hcg
Guru
First time to code this and help is greatly appreciated.
PREOPERATIVE DIAGNOSIS: Recurrent malignant right pleural effusion secondary to metastatic adenocarcinoma of the breast.
POSTOPERATIVE DIAGNOSIS: Recurrent malignant right pleural effusion secondary to metastatic adenocarcinoma of the breast.
SURGEON: Dr. A
ASSISTANT:
ANESTHESIOLOGIST:
ANESTHESIA: General.
OPERATION: Right thoracoscopy. Video-assisted evacuation of recurrent pleural effusion. Multiple biopsies of pleural nodules. Talcum powder pleurodesis. Placement of 34-French angled apical and inferior sulcus chest tubes.
INDICATIONS FOR SURGERY
This patient is a 51-year-old patient undergoing treatment for metastatic adenocarcinoma of the breast over the past several years. She has had recurrent bilateral pleural effusions. The left pleural effusion was treated at the XX Hospital by Dr. B with placement of a chest tube which was left in place for some time. It was ultimately removed with resolution of her pleural effusion. She has recently developed right pleural effusions requiring recurring thoracentesis of 2-3 liters of fluid ultimately prompting request for thoracic surgical evaluation relative to possible right thorascopic talcum powder pleurodesis to resolve her recurring effusions. Following examination and review of the patient's studies, a video-assisted thorascopic evacuation of residual fluid, pleural biopsies and talcum powder pleurodesis with placement of chest tubes was recommended. The risks with and without surgery were discussed at length with the patient and her family, including the risks of bleeding, infection, recurrent effusions, possible heart/lung complications and possible need for postoperative ventilatory support. It was the patient's wish to proceed with surgery and it was scheduled accordingly.
DESCRIPTION OF PROCEDURE AND FINDINGS
The patient was taken to the operative suite. Following time-out for patient and operative site identification, general anesthesia was induced with the placement of a Carlin's tube by the anesthesiologist. Following placement of appropriate monitoring lines, the patient was placed in the left lateral decubitus position, carefully padding all pressure points, and prepped and draped so as to expose the right chest. A right anterolateral 8th intercostal incision approximately 5 cm in length was made, splitting the fibers of the serratus muscle, incising intercostal muscles and entering the pleura. Approximately 1.5 liters of straw-colored fluid was evacuated. A 5 mm, 30-degree thoracoscope was introduced and examination of the parietal pleura demonstrated multiple tiny 2 mm nodules suspicious for malignancy. Multiple biopsies were taken and sent to pathology for permanent
histologic examination. Five grams of sterile talcum powder was then aerosolized into the right pleural space under direct vision. Two 36 angled chest tubes were positioned under direct vision, one within the apex and the other in the inferior sulcus area. They were brought out through separate incisions, securely sutured and connected to dry suction at -40 mmHg. Following correct sponge and instrument count, the incision was closed using running 3-0 Vicryl to the muscle layer and 4-0 Monocryl subcuticular suture to close the skin. A light dressing was applied. The patient was repositioned supine, extubated and returned to the recovery room in stable condition.
ESTIMATED BLOOD LOSS
50 ml.
BLOOD REPLACED
None.
PREOPERATIVE DIAGNOSIS: Recurrent malignant right pleural effusion secondary to metastatic adenocarcinoma of the breast.
POSTOPERATIVE DIAGNOSIS: Recurrent malignant right pleural effusion secondary to metastatic adenocarcinoma of the breast.
SURGEON: Dr. A
ASSISTANT:
ANESTHESIOLOGIST:
ANESTHESIA: General.
OPERATION: Right thoracoscopy. Video-assisted evacuation of recurrent pleural effusion. Multiple biopsies of pleural nodules. Talcum powder pleurodesis. Placement of 34-French angled apical and inferior sulcus chest tubes.
INDICATIONS FOR SURGERY
This patient is a 51-year-old patient undergoing treatment for metastatic adenocarcinoma of the breast over the past several years. She has had recurrent bilateral pleural effusions. The left pleural effusion was treated at the XX Hospital by Dr. B with placement of a chest tube which was left in place for some time. It was ultimately removed with resolution of her pleural effusion. She has recently developed right pleural effusions requiring recurring thoracentesis of 2-3 liters of fluid ultimately prompting request for thoracic surgical evaluation relative to possible right thorascopic talcum powder pleurodesis to resolve her recurring effusions. Following examination and review of the patient's studies, a video-assisted thorascopic evacuation of residual fluid, pleural biopsies and talcum powder pleurodesis with placement of chest tubes was recommended. The risks with and without surgery were discussed at length with the patient and her family, including the risks of bleeding, infection, recurrent effusions, possible heart/lung complications and possible need for postoperative ventilatory support. It was the patient's wish to proceed with surgery and it was scheduled accordingly.
DESCRIPTION OF PROCEDURE AND FINDINGS
The patient was taken to the operative suite. Following time-out for patient and operative site identification, general anesthesia was induced with the placement of a Carlin's tube by the anesthesiologist. Following placement of appropriate monitoring lines, the patient was placed in the left lateral decubitus position, carefully padding all pressure points, and prepped and draped so as to expose the right chest. A right anterolateral 8th intercostal incision approximately 5 cm in length was made, splitting the fibers of the serratus muscle, incising intercostal muscles and entering the pleura. Approximately 1.5 liters of straw-colored fluid was evacuated. A 5 mm, 30-degree thoracoscope was introduced and examination of the parietal pleura demonstrated multiple tiny 2 mm nodules suspicious for malignancy. Multiple biopsies were taken and sent to pathology for permanent
histologic examination. Five grams of sterile talcum powder was then aerosolized into the right pleural space under direct vision. Two 36 angled chest tubes were positioned under direct vision, one within the apex and the other in the inferior sulcus area. They were brought out through separate incisions, securely sutured and connected to dry suction at -40 mmHg. Following correct sponge and instrument count, the incision was closed using running 3-0 Vicryl to the muscle layer and 4-0 Monocryl subcuticular suture to close the skin. A light dressing was applied. The patient was repositioned supine, extubated and returned to the recovery room in stable condition.
ESTIMATED BLOOD LOSS
50 ml.
BLOOD REPLACED
None.
