TWilliam2019
Guru
32480
32666 vs 32608 or 32601
39402
38746
32507
1. Flexible bronchoscopy with cytology
2. Left Supraclavicular Lymph Node Biopsy
3. Mediastinoscopy
4. Robotic Assisted Video thoracoscopy, Right
5. Right Upper Lobe Wedge Resection
6. Right Thoracotomy
7. Right Upper lobectomy, lung
8. Mediastinal lymph node dissection
9. Intercostal nerve block
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. A surgical timeout was used confirm patient identity as well as the surgery to be performed.
Next, the flexible bronchoscope was inserted into the endotracheal tube and guided down into the trachea. The carina was visualized. The right mainstem bronchus was intubated. The orifice of the right upper lobe bronchus was identified and a sample for cytology was obtained. There were no gross lesions. The bronchus intermedius was intubated. The orifice of the right lower lobe and right middle lobe bronchi were identified and free from gross lesion. All right airways to the level of the segmental bronchi were serially investigated and found to be free of gross pathology. The bronchoscope was then returned to the carina and the left mainstem bronchus intubated. The orifice of the left upper and lower lobe bronchi and free of any gross lesion. All left airways were then serially investigated and found to be free of gross pathology. The airways were suctioned clear and the bronchoscope withdrawn from the patient.
Next, the patient was prepped and draped in the usual sterile fashion. An incision was made over the left clavicle and I dissected down through the platysma muscle and through a portion of the sternocleidomastoid muscle. Next, the internal jugular vein and subclavian veins were both identified. There was an abnormal lymph node that was identified dissected free and sent off to pathology. Next, hemostasis was achieved in the neck and the wound was closed with 2-0 vicryl, 4-0 monocryl, and dermabond.
Next, I then made an incision above the sternal notch for the mediastinoscopy. Next, I dissected down through the subcutaneous tissue and down on top of the trachea. The mediastinoscope was placed and I then dissected out a 4 R and 4L lymph node, took biopsies and sent to pathology. There was no level 7 lymph node identified. Next, hemostasis was then checked for and obtained, the mediastinoscope was removed and the incision was closed with 3-0 vicryl, 4-0 monocryl, and dermabond.
Next, the patient was re-intubated with a dual-lumen endotracheal tube by the anesthesia team. The patient was then repositioned in the left lateral decubitus position with their right side up. The right chest was then prepped and draped in the usual sterile fashion. A second surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
Next, an approximately 1 cm skin incision was made overlying the 8th interspace in the mid axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered and video scope inserted. With the aforementioned assistant operating the video scope, additional robotic working ports were placed under direct vision and the robot was then docked.
Next, the right upper lung nodule was then identified and using serial endo GIA blue load robotic stapler a wedge resection of the nodule was completed removed and sent to pathology. The pathology returned as non small cell favoring primary lung cancer and therefore we continued with the planned lobectomy.
Next, I began by taking down the IPL up to the IPV, there was no level 8 or 9 lymph node identified. Next, the lung was then reflected anteriorly and the posterior hilum was dissected free up to the azygous vein. Again there was no level 7 lymph node identified. Next, the upper lobe bronchus and the bronchus intermedius was then identified and the level 11 sump node was dissected free and sent with the specimen. Next, the lung was reflected caudad and the superior hilum was dissected free. The lung was then reflected posteriorly and the superior pulmonary vein was identified, dissected free, and a vessel loop was placed around it. Next, the fissure was incomplete and the superior pulmonary vein was at an angle that was unable to be stapled with the robotic stapler. I continue to try and dissected the lung free from several other angle and was unable to make any progress and decided that it would be safer to convert to a thoracotomy to finish the lobectomy.
Next, the robot was undocked and removed from the field. The robotic ports were then removed. A standard thoracotomy incision was then made connecting some of the previous port sites. Next, I dissected through the subcutaneous tissue and muscle and onto the chest wall. The 5th interspace was then identified and entered. The 6th rib was then shingled and a portion was resected to aid in retraction. Next, the superior pulmonary vein was then re identified and resected with the covidean vascular endo GIA load. Next, the truncus anterior was then identified, dissected free and resected with a covidean vascular endo GIA load. This then freed up the backside of the upper lobe bronchus. Next the anterior portion of the upper lobe bronchus was then dissected free and the entire upper lobe bronchus was then resected with a covidean black endo GIA stapler. Next, there were two additional PA branches that were then identified and resected with a covidean vascular endo GIA load. This then freed the upper lobe to where the posterior ascending branch was identified dissected free and resected with a vascular endo GIA stapler. Next, at this point all the structures to the upper lobe were resected and a series of covidean purple endo GIA staplers were used to resect the fissure and pass the right upper lobe off the field. Next, the chest was irrigated, hemostasis was checked for and obtained. Preva leak was placed over the bronchus and staple lines. The middle lobe was on a pedicle so I decided to staple the middle lobe and lower lobe together to prevent middle lobe torsion.
Next, 30 mL of 0.25% marcaine was instilled into the 4th -8th interspaces under direct vision in order to affect an intercostal nerve block. Hemostasis again was verified. Two 28Fr Blake chest tube were placed the ribs were re approximated with number 2 vicryl sutures and the remaining lung was reexpanded under direct vision. All skin incisions were closed in layers with 0 and 2-0 Vicryl by the aforementioned assistant. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds.
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well.
32666 vs 32608 or 32601
39402
38746
32507
1. Flexible bronchoscopy with cytology
2. Left Supraclavicular Lymph Node Biopsy
3. Mediastinoscopy
4. Robotic Assisted Video thoracoscopy, Right
5. Right Upper Lobe Wedge Resection
6. Right Thoracotomy
7. Right Upper lobectomy, lung
8. Mediastinal lymph node dissection
9. Intercostal nerve block
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. A surgical timeout was used confirm patient identity as well as the surgery to be performed.
Next, the flexible bronchoscope was inserted into the endotracheal tube and guided down into the trachea. The carina was visualized. The right mainstem bronchus was intubated. The orifice of the right upper lobe bronchus was identified and a sample for cytology was obtained. There were no gross lesions. The bronchus intermedius was intubated. The orifice of the right lower lobe and right middle lobe bronchi were identified and free from gross lesion. All right airways to the level of the segmental bronchi were serially investigated and found to be free of gross pathology. The bronchoscope was then returned to the carina and the left mainstem bronchus intubated. The orifice of the left upper and lower lobe bronchi and free of any gross lesion. All left airways were then serially investigated and found to be free of gross pathology. The airways were suctioned clear and the bronchoscope withdrawn from the patient.
Next, the patient was prepped and draped in the usual sterile fashion. An incision was made over the left clavicle and I dissected down through the platysma muscle and through a portion of the sternocleidomastoid muscle. Next, the internal jugular vein and subclavian veins were both identified. There was an abnormal lymph node that was identified dissected free and sent off to pathology. Next, hemostasis was achieved in the neck and the wound was closed with 2-0 vicryl, 4-0 monocryl, and dermabond.
Next, I then made an incision above the sternal notch for the mediastinoscopy. Next, I dissected down through the subcutaneous tissue and down on top of the trachea. The mediastinoscope was placed and I then dissected out a 4 R and 4L lymph node, took biopsies and sent to pathology. There was no level 7 lymph node identified. Next, hemostasis was then checked for and obtained, the mediastinoscope was removed and the incision was closed with 3-0 vicryl, 4-0 monocryl, and dermabond.
Next, the patient was re-intubated with a dual-lumen endotracheal tube by the anesthesia team. The patient was then repositioned in the left lateral decubitus position with their right side up. The right chest was then prepped and draped in the usual sterile fashion. A second surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
Next, an approximately 1 cm skin incision was made overlying the 8th interspace in the mid axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered and video scope inserted. With the aforementioned assistant operating the video scope, additional robotic working ports were placed under direct vision and the robot was then docked.
Next, the right upper lung nodule was then identified and using serial endo GIA blue load robotic stapler a wedge resection of the nodule was completed removed and sent to pathology. The pathology returned as non small cell favoring primary lung cancer and therefore we continued with the planned lobectomy.
Next, I began by taking down the IPL up to the IPV, there was no level 8 or 9 lymph node identified. Next, the lung was then reflected anteriorly and the posterior hilum was dissected free up to the azygous vein. Again there was no level 7 lymph node identified. Next, the upper lobe bronchus and the bronchus intermedius was then identified and the level 11 sump node was dissected free and sent with the specimen. Next, the lung was reflected caudad and the superior hilum was dissected free. The lung was then reflected posteriorly and the superior pulmonary vein was identified, dissected free, and a vessel loop was placed around it. Next, the fissure was incomplete and the superior pulmonary vein was at an angle that was unable to be stapled with the robotic stapler. I continue to try and dissected the lung free from several other angle and was unable to make any progress and decided that it would be safer to convert to a thoracotomy to finish the lobectomy.
Next, the robot was undocked and removed from the field. The robotic ports were then removed. A standard thoracotomy incision was then made connecting some of the previous port sites. Next, I dissected through the subcutaneous tissue and muscle and onto the chest wall. The 5th interspace was then identified and entered. The 6th rib was then shingled and a portion was resected to aid in retraction. Next, the superior pulmonary vein was then re identified and resected with the covidean vascular endo GIA load. Next, the truncus anterior was then identified, dissected free and resected with a covidean vascular endo GIA load. This then freed up the backside of the upper lobe bronchus. Next the anterior portion of the upper lobe bronchus was then dissected free and the entire upper lobe bronchus was then resected with a covidean black endo GIA stapler. Next, there were two additional PA branches that were then identified and resected with a covidean vascular endo GIA load. This then freed the upper lobe to where the posterior ascending branch was identified dissected free and resected with a vascular endo GIA stapler. Next, at this point all the structures to the upper lobe were resected and a series of covidean purple endo GIA staplers were used to resect the fissure and pass the right upper lobe off the field. Next, the chest was irrigated, hemostasis was checked for and obtained. Preva leak was placed over the bronchus and staple lines. The middle lobe was on a pedicle so I decided to staple the middle lobe and lower lobe together to prevent middle lobe torsion.
Next, 30 mL of 0.25% marcaine was instilled into the 4th -8th interspaces under direct vision in order to affect an intercostal nerve block. Hemostasis again was verified. Two 28Fr Blake chest tube were placed the ribs were re approximated with number 2 vicryl sutures and the remaining lung was reexpanded under direct vision. All skin incisions were closed in layers with 0 and 2-0 Vicryl by the aforementioned assistant. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds.
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well.
