TWilliam2019
Guru
Procedure:
1. Video thoracoscopy with mini-thoracotomy, Left
2. Left lung biopsy
3. Left pleural biopsy
4. Mediastinal lymph node dissection, Left
32609
32674
vs
32097
38746
vats are my weakness
Indications:
Mr. patient is a 75 y/o gentleman w/ a hx/o CAD s/p CABG and remote hx/o tobacco abuse. He was referred following the discovery of a PET-Avid left upper lobe lung mass on imaging. Staging mediastinoscopy was performed which was negative. He was subsequently consented and brought to the operating room for biopsy and attempted resection.
*
Anesthesia:
General
*
Estimated Blood Loss:
25*mL
*
Wound Classification:
Clean
*
Findings:
A large hilar mass extending from the hilum and into the pericardium was present along the anterior/lateral border of the pulmonary artery. The patient's pericardium was fused directly to the surface of the heart. The tumor was deemed non-resectable. Biopsy returned positive for NSCLC on frozen section.
*
Specimens:
1. 1 Level 5 lymph node
2. 1 Level 11 L lymph node
3. Pleural biopsy, left
4. Hilar mass, left
5. Left upper lobe lung mass
*
Procedure Details:*
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. *Next, the patient was intubated with a dual-lumen endotracheal tube by the anesthesia team. The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, an approximately 1cm skin incision was made overlying the 5th interspace anterior to the midaxillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. A utility incision was made overlying the 3rd interspace in the anterior axillary line and a wound protector inserted.
*
Next, the lung was reflected inferiorly and posteriorly to expose the mediastinal pleural and apex. The mediastinal pleura was incised cephalad to the pulmonary artery in the aorto-pulmonary window. A level 5 lymph node was encountered here and, dissected free with electrocautery and passed off the field for frozen section. The utility incision was extended slightly into a mini-thoracotomy and a retractor inserted. Careful blunt dissection proceeded anteriorly towards the hilum. The left upper lobe border was freed from pericardial fat pads in this area. A lung based nodule was present here, as well as an anterior parietal pleural plaque. The were biopsied directly with biopsy forceps and passed off the field for specimen. A bulky mass was encountered along the anterior medial surface of the pulmonary artery, extending into the pericardium. The pericardium was fused to the heart here. This mass was biopsied with biopsy forceps and passed off the field as specimen. This returned positive on frozen section for NSCLC. The fissure was interrogated bluntly and a level 11 lymph node was encountered, dissected free and passed off the field as specimen. Given the extent of invasion into the mediastinum, the tumor was deemed non-resectable.
*
A thorough mediastinal lymph node dissection proceeded with specimens as stated above. Hemostasis was verified. A single 32Fr chest tube was placed through an anterior-inferior incision and directed towards the apex. The left lung was reexpanded under direct vision. All skin incisions were closed in layers with No. 2 Vicryl para-costal sutures used to close the interspace of the utility incision and 0 and 2-0 Vicryl to close the subq tissues. 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.
1. Video thoracoscopy with mini-thoracotomy, Left
2. Left lung biopsy
3. Left pleural biopsy
4. Mediastinal lymph node dissection, Left
32609
32674
vs
32097
38746
vats are my weakness
Indications:
Mr. patient is a 75 y/o gentleman w/ a hx/o CAD s/p CABG and remote hx/o tobacco abuse. He was referred following the discovery of a PET-Avid left upper lobe lung mass on imaging. Staging mediastinoscopy was performed which was negative. He was subsequently consented and brought to the operating room for biopsy and attempted resection.
*
Anesthesia:
General
*
Estimated Blood Loss:
25*mL
*
Wound Classification:
Clean
*
Findings:
A large hilar mass extending from the hilum and into the pericardium was present along the anterior/lateral border of the pulmonary artery. The patient's pericardium was fused directly to the surface of the heart. The tumor was deemed non-resectable. Biopsy returned positive for NSCLC on frozen section.
*
Specimens:
1. 1 Level 5 lymph node
2. 1 Level 11 L lymph node
3. Pleural biopsy, left
4. Hilar mass, left
5. Left upper lobe lung mass
*
Procedure Details:*
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. *Next, the patient was intubated with a dual-lumen endotracheal tube by the anesthesia team. The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, an approximately 1cm skin incision was made overlying the 5th interspace anterior to the midaxillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. A utility incision was made overlying the 3rd interspace in the anterior axillary line and a wound protector inserted.
*
Next, the lung was reflected inferiorly and posteriorly to expose the mediastinal pleural and apex. The mediastinal pleura was incised cephalad to the pulmonary artery in the aorto-pulmonary window. A level 5 lymph node was encountered here and, dissected free with electrocautery and passed off the field for frozen section. The utility incision was extended slightly into a mini-thoracotomy and a retractor inserted. Careful blunt dissection proceeded anteriorly towards the hilum. The left upper lobe border was freed from pericardial fat pads in this area. A lung based nodule was present here, as well as an anterior parietal pleural plaque. The were biopsied directly with biopsy forceps and passed off the field for specimen. A bulky mass was encountered along the anterior medial surface of the pulmonary artery, extending into the pericardium. The pericardium was fused to the heart here. This mass was biopsied with biopsy forceps and passed off the field as specimen. This returned positive on frozen section for NSCLC. The fissure was interrogated bluntly and a level 11 lymph node was encountered, dissected free and passed off the field as specimen. Given the extent of invasion into the mediastinum, the tumor was deemed non-resectable.
*
A thorough mediastinal lymph node dissection proceeded with specimens as stated above. Hemostasis was verified. A single 32Fr chest tube was placed through an anterior-inferior incision and directed towards the apex. The left lung was reexpanded under direct vision. All skin incisions were closed in layers with No. 2 Vicryl para-costal sutures used to close the interspace of the utility incision and 0 and 2-0 Vicryl to close the subq tissues. 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.