1. Flexible bronchoscopy.
2. Right muscle-sparing lateral thoracotomy with complete decortication of the lung with drainage of right lower lobe lung abscess.
DESCRIPTION OF OPERATION: The patient was brought to the operative suite, placed in the supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal tube, visualizing the distal trachea, carina, right and left main stem bronchus with primary and secondary divisions. No evidence of any endobronchial tumor was noted. What I did see was some crowding involving the right middle lobe and right lower lobe bronchi. The scope was then withdrawn.
A double-lumen endotracheal tube was then positioned by the anesthesiologist. The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A right muscle-sparing lateral thoracotomy was made. We entered via the fifth intercostal space. Careful exploration was carried out and findings were as stated above. The gelatinous material present in the right pleural space was completely evacuated. Adhesiolysis was carried out freeing up the entire right lung.
Decortication was next carried out, being careful not to injure the underlying lung parenchyma. The patient had a very thick pleural rind. While performing the decortication, I unroofed a 2 x 2 cm right lower lobe lung abscess. The contents were evacuated. I sent cultures of the abscess cavity as well as of the empyema cavity in separate containers to microbiology for examination. All decorticated tissue was also sent to pathology for examination as well. Excellent lung expansion was noted. I irrigated the entire region using several liters of warm antibiotic saline solution until the effluent came back clear and then I irrigated with several more liters.
Attention was then directed at closing. Two 32-French chest tubes were placed, 1 anteriorly and 1 posteriorly, and these were brought out through inferior stab wounds. The ribs were approximated using heavy Vicryl sutures. The chest wall muscles, fascia, skin and subcutaneous tissues were approximated using the same suture material. Dressings were applied. Marcaine 0.25% was used as a paravertebral/interfacet block at the level of T2 to T9. The patient tolerated the procedure well and was sent to the intensive care unit in stable condition.
1. Flexible bronchoscopy.
2. Cervical mediastinoscopy with biopsy and thyroid isthmusectomy.
PROCEDURE IN DETAIL: The patient was brought to the operative suite and placed in supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal tube visualizing the distal trachea, carina, right and left main stem bronchus of the primary and secondary divisions. No evidence of any endobronchial tumor was noted. The scope was then withdrawn. The patient was then prepped and draped in the usual sterile fashion. A shoulder roll was placed. A curvilinear incision was made above the suprasternal notch in the line of a skin crease. Dissection was carried down through the subcutaneous tissue down through the platysma muscle. The strap muscles were next identified and laterally retracted. We continued our dissection down to the pretracheal space. A thyroid isthmusectomy was done without any problems; this gave me clear access to the pretracheal space. A pretracheal plane was next developed. A mediastinoscope was placed. I saw multiple, firm right paratracheal lymph nodes. After first aspirating these structures to make sure they are not vascular in nature, generous biopsies were taken and sent to pathology for examination. Frozen section analysis revealed these to be consistent with lymphoma. Excellent hemostasis was obtained. The wound was irrigated using warm antibiotic saline solution. The wound was then closed in layers using Vicryl sutures. Dressings were applied. Marcaine 0.25% was used as a regional block. The patient tolerated the procedure and was sent to the recovery room in stable condition.
PREOPERATIVE DIAGNOSIS: Respiratory insufficiency.
POSTOPERATIVE DIAGNOSIS: Respiratory insufficiency.
OPERATION: Tracheotomy with division of thyroid isthmus.
ESTIMATED BLOOD LOSS: Less than 10 mL.
TECHNIQUE: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck.
A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed and then the strap muscles separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly-based tracheotomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin.
Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition.