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in an anterior to posterior fashion. The thoracoscope was switched to the anterior port, and an endo-catch bag was inserted
through the large utility port. The specimen was placed into the endo-catch bag and removed.
The pleural cavity was filled with saline, and the anesthesiologist was asked to ventilate the right lung. The staple line and lung
were inspected. There were no air leaks. Multilevel rib blocks with 0.5% marcaine was performed. One 28 French chest
tube was placed anteriorly, and one 28 French chest tube was placed posteriorly. The ports were removed, and the port sites
were inspected for hemostasis. The lung was re-expanded under direct vision. Prior to closure all instrument, sponge and
needle counts were confirmed correct. The port sites were closed using a #2-0 vicryl suture for the fascia and a #4-0 vicryl
suture on the skin. The chest tubes are connected to waterseal with no suction.
The patient was then repositioned in the right lateral decubitus position to proceed with the left sided procedure in a similar
fashion.
Estimated blood loss was [X] cc. There were no intra-operative adverse events. The patient was extubated in the operating
room and subsequently transferred to the postoperative thoracic surgery unit.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
28. VATS Wedge Resection
John R. Spratt, MA, MD and Eitan Podgaetz, MD, MPH
University of Minnesota, Minneapolis, MN
Essential Operative Steps
1. Availability of relevant imaging in OR
2. Operative-side-up lateral decubitus jackknife positioning with reverse Trendelenberg allowing chest wall to be
parallel to the floor
3. General endotracheal anesthesia with double lumen endotracheal tube and single-lung ventilation
4. Double lumen tube position must be confirmed by flexible bronchoscopy
5. Surgeon stands on anterior side of patient, assistants posterior
6. Placement of camera port low in the chest (7
th
-8
th
intercostal space, midaxillary or anterior axillary line)
7. CO2 insufflation can be considered to allow better lung collapse
8. First working port in 4-5
th
intercostal space in anterior axillary line
9. Inspection of lung and hilum with finger/ ring foreceps to determine placement of remaining incision(s) if needed
10. Placement of utility thoracotomy (2 – 4 cm) in 4
th
or 5
th
intercostal space between anterior border of latissimus dorsi
and lateral border of pectoralis major (anterior axillary line)
11. Retraction of soft tissue over utility thoracotomy for easy chest access. [Self-retaining plastic (i.e., Alexis) wound
protector]
12. Identification of target lesion and control with ring or Duval forceps proximal to lesion
13. Resection of target lesion with endoscopic stapler
14. Removal of specimen using endoscopic retrieval bag or through wound protector
15. Assess staple line integrity and hemostasis
16. Chest tube placement
17. Port closure
Potential Complications and Pitfalls
1. Incomplete flexion of patient during positioning
1. May compress intercostal spaces
2. Ipsilateral hip may limit freedom of thoracoscope
2. Patient intolerance of single-lung ventilation, requiring CPAP or intermittent ventilation of operative-side lung. Can
infuse ipsilateral lung with oxygen.
3. Improper endotracheal tube placement leading to hypoxemia or poor lung isolation
4. Failure to appropriately triangulate camera and working incisions around target tissue (good rule of thumb is to leave
a hand’s breadth between ports)
5. Failure to retract soft tissues over utility thoracotomy may result in lung re-expansion during intrathoracic suctioning.
This is especially true in obese patients.
6. Failure to remove sample using retrieval bag may lead to tumor spillage and port site recurrence
7. Avoid crushing the lesion with the ring forceps.
Template Dictation
Date of Service: [DATE]
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
Procedure(s) Performed: [L or R] VATS wedge resection
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
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Anesthesia: [BLANK]
Specimens: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Complications: [BLANK]
Drains: [BLANK]
Disposition: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a [SIZE] peripheral lung nodule discovered by [IMAGING
RESULTS]. The decision was made to perform VATS wedge resection of the lesion for pathologic diagnosis. The risks and
benefits of the procedure were described to the patient, who verbalized good understanding, and informed consent was
obtained.
Description of Procedure: The patient was taken to the operating room from the preoperative holding area. The patient’s
identity and planned procedure were verified and the patient was then placed on the operating room table in the supine
position. General endotracheal anesthesia was induced, and the patient was intubated with a double lumen endotracheal tube
[OR SINGLE LUMEN ENDOTRACHEAL TUBE AND SUBSEQUENT PLACEMENT O F A BRO NCHIAL
BLOCKER]. Tube position was confirmed by flexible bronchoscopy, allowing selective ventilation of the lung on the non-
operative side. Once this was completed, the patient was then moved into the [NONOPERATIVE SIDE]-lateral decubitus
position ensuring his bony prominences were well padded. The upper extremity was not on any undue stretch. The operating
table was maximally flexed at the level of the patient’s hip. Appropriate endotracheal tube placement was again confirmed
with a pediatric bronchoscope. The [SIDE] chest was then prepped widely from the axilla to inferior to the costal margin
longitudinally and from the midclavicular line to the tip of the scapula transversely. A surgical time out was performed to
identify patient and intended procedure.
The [SIDE] lung was isolated. Rib blocks with [VOLUME AND TYPE OF LO CAL ANESTHESIA] were made prior to
each incision. The 8
th
intercostal space was identified and a 2 cm skin incision was made [LOCATION]. Dissection down to
the parietal pleura was performed with electrocautery. The chest was entered sharply and the absence of adjacent adhesions
or adherent lung tissue was confirmed by finger palpation. A 10 mm trocar was placed, and the chest cavity was inspected with
a 10 mm 30-degree thoracoscope. [FINDINGS]. The chest was then insufflated with CO2 via the trocar to facilitate lung
collapse.
After determining that it was safe to proceed, a second port was placed in the 6
th
intercostal space in the midaxillary line using
the same technique as above. An endoscopic alligator grasper was used to retract the lung and inspect the pleura and the
anterior hilum, as well as to identify the lesion. A third and final incision, 3-4 cm in length, was made between the anterior
border of the latissimus dorsi and the anterior axillary line at the level of the 4
th
intercostal space, after instillation of local
anesthesia. A small wound protector was placed.
The target lesion was identified at [LOCATION] by visualization and direct finger palpation. The lesion and surrounding
lung parenchyma were grasped atraumatically using a Duval clamp. The lesion was elevated and resected with serial firings
of a [SIZE, COLO R, STAPLER TYPE] endoscopic stapler. The staple line was noted to be hemostatic. The stapler was
removed and a specimen retrieved through the wound protector.
Additional rib blocks were given under direct vision using [VOLUME AND TYPE OF LOCAL ANESTHESIA] and a
thoracoscopic aspiration needle. A [SIZE] chest tube was then placed through the camera port, tunneled anteriorly, and
directed posteriorly and towards the apex. Chest tube position was confirmed by thoracoscopic visualization. All the ports
were removed and the lung was reinflating with Valsalva maneuvers obliterating the pleural space and reversing atelectasis.
Each of the ports were closed in layers with absorbable suture.
The sponge, instrument, and needle counts were said to be correct at the conclusion of the procedure. The patient was then
extubated without incident and taken to the post-anesthesia care unit in [CONDITION].
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
29. VATS Sympathectomy
John R Spratt, MA, MD and Eitan Podgaetz, MD, MPH
University of Minnesota, Minneapolis, MN
Essential Operative Steps
1. Semi-Fowler position with reverse Trendelenburg, arms abducted beyond 90° bilaterally, and entire chest prepped
into the field
2. General endotracheal anesthesia with double lumen endotracheal tube and single-lung ventilation
3. Double lumen tube position confirmed by flexible bronchoscopy
4. Surgeon stands on ipsilateral side
5. 1 cm incisions over 5th intercostal space at lateral border of pectoralis major and 4
th
intercostal space in anterior
axillary line with placement of 5 mm trocars in each
6. CO2 insufflation to facilitate better lung collapse (pressure 6 to 10 mmHg)
7. Inspection of chest cavity and identification of sympathetic chain crossing rib heads posteriorly
8. Meticulous counting of ribs to determine proper level; 2
nd
rib is most superior rib visible from within pleural cavity,
T2 ganglion located between heads of 2
nd
and 3
rd
ribs
9. Use hook cautery to dissect parietal pleura above and below isolating the sympathetic chain at the levels desired
1. T2-T3 transection is best for palmar hyperhidrosis
2. T3-T4 transection is best for axillary hyperhidrosis
3. May extend as low as T5 for lower-extremity symptoms
4. T1-T3 for reflex sympathetic dystrophy
5. T4-T10 for chronic pancreatic pain
10. Cautery or clips may be used to transect/ clip sympathetic chain. (Clips are believed to be reversible in cases of
severe compensatory hyperhidrosis)
11. Lung is re-inflated under direct vision, may use small chest tube through one of the working incisions to evacuate
residual gas
12. Removal of chest tube following closure of subcutaneous layer, followed by skin closure
13. Procedure is then repeated on contralateral side
14. Chest radiograph in PACU
Potential Complications and Pitfalls
1. Meticulous identification of proper level of transection is mandatory
1. Landmarks:
1. 2
nd
rib is most superior rib visible from within the chest
2. Azygos vein lies at 5
th
interspace
3. Aortic arch reaches 4
th
interspace
2. Named ganglia located inferior to corresponding rib (e.g. T2 ganglion is located between heads of 2
nd
and 3
rd
ribs)
2. Bleeding complications rare, but may result from damage to intercostal vasculature or great vessels, hemothorax from
port site bleeding also possible
3. Clinically insignificant postop pneumothoraces are common
4. Horner’s syndrome may result from misidentification of level of transection
5. Compensatory sweating of the torso, thighs, and legs may result, can be as severe as original palmar/ axillary
hyperhidrosis in some cases
6. Patients must have documented proof of at least two medical treatments (topicals, iontophoresis, Botox, etc.) to be
considered for surgical intervention.
Template Dictation
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
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Procedure(s) Performed: [L or R] [LEVEL] VATS sympathectomy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Specimens: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Complications: [BLANK]
Drains: [BLANK]
Disposition: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [INDICATION]. The patient has failed maximal medical
management of this condition, which included [MEDICAL THERAPY], and the decision was made to perform thoracoscopic
sympathectomy. The risks and benefits of the procedure were described to the patient, who verbalized good understanding,
and informed consent was obtained.
Description of Procedure: The patient was taken to the operating room from the preoperative holding area. The patient’s
identity and planned procedure were verified and the patient was then placed on the operating room table in the supine
position. General endotracheal anesthesia was induced with the use of [SINGLE LUNG VENTILATION – double lumen
endotracheal tube, bronchial blocker, endobronchial intubation, etc.]; tube position was confirmed by flexible bronchoscopy,
allowing selective ventilation of the lung on the non-operative side. Once this was completed, the patient was moved into a
Semi-Fowler position with both arms abducted beyond 90 degrees. All bony prominences were padded, and it was ensured
that the patient’s upper extremities were not under undue stretch. The chest was prepped bilaterally from the clavicle to below
the costal margin longitudinally and to out to the tip of the scapulae transversely. The patient was draped appropriately and a
surgical time out was performed.
The [SIDE] lung was isolated. The fifth intercostal space was identified at the lateral border of the pectoralis muscle. A rib
block was performed with [VOLUME AND TYPE OF LOCAL ANESTHESIA], after which a 5mm skin incision was
made. Ventilation was held. A 5 mm trocar was placed and the chest was inspected with a 5 mm 30 degree thoracoscope.
The lung was noted to be deflated. [FINDINGS]. The chest was then insufflated with CO2 via the trocar to facilitate lung
collapse to a pressure of 10 mmHg. After determining that it was safe to proceed, a second 5 mm port was placed in the 4
th
intercostal space in the anterior axillary line using the same technique described previously.
The second rib was identified high in the chest cavity and this was used as a landmark to identify the location of the
[TARGET GANGLIA] ganglia along the visualized sympathetic chain. Hook cautery was used to open the parietal pleura at
[LEVELS]. The exposed sympathetic chain was dissected from the parietal pleura. Surgical clips were placed at the
proximal and distal level. A 14 French chest tube was then placed through the working trocar; the trocar was then removed
over the tube. Suction was applied to the chest tube. The lung was then re-inflated under direct vision and the subcutaneous
tissues were then closed after the final trocar and camera were withdrawn. The chest tube was removed under Valsalva
maneuver and the skin was closed in a subcuticular fashion with absorbable suture.
[PROCEDURE IS REPEATED ON CONTRALATERAL SIDE]
The sponge, instrument, and needle counts were said to be correct at the conclusion of the procedure. The patient was then
awoken from anesthesia, extubated in the OR, and then taken to the PACU in [CONDITION], where a chest radiograph is
pending at the time of this dictation.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
30. VATS Thymectomy
Manu S. Sancheti, MD and Allan Pickens, MD
Emory University, Atlanta, GA
Essential Operative Steps
1. Lines and Monitoring
2. General double lumen endotracheal tube anesthesia
3. Partial right lateral decubitus positioning
4. Prep and drape entire chest
5. Single lung ventilation
6. Thoracoscopic guided trocar placement
7. CO
2
insufflation 6 mmHg to 15 mmHg as tolerated
8. Additional left trocars placement
9. Open mediastinal pleura anterior to phrenic nerve
10. Isolate and divide left inferior horn
11. Free thymus from pericardium moving superiorly to thoracic inlet
12. Free thymus anteriorly from sternum along IMA/IMV
13. Enter right pleural space
14. Right trocars placement and move camera/ultrasonic coagulator to right
15. Isolate and divide right inferior horn
16. Free thymus from pericardium moving superior to thoracic inlet
17. Divide attachments to innominate vein
18. Isolate and divide right superior horn
19. Move camera and instruments back to left
20. Divide attachments to innominate vein
21. Isolate and divide left superior horn
22. Place thymus in endoscopic bag and remove
23. Examine specimen
24. Hemostasis
25. Ensure no residual thymic tissue present
26. Place chest tube transmediastinally
27. Observe lung re-expansion
28. Closure
Potential Complications and Pitfalls
1. Improper double lumen endotracheal tube placement
2. Improper positioning and poor padding of pressure points/traction on shoulder or elbow
3. Improper trocar positions
4. Lung injury with initial thoracoscopic guided trocar placement
5. Hemodynamic compromise with insufflation
6. Injury or division of phrenic nerve
7. Bleeding from thymic vessels at horns due to inadequate coagulation or clipping
8. Injury to IMA/IMV
9. Injury to right lung when entering right pleural space
10. Injury to innominate vein or inadequate control of vein branches from innominate vein
11. Poor hemostasis
12. Residual thymic tissue left at end of case
13. Chest tube not placed transmediastinally
14. Poor lung re-expansion
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g Myasthenia Gravis, Thymoma, Thymic cyst, Thymic carcinoma]
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Postoperative Diagnosis: Same
Procedure(s) Performed: Thoracoscopic thymectomy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT –e.g. chest pain,
muscle weakness, incidental finding]. Preoperative imaging revealed [RADIOLOGY RESULTS]. Patient was evaluated in
Thoracic Surgery Clinic and recommended to undergo thymectomy via bilateral thoracoscopy. Risks/alternatives discussed,
questions answered and patient agrees to proceed.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure verified, and the patient was placed on the operating room table in the supine position. General anesthesia was
obtained and the patient was intubated with a double lumen endotracheal tube. Proper position was confirmed with flexible
bronchoscopy. A Foley catheter was inserted under sterile conditions. [PREOPERATIVE ANTIBIOTIC AND DOSE] was
administered within 1 hour of skin incision. Bilateral lower extremity sequential compression devices were placed for DVT
prophylaxis. A warming blanket was placed for intraoperative hypothermia.
The patient was placed in a partial right lateral decubitus position with a bump placed under the patient’s left side. The left
arm was placed in a sling above the head. All pressure points were padded well and no traction was placed on the shoulder or
elbow. Hair removal was performed with clippers. The entire chest was prepped and draped in sterile fashion. The right lung
was selectively ventilated. A time out was performed.
LOCAL ANESTHETIC MEDICATION AND DO SE] was used to infiltrate each trocar site prior to incision. A 12 mm
incision was made in the 7
th
intercostal space in the mid-axillary line. A 12 mm thoracoscopic port was placed into the left
pleural space under direct thoracoscopic guidance using a 10 mm 30-degree thoracoscope. Upon entrance into the pleural
space, insufflation was started up to 15 mmHg as tolerated. Two 5 mm thoracoscopic ports were then placed under direct
visualization: one in the left 4
th
intercostal space at the anterior axillary line and one in the left 6
th
intercostal space at the
anterior axillary line.
The dissection was started by opening the mediastinal pleura with a grasper and ultrasonic coagulator approximately 1-2 cm
anterior to the phrenic nerve. This was followed inferior to the diaphragm. The left inferior pole of the thymus gland was freed
from its attachments inferiorly. The thymus was then dissected free from the pericardium moving superiorly toward the thoracic
inlet. The thymus was then mobilized from the sternum anteromedially along the length of the internal mammary artery/vein.
The right pleura was then opened and carried inferiorly. Next, two 5 mm thoracoscopic ports were placed under direct
visualization in the right inframammary fold approximately 8 cm apart. The thoracoscope was moved to one of these ports and
the ultrasonic coagulator in the other. The thymus was grasped from a left sided port and retracted towards the left. The right
inferior horn was isolated and divided. The thymus was then freed from the pericardium moving superiorly toward the thoracic
inlet being careful to stay at least 1-2 cm anterior to the phrenic nerve. Superiorly, the thymus was freed from its attachments to
the innominate vein using coagulation and clips. The right superior horn was then isolated and divided assisted by inferior
retraction of the gland. The camera was then moved back to the left-sided 5 mm port. The left superior horn was then isolated
and divided in a similar fashion. A 10 mm endoscopic bag was then placed through the 12 mm port. The thymus gland was
extracted in the bag from this port. The gland was examined on the back table and finding include [FINDINGS e.g. mass, cyst,
normal, etc]. The specimen was sent to pathology.
The entire chest cavity was inspected. Hemostasis was achieved. No evidence of residual thymus was visualized. A 19 French
Blake drain was placed through one of the right-sided 5 mm ports and crossed transmediastinally to the left. All ports were
removed except the camera port. Insufflation was removed and the lung was observed to expand fully. The final port was
removed. The 12 mm port site fascia was closed with #2-0 Vicryl. All skin incisions were closed with running #4-0 Monocryl
in a subcuticular fashion and Dermabond was placed on the skin. The chest tube was secured with #0 silk suture.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
extubated and taken to the Post-Operative Recovery Unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
31. Transcervical Thymectomy
J. Matthew Reinersman, MD, and Stephen D. Cassivi, MD, MSc
Mayo Clinic, Rochester, MN
Essential Operative Steps
1. Patient Selection
1. Partnering with an experienced neurologist specializing in myasthenia gravis and similar motor disorders is
essential to preoperatively confirm the diagnosis of myasthenia gravis.
2. Patients with suitable body habitus for this procedure are those patients who can adequately extend their neck
and do not have limiting osteoarthritis of the cervical spine or significant osteophytes.
3. Patients presenting with a presumed thymoma visible on imaging are not preferred for this approach and should
be considered for thoracoscopic thymectomy.
4. This approach can also be used to resect a thymus gland containing an active ectopic parathyroid gland.
2. Lines and Monitoring
1. Standard peripheral venous access is usually sufficient along with standard non-invasive intraoperative
monitoring. When possible, venous access should be obtained from the right upper extremity.
3. Patient Positioning and Preparation
1. The patient is positioned supine with an inflatable pillow placed behind the shoulders to assist with neck
extension.
2. The operative table is shifted away from the usual anesthetic equipment so that the head of the bed accessible to
the surgeon and surgical assistant.
3. The patient is prepped and draped from the chin to just above the umbilicus to allow for possible conversion to
median sternotomy.
4. General endotracheal anesthesia without use of neuromuscular blockade
5. Low collar incision
6. Create superior and inferior subplatysmal flaps
7. Divide midline strap muscles
8. Dissect upper poles of thymus gland from underneath the strap muscles on each side and divide between suture
ligatures, leaving the ligatures on the thymus side long as means of retraction
9. Just behind the sternal notch, bluntly dissect the plane posterior to sternum, place Cooper retractor, let down
inflatable shoulder pillow
10. Retract thymus forward and upward to display veins draining into innominate vein. Ligate and divide the draining
thymic veins
11. Carry dissection along posterior aspect of thymus into mediastinum along anterior pericardium
12. Utilize 5-mm, 30-degree thoracoscope to improve visualization
13. Dissection carried on the right side laterally and then the left side laterally.
14. Continue dissection anteriorly to divide the attachments of the anterior thymus to the retrosternal surface
15. Remove the specimen intact, weigh it, take to pathology
16. Re-examine thymectomy space for any residual thymus or fatty tissue and assess hemostasis
17. Reapproximate midline strap muscles, close platysma and skin
Potential Complications and Pitfalls
1. Patient selection is critical - nonthymomatous myasthenia. This approach should not be utilized for patients with
thymoma or thymic carcinoma. Other relative contraindications include previous median sternotomy, severe
osteoarthritis or previous cervical spine surgery, or previous thyroid surgery.
2. Prep and drape entire neck and anterior chest, have sternal saw immediately available and be prepared to perform
sternotomy if difficult visualization, bleeding, or other problems occur.
3. Completing the posterior dissection between the thymus and the pericardium first prior to dissecting anteriorly
between the thymus and sternum is highly recommended as it allows for better visualization. Maintaining the anterior
attachments between the sternum and the thymus help to keep this tissue retracted anteriorly while the posterior
dissection is completed down to the pericardiophrenic angles.
4. Avoid injury to phrenic nerves; Use of electrocautery in the deep lateral extent can put the phrenic nerves at risk; use
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low power in a patient free of muscle relaxants.
5. Entry into the pleural space can occur but is usually inconsequential and does not require a formal chest tube drainage
if the lung has not been injured. Evacuation of the pleural space air can be accomplished at the end of the procedure
by placing a drainage tube to underwater seal into the pleural space via the cervical incision. Sustained positive
pressure breaths are obtained and the tube is pulled when the pleural air has been sufficiently cleared prior to closure
of the incision.
6. If necessary, arterial monitoring line should be placed in the left upper extremity due to possible intermittent
compression of the innominate artery throughout the operation may lead to false determinations of a low blood
pressure. Venous lines should be placed in the right upper extremity.
7. Utilization of a 5-mm, 30-degree thoracoscope assists with visualization
8. Muscle relaxants are avoided in myasthenia gravis cases to reduce the postoperative complications due to
exacerbated motor nerve disturbances, especially respiratory muscle weakness.
Template Dictation
Preoperative Diagnosis: Nonthymomatous myasthenia gravis
Postoperative Diagnosis: Same
Procedure(s) performed: Transcervical Thymectomy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a history of [SYMPTOMS] and a diagnosis of
[DIAGNOSIS] presents for transcervical thymectomy.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient's identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. Following induction of
general anesthesia without the use of muscle relaxants, the patient was intubated with a single-lumen endotracheal tube. The
patient's arms were tucked at the side and an inflatable pillow was placed behind the shoulders and inflated to allow extension
of the neck. The entire neck and anterior chest were then prepped and draped.
A 4 cm incision was made one fingerbreadth above the sternal notch in a curvilinear transverse fashion. The platysma was
incised and superior and inferior subplatysmal flaps were then created, extending to the level of the sternal notch inferiorly and
to the inferior border of the thyroid superiorly. The midline between the strap muscles was then incised along the midline
raphae and the upper poles of the thymus gland were detected behind these structures. The left upper pole of the thymus gland
was identified, isolated, and then ligated underneath the sternohyoid and sternothyroid muscles. The pedicle was controlled
between two #2-0 silk ligatures and then divided. The silk ligatures on the thymus were left long for traction purposes.
Similarly the right superior pole was dissected under the right side strap muscles. The upper pole ligatures were then used to
allow gentle retraction during the remainder of the procedure. Dissection was then carried down to the level of the innominate
vein, posterior to the superior portions of the thymus gland. A space was cleared in the plane between the posterior sternal
notch and the anterior thymus gland for placement of the Cooper retractor. With the Cooper retractor in place, the sternum was
elevated anteriorly and the inflatable cushion was deflated allowing the mediastinal contents to fall away from the sternum.
The thymus was then carefully dissected off of the innominate vein. Multiple small venous branches of the innominate vein
were carefully ligated and divided. A 5-mm, 30-degree thoracoscope was then inserted through our incision to aid in
visualization and dissection. The dissection was then continued along the anterior pericardium all of the way down to the
diaphragm. The right side was then dissected free laterally, followed by the left side. We then carried our dissection
anteriorly to divide the attachments of the anterior thymus to the retrosternal surface. The thymus was then able to be
completely delivered through the cervical incision. It was removed intact within its capsule. It weighed [WEIGHT] grams.
Pathology revealed [PATHOLOGY DIAGNOSIS]. At this point after sending the specimen off, we reinserted the
thoracoscope and reinspected the mediastinum for any further thymic or fatty tissue. We assured hemostasis. Once we were
satisfied, the Cooper retractor was removed, the strap muscles were reapproximated with two interrupted Vicryl sutures. The
platysma was then closed with a running Vicryl suture. The incision was then irrigated and the skin was closed with #4-0
Monocryl suture. The incision was washed, dried, and dressed. The patient was recovered from anesthesia, extubated and
brought to the recovery room in stable condition. At the end of the case, both sponge and instrument counts were correct, and
the estimated blood loss was [BLOOD LOSS].
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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