were easily mobilized and were not incorporated within the staple line. The specimen was oriented. The stapler was fired. The specimen was transected and the specimen was sent for pathologic analysis, confirming a clear bronchus margin. Aortopulmonary window lymph nodes were harvested at the beginning of the operation during the arterial phase of this procedure. These lymph nodes were removed without any trauma and the recurrent laryngeal nerve remained undisturbed. Hemostasis achieved with surgical clips.

The left inferior pulmonary ligament was mobilized and the left inferior pulmonary ligament lymph node was harvested accordingly. The subcarinal lymph nodes were not removed as it was a difficult dissection trying to get into the subcarinal space following the left upper lobe lobectomy and in light of the normal PET scan and the additional morbidity that may be accomplished, we have chosen not to harvest that subcarinal lymph node. It was normal on CT scan and normal on PET scan.

The left upper lobe inflates quite nicely and is reoriented in anatomical location within the left chest. The chest was drained with 36 French chest tubes anteriorly and posteriorly, each secured with nylon sutures. Intercostal nerve block performed with 0.25% Marcaine with epinephrine two interspaces above the incision, two interspaces below the incision, as well as at the level of the incision itself. There was no intravascular administration and hemostasis remains complete. The chest has been irrigated with normal saline. There is no active bleeding and there is no air leak at 25 cm of inspiratory pressure from the parenchyma, nor from the bronchus. The chest was drained with 36 French tubes placed anteriorly and posteriorly, each secured with nylon sutures. The ribs were closed with #3 Vicryl pericostal sutures and a rib punch.

The first Accufuser bupivacaine pump was a 10 inch long catheter from an anterior approach running underneath the inferior aspect of the sixth rib from anterior to posterior. It was curved and incorporated into the previously mobilized posterior paraspinal musculature. It was secured to the soft tissues with 3-0 chromic, secured to the skin with 3-0 Prolene. The serratus anterior muscle was closed with 0 Vicryl. The next Accufuser bupivacaine pump was a 5 inch long catheter, also from an anterior approach running underneath the latissimus dorsi muscle but anterior to the serratus anterior muscle. It also was secured to the soft tissues with 3-0 chromic and also secured to the skin with 3-0 Prolene.

The latissimus dorsi muscle was closed with 0 Vicryl. Rhomboid muscle closed with the remaining #2 Vicryl suture. The subcutaneous tissues were irrigated and closed with 2-0 Vicryl. Skin was closed with a running bidirectional 3-0 Monocryl subcuticular closure. Sterile dressings were applied. The sponge, needle and instrument counts were correct. The estimated blood loss was 150 mL. The patient tolerated the procedure well. He remained hemodynamically stable and will be transferred to the intensive care unit for postoperative monitoring.