General Surgery Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Lung cancer.

POSTOPERATIVE DIAGNOSIS:  Lung cancer.

PROCEDURE PERFORMED:  Subcutaneous port central venous catheter placement via the right internal jugular vein with Site-Rite ultrasound guidance for venous access and fluoroscopic guidance for catheter placement.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with MAC.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent and identification of the patient, the patient was transported to the operating room where monitoring and sedation was provided by the anesthesia service.  The patient was placed supine with the head turned somewhat to the left, prepped with DuraPrep and draped exposing the right side of the neck and upper chest area.  The Site-Rite ultrasound was draped sterilely and used to image over the right side of the neck identifying the internal jugular vein with the transducer observing the vein, the skin above and adjacent to the transducer was anesthetized with local anesthetic.

An 18 gauge thin-wall needle was introduced through the skin and advanced until the vein was penetrated observing penetration with the ultrasound and noting free return of blood.  The syringe was removed from the needle and the guidewire passed without resistance.  The ultrasound was used to image over the vein and could visualize the guidewire within the vein.  Fluoroscopy was then used to image over the lower neck and chest and confirm the guidewire directed into the superior vena cava.  The guidewire was secured and then a skin marker used to outline a planned course for the catheter and pocket location over the upper chest.  Additional local anesthetic was infiltrated along the catheter course, and at the pocket location, a small incision was made adjacent to the guidewire.

Then, another incision was made at the location for the port site.  Dissection at the port site created a pocket on the pectoralis fascia for the port placement.  Next, a tunneler was used to create a tunnel from the port site up to the neck wound site and the catheter was drawn through the tunnel.  A catheter introducer was then passed over the guidewire and observed to enter the superior vena cava under fluoroscopy.  The dilator and guidewire were removed and the catheter passed through the introducer, and the introducer then split and withdrawn.  The catheter position was observed with fluoroscopy with the catheter secured and pulled to length with the tip of the catheter in the superior vena cava near the junction with the right atrium.  The loop of the catheter was secured under the skin in the neck.

Two 3-0 Prolene sutures were placed in the pectoralis fascia and brought through the securing sites on the edges of the port.  Then, the catheter was cut at the port site and connected to the port securely.  The port was then placed within the pocket and the Prolene sutures secured into the pectoralis fascia.  Then, a Huber needle was passed through the skin overlying the port into the port.  Aspiration noted free return of blood and the port was flushed with sterile saline.  Then, the entire course of catheter was observed under fluoroscopy and noted to have a smooth curve to the catheter and the tip remaining in the superior vena cava near the junction with the right atrium.

The subcutaneous tissue at both incision sites was closed with 3-0 Vicryl suture and the skin closed with subcuticular 4-0 Vicryl sutures.  Steri-Strips and dressings were applied over the wounds.  Aspiration on the port again noted free return of blood.  It was flushed again with saline followed by heparinized saline and then a dressing was placed over the needle entry site.  The patient tolerated this procedure well and was returned to the same day surgery unit in apparently good condition.


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