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Thoracic Surgery Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Recurrent left pleural effusion.
2. Trigeminal neuralgia.
3. Advanced age.
POSTOPERATIVE DIAGNOSES:
1. Recurrent left pleural effusion.
2. Trigeminal neuralgia.
3. Advanced age.

OPERATIONS/PROCEDURES PERFORMED:
1. Flexible bronchoscopy.
2. Left muscle-sparing lateral thoracotomy with wedge resection of left lower lobe lung mass and talc pleurodesis.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ANESTHESIOLOGIST: Jean Doe, MD

DESCRIPTION OF OPERATION/PROCEDURE: 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, right and left main stem bronchus with 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 The scope was then withdrawn.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 right lateral decubitus position and prepped and draped in the usual sterile fashion. A left muscle-sparing lateral thoracotomy was made. We entered via the 5th intercostal space. Careful exploration was carried out. The patient had multiloculated bloody left pleural effusion. This effusion was completely evacuated. Adhesiolysis was then carried out freeing up the lung from the chest wall.

At this point, I could clearly visualize that the patient had extensive studding of both the lung and the chest wall with tumor. I performed the wedge resection of representative sample of the tumor from the left lower lobe. Frozen section analysis revealed this to be mesothelioma with quite a bit of necrosis present in the specimen. I irrigated the entire area using several liters of warm antibiotic saline solution. I used a video-assisted thoracoscope in order to gain access to all parts of the patient’s pleural space. Then, 5 grams of talc was next insufflated into the left pleural space. Two 32-French chest tubes were positioned, one anteriorly, one posteriorly and these were brought out through inferior stab wounds.

Attention was then directed towards closure. The wound was then closed in layers using Vicryl sutures. Then, 0.25% Marcaine was used as a paravertebral/interfacet block at the level of T2 to T9. The patient tolerated the procedure well and was sent to the recovery room in stable condition.


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Mass in the right upper lateral lung field.

OPERATION PERFORMED:  Right thoracotomy with partial decortication and placement of chest tubes.

SURGEON:  John Doe, MD

FINDINGS AND DESCRIPTION OF OPERATION:  With the patient in the left lateral recumbent position after a dual-lumen endotracheal tube had been placed and the patient was positioned with the right arm at right angles to his body and slightly superiorly to mobilize the mid scapula laterally, a standard parascapular paracostal incision was made.  Areas of bleeding were controlled with electrocauterization.  The latissimus dorsi muscle was divided.  The serratus muscles were divided.  We examined the rib cage.  The rib spaces were counted from the first rib posteriorly down to the fifth interspace.  The periosteum along the superior aspect of the fifth rib was cauterized.  The periosteum was removed from the rib.  The ribs were separated and the pleura identified.  The pleura was extremely hard.  We could not mobilize through this.  We separated the ribs a little bit more with a rib retractor and gradually we were able to get in medially and dissected posteriorly.  The pleura was very thickened, very hard.  A portion of pleura was excised and sent for frozen section.  More dissection was carried out.  We separated the mass from the rib cage utilizing a combination of blunt dissection.  The pleural mass was excised as much as possible inferiorly.  We dissected superiorly as much as possible.  However, this patient has advanced COPD, has bullous emphysema, and it was felt that we should be as conservative as possible in view of the fact that we do not yet have a diagnosis.  The lower lobe appeared to be soft.  We removed a large piece of pleura from the posterolateral aspect of the right chest.  A chest tube was placed within the right chest with multiple holes in it extending from the right anterolateral aspect of the lower chest.  The chest tube extended lateral, posterior, and superiorly.  Once we were satisfied the hemostasis was adequate, double strands of #1 chromic were placed around the fifth rib and the fourth rib.  Five of these sutures were used.  Once they had been placed, rib approximator was brought to the operative site.  The ribs were approximated.  The sutures were ligated following which the thoracic fascia was approximated with a continuous suture of #1 Vicryl suture.  The latissimus dorsi muscle was approximated with a continuous near-and-far suture of 0 Vicryl suture.  The serratus muscles were reapproximated.  The superficial thoracic fascia was reapproximated, and the skin edges were approximated with skin staples.  The chest tube had been sutured in place with #1 silk suture and was attached to underwater suction, and the patient had been returned to recovery room in satisfactory condition.