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Indications:
68 y/o gentleman who presented to hospital with general malaise and leukocytosis. A CT Chest was concerning for left empyema, as well as multiple lung nodules and lymphadenopathy. For these reasons, he was consented and brought to the operating room for the aforementioned procedures.
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Anesthesia:
General
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Estimated Blood Loss:
150*mL
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Wound Classification:
Dirty / Infected
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Findings:
Significant pleural thickening, pleural and lung based nodularity with partial fibrothorax of the left lower lobe. Approximately 300ml and white, cloudy effluent was drained upon initial pleural entry. Multiple pleural and lung biopsies were taken. Fluid was sent for culture and cytology.
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Specimens:
1. Left pleural fluid for culture
2. Left pleural fluid for cytology
3. Left pleural biopsy
4. Left lower lobe, lung biopsy
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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 a dual-lumen endotracheal tube was affected 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.
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Next, an approximately 1cm skin incision was made overlying the 8th interspace lateral to the anterior axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. Cloudy effluent was evident upon pleural entry, some of which was sent off the field in a Luekens’ trap for culture. 2 additional working incisions were placed, one overlying the auscultory triangle and one overlying the 6th interspace and one in the 9th interspace anteriorly. The lower lobe of the lung was significantly adhered to the diaphragm and chest wall in several areas. In these areas, the parietal pleura was thickened up to 1cm, and there was significant pleural and lung based nodularity. Several areas of which were taken for biopsy using biopsy forceps. In order to attempt a decortication, the decision was made to extend our original incision to a mini thoracotomy.
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Next, the initial incision was extended with a 10-blade scalpel. Dissection was carried down through the subcutaneous tissues with electrocautery. A small portion of latissimus was divided. The intercostal muscle overlying the 9th rib was divided and retractor inserted. The lower lobe was bluntly dissected free from the chest wall. There was thick, almost early fibrothorax present overlying most of the lower lobe. On the superior segment of the lower lobe nodularity was present. This area was biopsied sharply the the thickness of tissue was unable to accommodate a linear cutting stapler. Hemostasis was obtained. The upper lobe was lightly fused to the chest was and pericardium. The pericardial surface was left in place, while the apex and posterior surfaces were freed using blunt dissection. Several small pleural rents were made during this process.
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Next, two 36Fr chest tubes were placed under direct vision. An anterior tube was directed towards the apex, while a posterior/inferior curved tube was placed along the diaphragm. The left upper lobe was reexpanded under direct vision. Number 2 Vicryl paracostal sutures were placed to close the interspace. All skin incisions were closed in layers with 0 and 2-0 Vicryl. 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. I was present, scrubbed and active throughout the entirety of the procedure.