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Laryngoscopy Bronchoscopy Tracheotomy Operative Sample


PREOPERATIVE DIAGNOSIS:  Tracheal mass with airway obstruction.

POSTOPERATIVE DIAGNOSIS:  Tracheal mass with airway obstruction.

1.  Direct laryngoscopy.
2.  Flexible bronchoscopy.
3.  Tracheotomy.
4.  Rigid bronchoscopy.
5.  Transtracheal removal of tracheal mass.

SURGEON:  John Doe, MD



FLUIDS:  Crystalloid.


PROCEDURE FINDINGS:  A 1.5 cm tracheal mass at the prior tracheotomy site.  It became a foreign body upon being freed up from its pedicle, and the remaining portion of the procedure was involved with removal of the floating free body.  This was successfully accomplished.  The patient also was incidentally noted to have small left arytenoid nodules, clinically insignificant, followed subsequently as an outpatient.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position.  She was intubated intraorally and given general anesthesia.  Care was taken to use a small tube and cuff just below the cords so as not to disturb the tracheal mass, which was at the old tracheotomy site, approximately 3 cm subglottically.  The anterior neck was prepped and draped in the usual sterile fashion.  The old tracheotomy scar at the skin was excised; this was at the level of the cricoid ring.  The anterior tracheal subcutaneous scar tissue was excised.  The strap muscles were separated in the midline.  There was some remnant of thyroid isthmus, which was electrocauterized to expose the anterior tracheal wall.  An inferiorly-based tracheotomy flap was created using the second and third tracheal rings, and this was sewn to the inferior dermis margin using 3-0 chromic stitch.

Upon elevating the inferiorly-based tracheotomy flap, the mass was visible in the trachea.  It was a smooth covered black mass with a very narrow pedunculation on the anterior tracheal wall, which was just above the entry into the tracheotomy site at this time.  Attempts at mobilization of the mass freed up the mass and then the mass then proceeded down the trachea into the right mainstem bronchus.  At this point, a reinforced anode tube was passed into the left mainstem and the patient ventilated.  At this point, multiple attempts at removal of this tracheal mass, which was now a foreign body, was attempted.  Flexible bronchoscopy with a Fogarty catheter placed distal to the mass, attempts at withdrawal on multiple occasions were unsuccessful.  Multiple attempts then with rigid bronchoscope were unsuccessful as well.  An oral intubation tube was placed subglottically and a foreign body bronchoscope with a foreign body forceps attached was then passed and was able to grasp the foreign body.  The foreign body was then brought back up into the area of the newly created tracheotomy site.  At this point, it was grasped with a Blakesley-Wilde forceps off the sinoscopy set and retrieved.  Upon completion of removal of mass, flexible bronchoscopy was repeated down to both mainstem bronchi and found to be free of tumor.

At this point, the anode tube was removed and a fresh #8 Shiley low-pressure cuffed tube passed into the newly created tracheotomy site and sewn into place with four 2-0 silk ligatures.  Further ventilation occurred to the newly placed tracheotomy tube.  The patient was then allowed to awaken from anesthesia and taken to the recovery room in stable condition.

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