Thursday, November 24, 2011

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Repair of total anomalous pulmonary venous connection (OP Report Sample)


PREOPERATIVE DIAGNOSES: Total anomalous pulmonary venous connection, atrial septal defect, patent ductus arteriosus.

POSTOPERATIVE DIAGNOSES: Total anomalous pulmonary venous connection, atrial septal defect, patent ductus arteriosus plus the total anomalous pulmonary venous connection was of the mixed type with the left upper and left lower veins and the right lower veins draining to a common vein, which drained directly to the junction of the superior vena cava and the right atrium and the right upper and right middle veins drained directly to the superior vena cava.

OPERATION PERFORMED: Repair of total anomalous pulmonary venous connection with connection of the common vein to the back of the left atrium, suture closure of the atrial septal defect, and ligation of the patent ductus arteriosus.  The right upper and middle lobes veins were left draining to the superior vena cava as they were too small to transfer.

OPERATION: The patient was brought to the operating suite.  The patient was given general endotracheal anesthesia.  A right central venous catheter was inserted.  A femoral arterial line was inserted.  A Foley catheter was inserted.  The patient was prepped with Betadine solution, draped in a sterile fashion. A median sternotomy incision was made.  The thymus was subtotally resected for exposure purposes.  Heparin 3 mg/kg was injected directly into the atrium.  Cannulation was achieved with a 6-French arterial cannula in the ascending aorta and a single venous cannula in the right atrial appendage.  The patient was cooled to an arterial temperature of 18 degrees centigrade.  The head was surrounded with ice packs.  We immediately encircled the ductus arteriosus after we went on bypass and occluded it with a wet clip.  We then cooled the patient down. We visualized the connection to the caval-atrial junction and then also saw the right middle and upper lobe veins, which were small draining directly into the superior vena cava a little higher up.  After we had the patient cooled down, we placed an aortic cross-clamp and gave cold blood cardioplegia.  A pledgeted suture was placed in the apex of the ventricle and the ventricle was pulled upward and to the right.  We incised the common vein and carried the incision to each side.  The veins were small.  I could get a 2.5 mm probe into the left upper, left lower, and right lower veins.  The incision was made in the atrium.  We then underwent circulatory arrest and closed the atrial septal defect with a running suture 6-0 Prolene.  We then made the anastomosis of the atrium to the common vein by suturing it to the posterior pericardium surrounding the incision in the common vein, so as not to make an actual suture line to the small veins.  Once this was complete, we went through de-airing maneuvers.  The aortic cross-clamp was removed.  The heart returned to a regular rhythm.  We began rewarming the patient.  Once the patient was completely rewarmed, we weaned from bypass without difficulty.  Hemodynamics were good.  There was good ventricular function.  We started the patient on 5 of dopamine empirically.  Once off bypass, we ultrafiltered the patient as we gave the pump prime back to the patient.  Once this was complete, we removed all of the cannulas and gave protamine.  We used FloSeal and topical thrombin around the suture lines and once hemostasis was complete, we placed 7-mm Blake drain and closed the sternum with interrupted 0 Ethibond.  The presternal fascia, subcutaneous tissue, and subcuticular layer were closed with absorbable sutures.  Sterile dressings were applied.  The patient tolerated the procedure well, was taken to the intensive care unit in stable condition.

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