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32652-RT J94.2, J98.4
Surgeon: Surgeon(s) and Role:
* XXXXX, XXXXXXX, MD – Primary
Case Length: 3 Hr 2 Min 20 Sec
Pre-Operative Diagnosis: right retained hemothorax
Post-Operative Diagnosis: Same
Operation Performed: Right Video Assisted Thoracic Surgery (VATS) and total lung decortication
with removal of large retained old hematoma
Findings (Normal + Abnormal): Large amount of old organized thrombus in the right hemithorax with trapped and scarred portions of the lung. Hematoma removed, trapped lung was released. At the end the lung was completely expanding. Good hemostasis
The patient was brought into the operating room and was placed in a supine position. A time out procedure was carried out identifying a correct patient and site. Then general endotracheal anesthesia with a double lumen tube was placed. The patient was placed in a left lateral decubitus position. Then, the first port was placed along the posterior axillary line. A laparoscope was placed the lung was down. Then the second 5 mm port of was placed in a 5th intercostal space in the posterior axillary line. The third incision was placed in the anterior axillary line in the 5th intercostal space. All the ports were placed under a direct visualization. The soft adhesions were carefully released with a blunt laparoscopic grasper. There were soft clots in the apex that were suctioned. There was an area of the lung that was attached to the chest wall which was gently released with blunt dissection. The chest cavity was irrigated with a warm saline. Then we inspected the right chest for bleeding and meticulous hemostasis was obtained. Then a 36French chest tube was placed through the incision on the 7th intercostal space. The chest tube was secured with a #1 silk sutures. The other incisions the muscle was closed with a silk suture. Then the 2-0 Vicryl for a deep dermal tissue and a 4-0 Monocryl for skin was used. Then, glue applied. All the sponge and instrument counts were correct. The patient was extubated and was transferred to the post operative anesthesia care unit.
Rapid Frozen Section Telephone Diagnosis: None
Specimens Removed: None
Wound Classifications: Clean Contaminated