TWilliam2019
Guru
1. Right VATS with therapeutic upper lobe wedge resection of pulmonary nodule 32666
2. Drainage of right subpleural abscesses
3. Evacuation of right pleural effusion
4. Multilevel intercostal nerve block
Procedure in detail:
A 10 mm incision was made at approximately the eighth intercostal space, posterior axillary line. The soft tissues were divided with electrocautery and access into the right pleural space was achieved at the costophrenic angle. Gross inspection of the right pleural cavity was then undertaken. A 10 mm incision was made at the cardiophrenic angle and a third 10 mm incision was made at approximately the fifth intercostal space.
The pleural effusion was then drained, with portions of it collected within traps and submitted for routine, AFB, and fungal cultures. The remaining portion was submitted for cytology. An estimated total of 350 to 400 mL of fluid was removed. Once this was completed, the right upper lobe was found to be adherent to the posterior chest wall. It was gently taken down with blunt dissection. Upon breaking the adherent plane, purulence poured from the subpleural second intercostal space. The purulent drainage was collected and submitted for routine, AFB, and fungal cultures. Once the right upper lobe was completely mobilized, the posterior pleura was further inspected. The second interspace was opened further with hook electrocautery along the parallel axis of the intercostal space. The third interspace was also opened in a similar fashion with more purulent material drained. Care was taken not to jeopardize the sympathetic chain posteriorly.
Once the pleural abscesses were completely drained, the nodule was identified in the anterior portion of the right upper lobe. Using thick tissue stapling loads, a wedge resection was performed of the right upper lobe nodule and it was placed within an Endo Catch bag. Frozen section of the nodule showed no malignancy and was more concerning for an inflammatory process.
The right pleural space was then copiously irrigated with normal saline and suctioned out. A 28 French straight chest tube was positioned posteriorly near the subpleural abscess region. A multilevel intercostal nerve block was performed by injecting half percent Marcaine with epinephrine and interspaces 4 through 9 under direct visualization. The lung was ventilated with full reexpansion in all ports were found to be hemostatic. The soft tissues were then closed with 2-0 Vicryl after being injected with Marcaine for local anesthesia. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated the procedure well, was extubated, then transferred to recovery.
2. Drainage of right subpleural abscesses
3. Evacuation of right pleural effusion
4. Multilevel intercostal nerve block
Procedure in detail:
A 10 mm incision was made at approximately the eighth intercostal space, posterior axillary line. The soft tissues were divided with electrocautery and access into the right pleural space was achieved at the costophrenic angle. Gross inspection of the right pleural cavity was then undertaken. A 10 mm incision was made at the cardiophrenic angle and a third 10 mm incision was made at approximately the fifth intercostal space.
The pleural effusion was then drained, with portions of it collected within traps and submitted for routine, AFB, and fungal cultures. The remaining portion was submitted for cytology. An estimated total of 350 to 400 mL of fluid was removed. Once this was completed, the right upper lobe was found to be adherent to the posterior chest wall. It was gently taken down with blunt dissection. Upon breaking the adherent plane, purulence poured from the subpleural second intercostal space. The purulent drainage was collected and submitted for routine, AFB, and fungal cultures. Once the right upper lobe was completely mobilized, the posterior pleura was further inspected. The second interspace was opened further with hook electrocautery along the parallel axis of the intercostal space. The third interspace was also opened in a similar fashion with more purulent material drained. Care was taken not to jeopardize the sympathetic chain posteriorly.
Once the pleural abscesses were completely drained, the nodule was identified in the anterior portion of the right upper lobe. Using thick tissue stapling loads, a wedge resection was performed of the right upper lobe nodule and it was placed within an Endo Catch bag. Frozen section of the nodule showed no malignancy and was more concerning for an inflammatory process.
The right pleural space was then copiously irrigated with normal saline and suctioned out. A 28 French straight chest tube was positioned posteriorly near the subpleural abscess region. A multilevel intercostal nerve block was performed by injecting half percent Marcaine with epinephrine and interspaces 4 through 9 under direct visualization. The lung was ventilated with full reexpansion in all ports were found to be hemostatic. The soft tissues were then closed with 2-0 Vicryl after being injected with Marcaine for local anesthesia. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The patient tolerated the procedure well, was extubated, then transferred to recovery.