Postoperative Diagnosis: Left lung mass with mediastinal involvement/encroachment.

Operation: Chamberlain procedure. Mediastinal lymph node biopsy. Left chest tube insertion.

Anesthesia: General

Procedure: The patient was prepped and draped in sterile manner. Following this, the second intercostal space was isolated, third rib isolated, and the sternum mapped out as a landmark. An 8-cm incision was made over the third rib proximally from the sternum laterally with #15 blade through the skin. Incision was carried down through the subcutaneous tissue and fascia to the medial portion of the third rib with the use of electrocautery using the cut. Hemostasis was maintained using coagulation with the electrocautery. A rib spreader was used to scrape away adherent fascial tissue from the rib. Following this, the rib was adequately isolated, hemostasis maintained, and a rib cutter utilized to remove a portion of the costochondral junction from the sternum medially to the 8-cm mark laterally. After the rib cutter was implemented, the rib dissection of the costochondral junction of the third rib was removed. At this point attention was turned to laterally displacing the left lung apically. This was attempted as we did this with blunt dissection, being careful secondary to the mediastinal structures. A cavity was entered apically and medially to the left lung apex which was seen to be necrotic and foul-smelling. Purulent material was suctioned out of this cavity and cultures sent. Subsequent to this, various mediastinal nodes were isolated and shown to be involved with the active disease process. Various lymph nodes were taken from this mediastinal area and sent to pathology. During this dissection, the lung parenchyma was never entered. Further exploration of this cavity was carried out. Medially, the left phrenic nerve was isolated and visualized. Care was taken not to transect or injure this nerve. Hydrogen peroxide solution was implemented in the cavity space and suctioned out, and the cavity was then irrigated with bacitracin solution. Following irrigation the cavity was again visualized, and the apex of the lung was visualized and the posterior pleural membrane apically to check for any extension of disease. After this, a left chest tube was placed at the fifth and sixth interspace by using sharp dissection continued through the chest wall using hemostats to enter the space and spread along the pleural membranes between the parietal and visceral layers. A 32 French tube was placed and secured in place with two sutures, one medial and one lateral to the chest tube, closing the incision and make the tube snug. This was hooked up to a Pleur-Evac. Chest x-ray showed good placement of the chest tube. The cavity was again visualized and was dry. A suture was used to fasten the third rib to the second rib by throwing a suture around the third rib inferiorly and through the second rib, and the third rib was subsequently secured down to the second rib. Fascia was closed with a running suture. Anterior chest wall was closed in interrupted fashion, and the subcutaneous tissue closed with a running suture. The wound was irrigated and staples used to close the skin. Patient tolerated the procedure well and was sent to Surgical ICU with chest tube in place in the left chest to wall suction. The patent was left intubated, on the ventilator.