Once this was performed, a mosquito clamp was then carefully used to dilate the subcutaneous tissues immediately deep to the skin. A #11 blade scalpel was used to slightly enlarge the skin nick in the neck at the site of the guidewire insertion. Once the pocket was of adequate size to accept the port, local anesthetic was then used to infiltrate subcutaneously the path between the Port-A-Cath pocket and the guidewire insertion site. ![]() A skin flap was then raised inferiorly deep to the investing adipose of the skin for the port itself. Local anesthetic was then used to infiltrate the underlying subcutaneous tissues deep and inferior to this for the purpose of development of the Port-A-Cath pocket. The incision was made and extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Once drawn on the skin, local anesthetic was used to infiltrate the underlying dermis and subcutaneous tissue. This was for a length of approximately 3 cm below the clavicle, between the shoulder and the chest, in the midclavicular line, approximately 3-4 cm below the clavicle. A transverse incision was drawn on the skin, planned with a sterile skin marker. The cannulation needle was then removed and our attention was turned to the formation of a pocket for the port. Guidewire was then passed with the cannulation needle, and under fluoroscopic control, advanced until it was in the proximal superior vena cava. The locator needle was removed and passed off the field. This was inserted and the internal jugular vein accessed, evidenced by aspiration of venous blood. Having accessed venous blood, the cannulation on a syringe was then inserted adjacent to the locator needle. With the patient’s head turned slightly to the left, once the wheal was raised, a locator needle consisting of a 25-gauge needle on a syringe was carefully inserted while aiming at a 30-degree angle for the ipsilateral nipple. A small wheal of local anesthetic was raised at the superior apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle on the right side. We then turned our attention to the performance of cannulation of his internal jugular vein on the right side. Cannulation needle was then inserted under the clavicle, but because of the broadness of his clavicle, we were unable to pass the needle under the clavicle, and therefore, this mode of access was abandoned. Once this wheal was raised, local anesthetic was then extended from that site to the clavicle. Local anesthetic was used to raise a wheal of local within the dermis under the clavicle on the right side at a distance of approximately two-thirds between that of the sternal notch and the shoulder. A time-out was called, and the patient’s identity as well as the procedure planned, site, and side confirmed before we proceeded. Right side of the chest, the neck, and upper arm were then prepped and draped in the usual aseptic fashion. ![]() The bed was then adjusted to Trendelenburg position. ![]() His arms were tucked and a small roll placed between his scapulae along his spine. ![]() Postoperative chest x-ray also demonstrated good placement of the tip of the catheter and the port itself with no evidence of pneumothorax or hemothorax.ĭESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. The catheter accessed with a Huber needle, could be easily aspirated as well as flushed with heparinized saline. There was no evidence on intraoperative fluoroscopy for a hemothorax or pneumothorax. INTRAOPERATIVE FINDINGS: Intraoperative fluoroscopy demonstrated that the tip of the catheter was in the proximal superior vena cava. PROCEDURE PERFORMED: Port-A-Cath insertion via the right internal jugular vein.ĪNESTHESIA: Local, 18 mL of 0.5% lidocaine with 0.25% Marcaine at final concentration, with monitored anesthesia care. POSTOPERATIVE DIAGNOSIS: History of resected cholangiocarcinoma. PREOPERATIVE DIAGNOSIS: History of resected cholangiocarcinoma.
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