Standard Operative Note

Operative Note – Standard Surgical Procedure

Procedure Name and Indication

• Patient: Thabo Mokoena (ID: 780412 5182 084, Folder No: GP-4829103)
• Procedure: Ultrasound-guided right tube thoracostomy (intercostal drain insertion) and pleural biopsy.
• Anatomical Site: Right 5th intercostal space, mid-axillary line.
• Indication: Large symptomatic right-sided exudative pleural effusion secondary to suspected tuberculous pleuritis, presenting with worseningSOB and hypoxia.

Date, Team, and Anaesthesia

• Date: 14/05/2024
• Time: 14:15 – 14:50 SAST
• Facility: Tertiary Hospital – Minor Procedure Theatre
• Primary Operator: Dr L. Ndlovu (Internal Medicine Specialist)
• Assistant: Dr S. Patel (Medical Officer)
• Anaesthesia: Local anaesthesia infiltration using lidocaine (Xylocaine®) 1% 100 mg (10 mL) SC/IM, administered by the primary operator.

Patient Positioning and Site Preparation

• Patient positioned seated upright, leaning forward over a Mayo stand with the right arm abducted.
• Insertion site confirmed via bedside ultrasound and marked prior to preparation per local theatre protocol.
• Skin prepped with chlorhexidine gluconate 0.5% in 70% alcohol and draped in standard sterile fashion.

Surgical Steps and Intraoperative Details

• Local anaesthetic infiltrated from skin down to the parietal pleura above the 6th rib; straw-coloured fluid aspirated to confirm pleural space entry.
• 1.5 cm skin incision made at the superior border of the 6th rib using a #11 scalpel blade from a standard state hospital thoracostomy tray.
• Parietal pleura biopsied using an Abrams pleural biopsy needle; 4 core specimens obtained at the 4, 6, and 8 o'clock positions and placed in formalin and normal saline.
• Blunt dissection performed through intercostal muscles using curved Kelly forceps into the pleural cavity.
• Finger sweep performed to confirm absence of focal adhesions.
• 24 Fr Malecot intercostal drain introduced into the pleural space and directed posteriorly and apically.
• Drain connected to an underwater seal bottle; good swing and bubbling observed.

Findings and Key Observations

• Thickened parietal pleura encountered during biopsy and blunt dissection.
• Free-flowing, turbid, straw-coloured pleural fluid drained; 1,200 mL evacuated initially before clamping briefly to prevent re-expansion pulmonary oedema.
• No loculations or palpable pleural masses felt on digital exploration.

Complications and Intraoperative Management

• None. Estimated blood loss < 10 mL.
• Patient tolerated the procedure well with SpO2 improving from 89% on room air to 95% post-drainage.

Closure and Postoperative Plan

• Drain secured to skin using a 1-0 silk purse-string and anchoring suture.
• Sterile split-gauze dressing and adhesive strapping applied.
• Postoperative Plan:
  • Transfer back to General Medical Ward.
  • Urgent portable CXR to confirm tube position and exclude iatrogenic pneumothorax.
  • Drain maximum of 1,500 mL over the first hour, then allow free drainage.
  • Send pleural fluid for MC&S, ADA, LDH, protein, and GeneXpert MTB/RIF Ultra; send biopsy specimens for histology and TB culture.
  • Analgesia: paracetamol (Panado®) 1,000 mg PO QID and tramadol (TramaHexal®) 50 mg PO TID PRN.
  • Daily review of drain output and oscillation by ward team.