Venous Access Port Insertion Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Hodgkin lymphoma.

POSTOPERATIVE DIAGNOSIS:
Hodgkin lymphoma.

OPERATION PERFORMED:
Insertion of an implantable venous access port.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Plain Marcaine 0.5% and 1% plain lidocaine along with intravenous sedation.

INDICATION FOR PROCEDURE:  The patient is a (XX)-year-old male patient of Dr. John Doe, who was found to have Hodgkin lymphoma. He is a candidate for chemotherapy, and insertion of an implantable venous access port was requested.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed supine on the operating room table. After adequate intravenous sedation was obtained, a rolled towel was placed longitudinally between the shoulder blades, thereby extending the patient’s neck and chest. The patient’s chest and neck were prepped with Betadine solution and sterilely draped in the usual manner for a procedure in this area. The skin and subcutaneous tissues of the right supraclavicular and right subclavian fossa were anesthetized. The patient was placed in the Trendelenburg position.

The right subclavian vein was percutaneously cannulated through a supraclavicular approach. The guidewire was threaded into the right subclavian vein and into a central location. The patient was taken out of the Trendelenburg position. Good location of the guidewire was confirmed with C-arm fluoroscopy.

A subclavian incision was created and extended through the subcutaneous tissues to the pectoralis major muscle fascia, and a subcutaneous pocket was created. An appropriate saline primed Bard MRI implantable venous access port was inserted into the subcutaneous pocket and anchored to the pectoralis major fascia with 2-0 Prolene sutures. The catheter was threaded through the supraclavicular puncture site using the metal tunneling device. There, it was appropriately tapered and threaded into the right subclavian vein and into a central location using the peel-away catheter technique. Once again good location of the catheter tip and expansion of the right lung was confirmed with C-arm fluoroscopy.

The subcutaneous tissues were approximated with a running suture of 3-0 PDS. All skin incisions were closed with subcuticular sutures of 4-0 PDS. The port was accessed with a right angle butterfly Huber needle. Good venous flow returned. It was heparinized with a solution of 100 units of heparin per mL of saline. Steri-Strip tapes were applied to both incisions. A bulky sterile occlusive dressing was applied over the site.

The patient tolerated this procedure well and was transferred back to his room in stable condition. Estimated blood loss was 3 mL. Sponge, needle and instrument counts were correct at the end of the procedure.

wordpress visitors