DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left alpha hemolytic streptococcus empyema.
POSTOPERATIVE DIAGNOSIS: Left alpha hemolytic streptococcus empyema.
PROCEDURES PERFORMED:
1. Left video-assisted thoracoscopy.
2. Drainage of empyema.
3. Decortication of the left lung.
4. Intercostal nerve block.
5. Fiberoptic bronchoscopy.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The patient had a large amount of fibrinous debris and fibrous peel over the lower lobe laterally, posteriorly, and inferiorly. The upper lobe was partially entrapped posteriorly. At the end of the procedure, the left lower lobe expanded well. The upper lobe clearly was not entrapped but did not expand, thus a fiberoptic bronchoscopy was done after a double lumen procedure was switched to a single lumen tube to help for re-expansion of this upper lobe. Suctioning prior through the double lumen tube did not appear to help.
DESCRIPTION OF OPERATION: The patient was placed in the supine position for thoracoscopy and procedures as noted above. General anesthesia was established using double lumen oral endotracheal intubation and its position was confirmed fiberoptically with bronchoscopy. The patient was in the right lateral decubitus position. All pressure points were padded, and Thromboguards were placed. The patient was on IV antibiotics of cefepime and Avelox. The left chest was prepped and draped in the usual sterile fashion. The old chest tube had been removed prior to prepping and draping.
Two ports were made, the first one blind, the other under direct vision and palpation. The old chest tube site was also used and had a fair amount of purulent material in the soft tissues. Between the two ports, the fibrinous debris was removed. Prior to removing fibrinous debris, fluid was sent for aerobic and anaerobic cultures.
After the fibrinous debris was removed, it was clear that the majority of the lower lobe and much of the posterolateral portion of the upper lobe had a fibrous peel, and this was removed thoracoscopically using the ring forceps. Occasionally, we did use the Kelly clamps to develop a plane, and when developed, it seemed to maintain it pretty well.
After the lung was adequately decorticated, which was a slow, tedious process, two inferior ports, which were the new ports, were used for the chest tubes and a right angle 32 chest tube was placed posteriorly and another 36 chest tube was placed laterally and apically. It did appear that the upper lobe had a surface tear, and it may have been caused by the previous chest tube because it was an area which, for the most part, we did not need to work in. When reinflating the lung, the lower lobe reinflated nicely and started to fill the whole lower half of the chest cavity; however, the upper lobe did not inflate. After suctioning, it still did not inflate, but it did appear that it was nice and soft and there was no fibrinous peel, and confident in that, we decided to close and switch over to a single lumen tube and do a fiberoptic bronchoscopy at the end to suction out the upper lobe.
The intercostal nerve block with 0.5% Marcaine was injected into each of the ports. Around the chest tubes, the subcutaneous tissue was cinched around using interrupted 0-Vicryl suture. The skin was closed close to the tube using interrupted horizontal mattress of Monocryl. The more superior port, which had been the previous chest tube site, had the muscle layer closed with interrupted 0-Vicryl suture and the remainder was irrigated and was packed with 4 x 4s. The chest tube was connected to a single Pleur-evac drain using a Y connector.
The patient was placed in the supine position. The double lumen tube was exchanged for a single lumen tube. Fiberoptic bronchoscopy was performed and the left side suctioned of secretions to help re-inflate the upper lobe. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
