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Pulmonary/Vascular

PROCEDURE: Bronchoscopy

The bronchoscope was passed transnasally. The vocal cords were normal and moved well. The larynx was normal. The trachea was normal. The main carina was sharp. All bronchopulmonary segments were visualized. There was an endobronchial friable mucosal lesion seen in the left lower lobe bronchus, partially occluding the entire left lower lobe bronchus. No other endobronchial lesions or bleeding sites were noted.

Under fluoroscopic control, transbronchial biopsies of this left lower lung area were obtained, as well as transbronchial needle aspiration, bronchial brush biopsies and bronchial brush washings for cytology. Sterile brush cultures for culture and sensitivity, acid-fast bacilli, fungus and Legionella were done.

The patient tolerated the procedure well.

OPERATIVE PROCEDURE: Right Carotid Artery Endarterectomy

The patient was placed supine on the operating table. The right neck was prepped and draped in the usual sterile fashion.

An oblique incision paralleling the sternocleidomastoid was made on the right side of the neck. Following this, the incision was carried down to the muscle with electrocautery. The sternocleidomastoid muscle was retracted. The internal jugular vein was identified, as was the right carotid artery. The right common carotid artery, the right external carotid artery and the right internal carotid artery were each isolated with vessel loops as was the first branch of the external carotid artery. The hypoglossal nerve was noted and gently retracted.

The right carotid bulb and the internal carotid artery were noted to have plaque within them by palpation. The external carotid artery was clamped as was the first branch of the external carotid artery. The common carotid artery was also clamped.

Following this, incision is made on the anterior surface of the carotid bulb, distally to the internal carotid artery, thus exposing the plaque which was removed with the Freer dissector. Following removal of the plaque, the shunt was then placed; a Pruitt shunt was used, the first catheter entering the internal carotid artery and the second catheter entering the common carotid artery, thus establishing the shunt after release of the respective clamps.

Following this, the carotid artery was then reapproximated using 6-0 Prolene suture, starting at the proximal end and the distal end, meeting in the center. Prior to tying the sutures centrally, the clamps were released and good blood flow was noted. After noting good blood flow, the sutures were tied.

The wound was then irrigated with sterile normal saline solution, and then Surgicel was placed over the anterior aspect of the carotid artery. Hemostasis was achieved with electrocautery and silk suture ties. The platysma was reapproximated with running Vicryl suture. Prior to this, a Jackson-Pratt drain was placed over the carotid artery, exiting distally and secured to the skin with a silk suture. The skin was reapproximated with staples.

OPERATIVE PROCEDURE:

With the patient in a left lateral decubitus position, the right chest was given a 5-minute Betadine wash and then prepped and draped in the usual sterile manner.

A standard posterolateral thoracotomy incision was made. The latissimus dorsi and the pectoralis major muscles were cut, as were the serratus muscles and intercostal muscles. The chest was entered through the 4th intercostal space. Palpation of the ribs beneath the scapula failed to reveal any invasion through the structures. The 4th and 5th ribs were transected at the costovertebral angle. With the Finochietto retractor, the chest was entered.

The tumor mass measured about 3 inches in diameter. The entire lobe was involved with an inflammatory necrotic process. An extrapleural dissection was carried out to free the upper lobe from the chest wall, which involved the 2nd, 3rd and 4th ribs for a distance of around 3 inches. This area was marked off with staples for possible use during postoperative radiotherapy.

A biopsy was obtained of the necrotic tumor mass in the upper lobe. Frozen section revealed necrosis and squamous cell tumor. The dissection was continued and nodes were taken from around the pulmonary artery in the hilum, and the trachea and right upper lobe bronchus junction. The nodes were reported as negative for tumor.

A small nodularity in the right lower lobe was excised by means of a subsegmental wedge resection and sent to the laboratory for frozen section. This was reported as being benign without evidence of tumor. The remainder of the thoracic cavity was found to be free of tumor. There were no implants on other portions of the parietal pleura.

The liver could be palpated across the intact diaphragm and this appeared to be smooth in nature.

The hilar dissection was begun and the pulmonary artery to the right upper lobe was isolated, doubly ligated with 0 silk and transected. The pulmonary vein to the right upper lobe was treated in a similar manner at the hilum and transected. The right upper lobe bronchus was then freed up. With a TIA-30, this structure was transected.

With saline in the chest, the lung was inflated and no leak appeared to be apparent at this time. A pleural flap was fashioned and the stump was covered with this for additional security. The horizontal fissure and the oblique fissure were attached to the middle and lower lobe. The artery to the posterior segment of the right upper lobe was then found at the hilum. This was doubly ligated with 0-silk and transected.

The GIA was then utilized to separate the incomplete fissure between the right upper lobe and the middle lobe. Care was taken to preserve the pulmonary artery to the superior segment of the right lower lobe. The remainder of the oblique fissure was transected utilizing the TIA-55 stapling device. A few small lung leaks were apparent, and these were oversewn with fine 3-0 catgut in a continuous fashion. The specimen was removed. The inferior pulmonary ligament was cut in order to mobilize the lower lobe and fill the chest adequately. This appeared to be more than adequate without any space problems.

Hemostasis was satisfactory. The sponge count was correct. The chest was then irrigated with sterile water in copious amounts. The heart action appeared to be excellent and the middle and lower lobe appeared to fill the chest adequately.

The middle and lower lobe were then stapled together using a TIA-30 in order to prevent torsion of the middle lobe. Hemostasis was satisfactory and the sponge count was correct. Two chest tubes of a #32 size were inserted through separate stab wound incisions and attached under water seal for drainage and suction.

The ribs were then approximated with 1 chromic catgut which was doubled for the pericostals, 0-chromic catgut was used to approximate the 2 layers of muscle, and 2-0 chromic catgut was used to approximate the subcutaneous tissue. A 3-0 nylon in a running vertical mattress suture was used to approximate the skin. A dry sterile bacitracin dressing was applied.

The patient seemed to tolerate this procedure well. The patient was then placed in the supine position. The double-lumen endotracheal tube was removed and a single-lumen, larger endotracheal tube was inserted by the anesthesiologist.

A flexible fiberoptic bronchoscopy was carried out, with saline irrigation of both the right and left bronchi. Patent bronchi and segmental orifices were noted on both sides. The scope was withdrawn.

OPERATIVE PROCEDURE:

FINDINGS: Proximally, the pericardium was noted to be under a large amount of pressure. There was approximately 800 mL of straw-colored fluid withdrawn. The pericardium did not appear thickened. There did appear to be a diffuse fibrinous exudate covering the epicardium.

PROCEDURE: With the patient in a semi-Fowler position, the abdomen and chest were prepped and draped in the usual sterile fashion. The abdominal midline from just above the xiphoid distally was infiltrated with 1% plain Xylocaine.

An approximately 6-cm midline incision was made, begun just above the xiphoid. The incision was carried down through subcutaneous tissues. Hemostasis was obtained with electrocoagulation. The linea alba was incised and the xiphoid identified. The xiphoid was then excised. One large arterial pumper from the side of the xiphoid was controlled with a hemoclip.

The pericardium was exposed beneath the sternum and grasped with a clamp. The pericardium was noted to be tense. It was incised with Metzenbaum scissors with a large rush of fluid appreciated. Fluid was obtained and sent for aerobic, anaerobic, acid-fast bacillus and fungal cultures, cytology and chemistries.

Approximately a 3 x 3-cm portion of pericardium was then excised and also sent for cultures and pathology. The pericardium was felt and did not appear to be nodular. The pericardial fluid was suctioned free. A large drain was then inserted through a separate stab wound, and then cut and placed in the pericardial sac inferiorly and secured to the skin with a 1 Ethibond suture. The linea alba was reapproximated then using a running 0 Vicryl suture. The subcutaneous tissues were reapproximated using running 2-0 Vicryl sutures, and the skin was reapproximated using a running 3-0 Vicryl subcuticular suture. Mastisol and Steri-Strips were then applied.

Sponge and instrument count were correct at the conclusion of the procedure. It was noted that the patient's blood pressure rose and the pulse dropped with relief of the tamponade.