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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана
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was held with the patient including but not limited to the following risks: (RISKS). The patient agrees to proceed.
Description of Procedure: After obtaining informed consent, the patient was identified in the preoperative holding area, taken
to the operating room, and placed in the supine position on the operating room table. All appropriate monitoring devices were
placed. Following an uneventful induction of general anesthesia, the patient was intubated using a single lumen endotracheal
tube. A timeout was conducted. Flexible bronchoscopy was performed. A complete examination of the lower trachea,
bilateral mainstem and lobar bronchi, and segmental bronchi was performed. No blood, pus, or endobronchial lesions were
noted. The patient has normal endobronchial anatomy.
The single lumen endotracheal tube was exchanged for a dual lumen endotracheal tube. The patient was then turned to the
(SIDE) lateral decubitus position. An axillary roll was placed. The arms were secured in an elevated arm support with a
padded arm board. Site identification was rechecked, and the patient was prepped and draped in sterile fashion. Anatomical
landmarks were identified, and the camera port was created in the 7
th
intercostal space in the anterior axillary line. The
thoracoscope was then introduced, and the chest wall was inspected. A second working (SIZE) incision was made in the
(INTERSPACE) interspace (LOCATION). There was no pleural effusion. The anterior and posterior mediastinal pleura
were visualized. The parietal pleura was inspected. No abnormalities were noted. The lung was then retracted to the anterior
working incision to allow digital palpation. The fissures were then investigated visually and by palpation. The thoracoscope
was changed to the working incision to allow thorough investigation of the diaphragm. Biopsies were taken from (SITES OF
BIO PSY) and the specimen(s) were sent for frozen section. Frozen sections demonstrated the presence of (FINDINGS).
Hemostasis at the biopsy and port sites was assured. Multilevel intercostal nerve blocks were performed using (LOCAL
ANESTHETIC) from one rib space above the most cranial port site to one rib space below the most caudal port. A 28
French single chest tube was placed through the camera port and secured to the skin using 0 silk suture. Double lung
ventilation was initiated and the (SIDE) lung fully inflated under direct vision. All sponge and instruments counts were
correct. The anterior working incision was closed using 2-0 vicryl for musculofascial closure, 3-0 vicryl for deep dermal, and
4-0 vicryl for subcuticular closure. Sterile dressings were applied. The patient was extubated in the OR and transferred to
the PACU in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
7. Tunneled Catheter Placement
Elena M. Ziarnik, MD and Otis Rickman, DO
Vanderbilt University Medical Center, Nashville, TN
Essential Operative Steps
1. Patient positioned in lateral decubitus, 30 degrees. Effusion side up.
2. Ultrasound guidance to evaluate the location of effusion, lung and diaphragm
3. Mark point of entry (approximately 4
th
-5
th
intercostal space at the mid-axillary line).
4. Mark exit site (at the costal margin in the midclavicular line)
5. Prep and drape, centering on the entry and exit site marks
6. Infiltrate skin and subcutaneous tissue with 5cc 1% lidocaine
7. Infiltrate exit site and planned tunnel with 10cc 1% lidocaine
8. Access fluid with the introducer needle (placed through the catheter) while applying suction with syringe
9. Remove needle and syringe, place guidewire through catheter, remove catheter
10. Make incisions for entry and exit sites with #11-blade. Exit site should be just big enough to tightly fit tunneling
device. Access site should be large enough to accommodate catheter and peel-away trochar
11. Using tunneling device, create a tunnel from catheter exit incision to access incision
12. Position the catheter cuff just deep to the exit site
13. Sequentially dilate pleural tract over the guidewire, and insert the large bore peel-away trochar via Seldinger
technique
14. Insert tunneled pleural catheter through trochar and peel away. Have patient hum to minimize air entry into pleural
space.
15. Connect to drainage device to ensure catheter is not kinked
16. Secure catheter at exit site with #2-0 silk
17. Close access site with #2-0 silk horizontal mattress
18. Drain fluid as needed, can connect to low wall suction using provided adapter for initial drainage
19. Disconnect from drainage and secure to patients side with padded dressing.
Potential Complications and Pitfalls
1. Lung injury
2. Pneumothoarx
3. Bleeding, intercostal artery laceration
4. Positioning the catheter below the diaphragm
5. Pain with too aggressive initial drainage
6. Poorly positioned exit site (posteriorly or on a rib), which can increase patient discomfort
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Malignant pleural effusion]
Postoperative Diagnosis: Same
Procedure(s) Performed: Indwelling tunneled pleural catheter placement, US guidance for catheter placement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [CO MPLAINT – e.g. increasing
shortness of breath]. Pre-procedure CXR reveals [SIDE] pleural effusion. [Recurrent after thoracentesis, known malignancy,
trapped lung}
Description of Procedure: The patient was positioned in lateral decubitus position with the head of bed at 30 degrees with the
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[AFFECTED] side up. Pleural fluid was identified on the [AFFECTED] side using ultrasound. The access site at the 5
th
intercostal space in the midaxillary line, and exit site just below the [AFFECTED SIDE] costal margin were marked. The
chest was prepped and draped in the usual sterile fashion. The tunnel and exit site were anesthetized with 10 cc of 1%
lidocaine, and the access site to pleural space was anesthetized with an additional 5 cc 1% lidocaine. Appropriate choice of
the access site was confirmed by free flow of pleural fluid upon aspiration with a finder needle. The pleural space was
accessed with a small-bore catheter over a needle. After confirming access into the pleural space by free flow of pleural fluid,
the needle was removed, and catheter was left in the pleural space. The wire was advanced into the pleural space through the
catheter. Stab incisions were made at the planned exit and access sites with an #11-blade scalpel. Using the tunneling device,
the catheter was tunneled through subcutaneous tissue. The cuff was positioned about 5 cm from exit incision. A tapered
dilator and peel away sheath trochar were advanced over the wire and advanced into the pleural space. The inner dilator and
wire were removed, and the tunneled catheter was fed into the pleural space without resistance. The peel away trochar was
pulled apart while advancing and holding pressure on the catheter until the trochar was removed and the catheter was
completely in the pleural space. There was no kinking of the catheter. Pleural fluid was easily drained from the catheter.
The access site was closed with a #2-0 silk horizontal mattress suture, and the catheter was secured at exit site with a #2-0 silk
suture in a Roman sandal fashion. The catheter was capped after cleaning it with alcohol. Skin at the exit site was prepped.
Foam padding and a bio-occlusive dressing were applied.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
8. Open Thoracostomy (Eloesser Flap and Clagett Window)
Jacob Moremen, MD and Thomas Birdas, MD
Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
Essential Operative Steps
1. Lines and monitoring
2. General endotracheal anesthesia
3. Two lung ventilation (unless empyema not drained and potential for lung reexpansion)
4. Lateral decubitus positioning
5. Skin incisions vary (must include most dependent portion of chest, may include prior incisions and tube thoracostomy
site if possible)
6. Clagett window: Lateral 6-8 cm thoracotomy and extended in a “Y” fashion laterally and medially; or elliptical
incision may be used
7. Eloesser flap: uses U-shaped incision
8. Raise skin flaps
9. Clagett: 2-3 cm circumferentially
10. Eloesser: Single long flap (area inside the U-curve)
11. Removal of 1-3 ribs (ensure large access to most dependent portion of pleural space)
12. Complete debridement of necrotic tissue and irrigation of space
13. Marsupialize space with heavy absorbable suture
14. Clagett: sew edges of flaps to thickened parietal pleura circumferentially
15. Eloesser: sew large skin flap into base of opened area
16. Ensure adequate hemostasis
17. Pack with sterile moist gauze
Potential Complications and Pitfalls
1. Large window is key
2. Inadequate thoracostomy can result in premature closure of skin before deep space granulation
3. Incision too cephalad may not completely drain basilar space
4. May require single lung ventilation if empyema not fully drained preoperatively
5. Used in patients too frail or with inadequate tissue for muscle flap thoracoplasty or as part of staged repair of
bronchopleural fistula
6. Inadequate drainage of infection, debridement of necrotic tissue
7. Chronic apical space problems are better managed with extrapleural thoracoplasty
Template Dictation
Preoperative Diagnosis: Chronic basilar space infection [ADDITIONAL SPECIFICS – e.g. bronchopleural fistula,
tuberculosis]
Postoperative Diagnosis: Same
Procedure(s) Performed: Open thoracostomy [Clagett window or Eloesser flap]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of basilar pleural space infection
following [ORIGINAL PROCEDURE/DIAGNOSIS] and failed conservative therapy with antibiotics and tube thoracostomy.
Prior decortication did not successfully obliterate space and is here today for open drainage and thoracostomy.
Description of procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
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procedure verified, and the patient was placed on the operating room table in the supine position. Appropriate intravenous
antibiotics and subcutaneous heparin were administered prior to the induction of anesthesia. General anesthesia was induced,
and the patient was intubated with a double lumen endotracheal tube. Position of the tube was verified via flexible
bronchoscopy and was found to be adequate. The patient was then placed in the [SIDE] lateral decubitus position. The tube
thoracostomy was removed, and the entire chest prepped and draped in sterile fashion. An 8 cm posterolateral thoracotomy
incision was made over the most dependent portion of the right pleural space. Cautery dissection was carried down through
muscle layers, and the pleural space was entered on the superior aspect of the rib. A finochietto rib retractor was inserted.
The skin incision was extended in a Y-shaped fashion [or ELIPTICALLY] for better exposure of the ribs. A 2 to 3 cm skin
flap was raised circumferentially. The [NUMBER] ribs were identified for resection to optimally expose the basilar space.
A 6-8 cm length of each rib was exposed and freed from the surrounding tissue attachments circumferentially with Doyen
dissector. A bone cutter was used to divide each rib laterally and medially, and the [NUMBER] ribs were resected. The
neurovascular bundles were suture ligated proximally and distally and Intervening tissue resected and discarded.
With the space fully exposed, a sample of the empyema fluid was sent for culture. All necrotic, infected debris was
decorticated from the lung and chest wall. A sample of the empyema rind was sent for culture. The chest was irrigated with
two liters of warm antibiotic-containing saline. Hemostasis was achieved. Skin flaps were sutured with 0 Prolene suture in
interrupted fashion to the thickened parietal pleura circumferentially. The wound was packed with several rolls of moist gauze
and a large dry dressing applied over the defect.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
subsequently transferred to the postoperative surgical intensive care unit in critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
9. Pleural Biopsy (Open/Thoracoscopic)
David Graham, MD, and Kemp Kernstine, MD, PhD
University of Texas-Southwestern, Dallas, Texas
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia
3. Single lung ventilation with bronchial blocker or dual-lumen endobronchial tube
4. Lateral decubitus position
5. Mark potential thoracotomy incision (generally resection of 7
th
rib via S-shaped incision)
6. Ask anesthesia to deflate lung on the operating side
7. Open Technique
1. Review preoperative imaging and mark an area along the thoracotomy line where there appears to be significant
thickened pleural tumor
2. Make a limited 1-4 cm incision depending on thickness of soft tissue from the skin to chest wall
3. Divide latissimus dorsi, dissect onto chest wall
4. Dissect above rib dividing intercostal muscles and identify the hard, white pleural mass
5. (A mediastinoscope can be used to facilitate exposure)
6. Sharply resect (scalpel or biopsy forceps) a 1 cm square piece of pleura for improved histology and
microbiology studies
7. If more tissue needed, obtain more biopsies along the chest wall near the incision site
8. Place saline into the wound and have anesthesia give a Valsalva maneuver up to 30 mmHg. If no bubbling, close
wound in layers. If bubbling, place a Blake drain and close wound in layers.
8. Thoracoscopic Technique
1. According to the chest computed tomogram findings and the topographical anatomy of the chest wall, use 25-
guage sounding needle to locate effusion; send fluid for cytology/culture
2. Make a skin incision and insert a 5 or 12 mm trocar into this location
3. Place the 5 mm 30-degree thoracoscope into the trocar to confirm chest entry and to inspect pleura
4. Insufflate with 5-10 mmHg CO
2
as needed to help with visualization
5. Aspirate fluid and send to pathology for culture/cytology/gram stain
6. Use mediastinal biopsy forceps or thoracoscopic biopsy forceps within the same port to remove tissue
7. An additional port may be required (along the previously placed thoracotomy incision) if single port/incisional
access inadequate
8. Obtain hemostasis with hook electrocautery as needed
9. Place chest tube (Blake or Argyle) through port site and secure using Nylon or Ethibond suture
Potential Complications and Pitfalls
1. Certain tumors especially mesothelioma has a propensity to seed and subsequently grow in surgical sites; therefore,
keep all biopsy incisions within the planned line of thoracotomy incision.
2. NEVER biopsy the visceral pleura without using a stapling device; this will cause a persistent air leak and delay
treatment
3. If additional tissue is needed, do not resect more pleural rind on the lung (Pitfall #2, obtain more tissue along chest
wall)
4. Take care not to dissect too deeply into chest wall when taking parietal pleural biopsies as meddlesome bleeding can
occur
5. If definitive procedure planned in the near future, chest tube placement without pleurodesis is appropriate; however,
if delay is anticipated, then palliation of the effusion can be performed. If the lung fully expands, intraoperative talc or
Betadine pleurodesis is an option. If the lung is entrapped, a tunneled, valved pleural catheter for external intermittent
drainage would be best for palliation.
Template Dictation
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Preoperative Diagnosis: [INDICATION – e.g. Recurrent bloody pleural effusions, Pleural thickening, Pleural neoplasm]
Postoperative Diagnosis: Same
Procedure(s) Performed: Open pleural biopsy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AG E] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. increasingly
dyspnea and recurrent bloody pleural effusions, preoperative imaging shows concern for pleural thickening and prior attempts
for percutaneous biopsy and cytology have been negative. Thoracic surgery was consulted for open surgical biopsy.
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 a dual-lumen endobronchial tube was then placed. The patient was positioned in the lateral decubitus position.
We then proceeded to prep and drape the chest in sterile fashion. An Ioban dressing was placed. A time out was performed.
A posterolateral thoracotomy incision was marked at approximately the level of the 6
th
intercostal space. A 2 cm incision was
made using a #15 blade along this marking in the posterior axillary line. The dissection was carried down through the
latissimus dorsi and onto the chest wall using electrocautery. The intercostal muscles were divided on the superior border of
the rib. A white firm mass was encountered. Sharp resection of this mass was performed and sent to pathology for
examination. Saline was placed into the wound and anesthesia provided a Valsalva maneuver at 30 mmHg. No air leak was
noted. The wound was closed in layers using Vicryl suture followed by a subcuticular monofilament suture. Tegaderm was
placed as the sterile dressing.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
10. Pleurectomy and Decortication
Abby White, DO and Scott J. Swanson, MD
Brigham and Women’s Hospital, Boston, Massachusetts
Essential Operative Steps
1. Lines and monitoring
1. Arterial catheter
2. Central Venous Catheter
3. Naso-gastric tube help avoid esophageal injury
2. General endotracheal anesthesia via dual lumen endotracheal tube.
3. Bronchoscopy
4. Posterolateral thoracotomy, through latissimus dorsi and sparing serratus anterior muscles
5. Sixth rib resection
6. Blunt and cautery dissection between endothoracic fascia and parietal pleura starting at the vicinity of entry and
proceeding laterally, anteriorly and posteriorly before reaching the apex.
7. Careful attention must be drawn to avoiding injury to the subclavian vessels, phrenic and vagal nerves, superior vena
cava, azygous vein, esophagus and the internal mammary vessels.
8. Packing with lap pads for hemostasis along raw surface areas to minimize blood loss
9. Mobilization of the pleura from the mediastinum, taking care to avoid injury to the phrenic and recurrent laryngeal
nerves.
10. Inferior dissection of the pleural off of the diaphragm
11. Mobilization toward the diaphragmatic sulcus, starting from the posterior costophrenic angle and moving anteriorly.
12. Avoid entry into the peritoneum where possible, though this is particularly difficult when dissecting around the
central tendon. Entry is repaired as soon as it is seen. We prefer to use running 2-0 Vicryl.
13. Dissection is carried to the posterior pericardium, which is removed en bloc if no planes between tumor and
pericardium can be safely identified.
14. Once dissection is complete to the hilum, the parietal pleura is entered and the visceral decortication undertaken.
15. Dissection in the fissures is undertaken with caution, using inflation and deflation of the lung for hemostasis and
identification of tissue planes between pleura and parenchyma respectively.
16. Systematic interlobar, hilar and mediastinal lymphadenectomy is done routinely
17. Hemostasis is obtained, often with the help of an Argon beam electrocaogulator to control raw surface area bleeding
at the chest wall.
18. The chest is irrigated with multiple liters of normal saline and water.
19. In carefully selected patients, intraoperative heated chemotherapy (IOHC) is delivered. We use weight-based dosing
of cisplatin and gemcitabine. We use a 60-minute chemotherapy run; shorter runs are utilized for patients with
borderline renal function.
20. If pericardial resection is required to achieve a complete resection, we reconstruct the pericardium with fenestrated
PTFE (0.1mm) to prevent cardiac herniation and epicarditis. The patch is fenestrated to prevent tamponade from
accumulation of pericardial fluid or blood
21. If the tumor extension involves the diaphragmatic muscle, with the diaphragm is reconstructed with PTFE (2 mm).
Two pieces of 20 x 30 DualMesh are stapled together to create a loose patch that decreases tension, reduces the
incidence of patch dehiscence and herniation of abdominal organs into the chest. We secure the diaphragmatic patch
circumferentially, using both interrupted 2-0 Prolene and the ProTack device.
22. Three chest tubes are placed, one anteriorly and directed towards the apex, one posteriorly and directed towards the
apex, and one right-angled chest tube along the diaphragm. Wide drainage is necessary to control air leaks and to
allow complete re-expansion of the lung.
23. The thoracotomy incision is closed in standard fashion.
Potential Complications and Pitfalls
1. Be prepared to manage significant blood loss and maintain closed loop communication with the anesthesia team
regarding this. We have typed and cross-matched blood available and in the operating room throughout the duration of
the procedure.
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2. Injury to the subclavian vessels can occur at the apices bilaterally.
3. On the right, the superior vena cava and azygous vein are at risk with dissection of the mediastinal pleural in this
area.
4. On the left, the plane between tumor and adventitia of the aorta, intercostal vessels, and the esophagus should be
sought judiciously.
5. Vocal cord injury should be treated with prompt injection medicalization to prevent aspiration in the early
postoperative period.
6. A tight pericardial patch can predispose to positional hemodynamic compromise and cardiac tamponade.
7. A tight diaphragmatic patch around the IVC can result in impaired cardiac filling
8. When delivering IOHC, careful attention must be paid pre-, intra- and post-operatively to adequate fluid resuscitation
to avoid potential renal toxicity from cisplatin
Template Dictation
Preoperative Diagnosis: [Indication – eg. [EPITHELIOD/BIPHASIC] Malignant Mesothelioma of the [LEFT/RIGHT]]
Postoperative Diagnosis: Same (Add invasion of relevant structures)
Procedure(s) Preformed: Bronchoscopy, [RIGHT/LEFT] pleurectomy and decortication, +/- diaphragmatic resection and
reconstruction, +/- pericardial resection and reconstruction, +/- Intraoperative Heated Chemotherapy (IOHC), and mediastinal
lymph node dissection
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure
Description of Procedure: The patient was brought to the operating room on [DATE]. Name, birthdate and nature of the
procedure were verified. After an uneventful induction of general anesthesia, the patient was intubated with a single-lumen
endotracheal tube without incident. Flexible bronchoscopy was performed. There were minimal secretions. No endoluminal
abnormalities or anatomic variations were noted.
Single-lumen endotracheal tube was exchanged to a [RIGHT/LEFT]-sided double lumen endotracheal tube and the patient
was repositioned in the [RIGHT/LEFT] lateral decubitus position and was prepped and draped in the usual sterile fashion. A
[RIGHT/LEFT] posterolateral thoracotomy was performed, transecting the latissimus muscle. The serratus anterior muscle
was preserved and retracted anteriorly. The sixth interspace was entered, and 15 cm of the rib was excised. Standard rib and
scapular retractors were placed. The extrapleural dissection proceeded circumferentially around the thoracotomy. Starting
posteriorly and inferiorly, we were able to define the extrapleural plane down to the base of the diaphragm and then superiorly
to the apex, taking care to identify and protect the subclavian vessels, aorta and esophagus. We then performed a radical
visceral pleurectomy and decorticated the tumor off the fissure and all lobes to the level of the hilar reflection. All gross
disease was resected. Because the diaphragm was involved, it had to be avulsed circumferentially.
Argon beam coagulation was used for tumorolysis and hemostasis along the entire lung surface into the fissures and chest wall.
A chemical scrub was performed with 3 cycles of hydrogen peroxide in 1 liter of water followed by 1 liter of saline. The chest
was then pulse lavaged. Intracavitary heated chemotherapy was then performed with cisplatin and gemcitabine for 60 minutes.
The abdominal peritoneum was inspected and any defects repaired primarily with running #2-0 Vicryl. The chest was
evacuated; all chemotherapy fluid was recovered. The chest was irrigated and checked for hemostasis. A Gore-Tex 1 mm
[2mm on Left] Dualmesh patch was fashioned to reconstruct the diaphragm and secured to chest wall with #2-0 Prolene
sutures around the chest wall thru the 8th interspace and thru the tip of the 5th rib anteriorly. The patch was secured posteriorly
using a laparoscopic tacking device. The rest of the patch was secured to the anterior chest wall and to the pericardium with
interrupted #0-Prolene sutures.
After ensuring hemostasis, three [RIGHT/LEFT]-sided chest tubes were placed as follows: a 28 French anterior angled chest
tube over the dome of the diaphragm into the costophrenic sulcus, a 28 French straight anterior, and a 28 French straight
posterior to the apex along the gutter. Number 2 Vicryl pericostal sutures were placed, and the lung was allowed to re-inflate
completely. The incision was closed in layers with Vicryl sutures. One previous port site excised completely down to chest
wall. The double lumen endotracheal tube was then exchanged to a single-lumen tube. Toilet bronchoscopy showed moderate
amount of secretions that were suctioned to clear. The patient was taken to the ICU intubated in stable condition. All note,
sponge, needle, and instrument counts were correct at the end of the operation.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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