TWilliam2019
Guru
Postoperative Diagnosis:*
1. Non-small cell lung cancer (right lower & middle lobe) s/p resection
Procedure:
1. Right thoracotomy
2. Removal of chest wall and diaphragm mesh
3. Open window thoracostomy (Claggett Procedure)
Indications:
53 y/o woman with NSCLC of the right middle and lower lobe. She underwent right bilobectomy with en-bloc chest wall & diaphragm resection &reconstruction several weeks ago and developed fever and leukocytosis. She underwent laparoscopic drainage of a perihepatic fluid collection, cultures of which failed to produce any growth. A PET CT revealed moderate uptake in the region of her chest wall mesh. For these reasons she was consented and brought to the operating room for the aforementioned procedures.
*
Anesthesia:
General
*
Estimated Blood Loss:
100*mL
*
Wound Classification:
Dirty / Infected.
*
Findings:
No purulence in the chest wall. Deep to the chest wall mesh, there was approximately 300mL of cloudy fluid drained. There was evidence of frank pus and exudate on the undersurface of the chest wall mesh. The right upper lobe was trapped and did not expand into the resultant space. Deep to the diaphragm mesh, in the retroperitoneal sulcus, there was a separate fluid collection of fran, pus that was drained. An open window thoracostomy proceeded with marsupialization of the resultant skin edges and serratus to the pleura.
*
Specimens:
1. Right pleural fluid for culture
2. Right chest wall mesh for culture
3. Retroperitoneal fluid for culture
4. Diaphragm mesh for culture
*
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. The patient was 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 surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, the previous extended posterior lateral skin incision was reopened with a scalpel. Dissection was carried down through subcutaneous tissues with electrocautery. Flaps were elevated above and below the latissimus muscle & serratus anterior, sparring them both. The musculature was retracted. Lung isolation was verified with anesthesia. The chest wall mesh was identified and incised sharply at its mid portion. There was cloudy effluent present in the pleural cavity with evidence of pus and fibrinous exudate along the undersurface of the chest wall mesh. This fluid was sent for culture. The chest wall mesh was explanted in its entirety. The resultant space was copiously irrigated. The right upper lobe was not expanding into the resultant space.
*
Next, the decision was made to remove the diaphragm mesh as well due to concern for contamination. The diaphragm mesh was removed in its entirety. There was a pocket of frank pus in the retroperitoneal area of the reconstruction. This was sent for culture as well. The dome of the liver was fused to the diaphragm edge. Given concern for reconstructing the resultant chest wall and diaphragm defects would lead to a space and further contamination, the decision was made to perform an open window Claggett procedure.
*
The right chest was then copiously irrigated with warm antibiotic irrigation and suctioned until clear. The thoracotomy incision was closed in layers of 2-0 and 3-0 Vicryl up to the level of the chest wall defect. The edge of the latissimus and serratus were marsupialized to the parietal pleural laterally and visceral pleura medially respectively. The skin edges were then sewn to the pleura with interrupted 0 PDS. Hemostasis was verified. The space was then packed with 2 rolls of Kerlix dressing tied together and soaked in a 1:1 solution of betadine and saline. A sterile dry ressing of 4x4 gauze was applied over this and secured.
*
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the cardiovascular recovery unit in stable condition having tolerated the procedure well. I was present, scrubbed and active during the entirety of the procedure.
*
Complications:
None.
*
Drains:
None.
*
Implants:
None.
*
Blood Products:
None.
1. Non-small cell lung cancer (right lower & middle lobe) s/p resection
Procedure:
1. Right thoracotomy
2. Removal of chest wall and diaphragm mesh
3. Open window thoracostomy (Claggett Procedure)
Indications:
53 y/o woman with NSCLC of the right middle and lower lobe. She underwent right bilobectomy with en-bloc chest wall & diaphragm resection &reconstruction several weeks ago and developed fever and leukocytosis. She underwent laparoscopic drainage of a perihepatic fluid collection, cultures of which failed to produce any growth. A PET CT revealed moderate uptake in the region of her chest wall mesh. For these reasons she was consented and brought to the operating room for the aforementioned procedures.
*
Anesthesia:
General
*
Estimated Blood Loss:
100*mL
*
Wound Classification:
Dirty / Infected.
*
Findings:
No purulence in the chest wall. Deep to the chest wall mesh, there was approximately 300mL of cloudy fluid drained. There was evidence of frank pus and exudate on the undersurface of the chest wall mesh. The right upper lobe was trapped and did not expand into the resultant space. Deep to the diaphragm mesh, in the retroperitoneal sulcus, there was a separate fluid collection of fran, pus that was drained. An open window thoracostomy proceeded with marsupialization of the resultant skin edges and serratus to the pleura.
*
Specimens:
1. Right pleural fluid for culture
2. Right chest wall mesh for culture
3. Retroperitoneal fluid for culture
4. Diaphragm mesh for culture
*
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. The patient was 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 surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, the previous extended posterior lateral skin incision was reopened with a scalpel. Dissection was carried down through subcutaneous tissues with electrocautery. Flaps were elevated above and below the latissimus muscle & serratus anterior, sparring them both. The musculature was retracted. Lung isolation was verified with anesthesia. The chest wall mesh was identified and incised sharply at its mid portion. There was cloudy effluent present in the pleural cavity with evidence of pus and fibrinous exudate along the undersurface of the chest wall mesh. This fluid was sent for culture. The chest wall mesh was explanted in its entirety. The resultant space was copiously irrigated. The right upper lobe was not expanding into the resultant space.
*
Next, the decision was made to remove the diaphragm mesh as well due to concern for contamination. The diaphragm mesh was removed in its entirety. There was a pocket of frank pus in the retroperitoneal area of the reconstruction. This was sent for culture as well. The dome of the liver was fused to the diaphragm edge. Given concern for reconstructing the resultant chest wall and diaphragm defects would lead to a space and further contamination, the decision was made to perform an open window Claggett procedure.
*
The right chest was then copiously irrigated with warm antibiotic irrigation and suctioned until clear. The thoracotomy incision was closed in layers of 2-0 and 3-0 Vicryl up to the level of the chest wall defect. The edge of the latissimus and serratus were marsupialized to the parietal pleural laterally and visceral pleura medially respectively. The skin edges were then sewn to the pleura with interrupted 0 PDS. Hemostasis was verified. The space was then packed with 2 rolls of Kerlix dressing tied together and soaked in a 1:1 solution of betadine and saline. A sterile dry ressing of 4x4 gauze was applied over this and secured.
*
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the cardiovascular recovery unit in stable condition having tolerated the procedure well. I was present, scrubbed and active during the entirety of the procedure.
*
Complications:
None.
*
Drains:
None.
*
Implants:
None.
*
Blood Products:
None.