DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Lung cancer.
POSTOPERATIVE DIAGNOSIS: Lung cancer.
OPERATION PERFORMED: Right internal jugular dual-lumen Port-A-Cath insertion.
SURGEON: John Doe, MD
ANESTHESIA: Local anesthesia with sedation.
DESCRIPTION OF OPERATION: The patient was brought to the operating room. Consent was obtained. Sedation was achieved by the anesthesiologist. The patient’s left neck was prepped and draped in the usual standard sterile fashion. The intention was on placing the Port-A-Cath in the left neck, given that this is the side of the patient's pathologic lung, and we did not want to risk him having a pneumothorax in his right lung. With this in mind, local anesthetic was infiltrated into the region under the left subclavian. A needle was passed with no difficulty in one pass into the subclavian vein. A wire was then advanced; however, we felt some resistance. Using fluoroscopy, we noted the wire was turning back up into the left jugular region. Under fluoroscopic guidance, we manipulated the wire somewhat further; however, we were unable to get it to head toward the right side of the heart, and this approach was abandoned. The left neck had already been prepped and was included in our draping. Using ultrasound guidance, we passed a needle into the left internal jugular with one pass. Again, the wire had some difficulty passing, and under fluoroscopic guidance, we were able to get the wire to head in the direction of the heart; however, it was unable to make the left-handed turn down the superior vena cava. The wire continuously traversed the vena cava and either headed back up or made a U turn. This approach did not lead to success and it was again abandoned.
At this point, we considered that there was a very low likelihood of the patient having an iatrogenic pneumothorax given that only two passes had been made, both in very straightforward fashion, and the patient has had a pleurodesis on the left and likely has a trapped lung already. We undraped, reprepped and redraped the right side, and we interrogated the right internal jugular with ultrasound. This vein did seem patent. It was easy to compress, and again, with local anesthetic and one pass of the needle, we were able to enter the internal jugular vein. On this attempt, the wire passed very easily. There were PACs noted on the electrocardiogram tracing, and with fluoroscopic guidance, we noted that the wire had actually passed the heart and was in the inferior vena cava. The wire was pulled back somewhat so that it was in approximately the right position. We then secured the wire to the bed and administered some local anesthetic into the right chest to create the port. The skin was incised with a knife and Bovie electrocautery. A subcutaneous port was made. There was no evidence of any ischemia at the completion of the case in this area. The port was noted to fit in the cavity with no difficulty. There was no evidence of any hemorrhage.
An 11 blade was used to widen the wire insertion site, and a 9.5 French dual-lumen Groshong catheter was fed retrograde from the wire insertion site to the port site. A dilator was then placed over the wire. The wire and the obturator were removed, and the catheter was inserted through the peel-away sheath. The peel-away sheath was then separated. The wire was maintained in position. Using fluoroscopy, we determined that the catheter was slightly low and this was pulled back to what appeared to be the SVC/right atrial junction region. There was no evidence of any cardiac arrhythmia in the position of the catheter. The catheter was then cut and secured to the port. The lock was applied and the port was inserted into the pocket. The pocket was then irrigated. Again, there was no evidence of any bleeding. It was closed with a combination of 3-0 Vicryl and 4-0 Monocryl. The wire site was also closed with a 4-0 Monocryl. Steri-Strips were applied covered by a dry sterile dressing. The patient tolerated the procedure well. A chest x-ray will be obtained in the recovery room.
