Surgical Technology Thoracic and Pulmonary Surgery 6th edition CHAPTER 33 Thoracic and Pulmonary Surgery Copyright ©2013 by Elsevier Inc. All rights reserved

Anatomy, Case Planning, and Procedures Lesson 33.1 Anatomy, Case Planning, and Procedures Identify key anatomical features of the respiratory structures in the thoracic cavity. Describe diagnostic procedures of the respiratory system. Discuss pathology of the respiratory system. Discuss specific elements of the case planning in surgery of the thoracic cavity and respiratory system. List and describe common thoracic procedures of the respiratory system. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Terminology Review Review terms and definitions listed at beginning of chapter Use your medical dictionary if necessary Familiarize yourself with the chapter terminology. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Respiratory Function Ventilation Diffusion Perfusion What is the diaphragm? (The diaphragm is a sealed barrier between the thoracic and abdominal cavities.) Describe the processes involved in respiratory function. (Ventilation involves contraction of the diaphragm and expansion of the lungs. Diffusion is the transfer of oxygen from the lungs to the bloodstream. Perfusion is the absorption of oxygen molecules into the body tissues.) Copyright ©2013 by Elsevier Inc. All rights reserved

The Upper Respiratory Tract Nose composed of cartilage and bone Internal and external nose Nasal sinuses: conchae or turbinates What is the function of nasal hairs? (Nasal hairs in the anterior nasal cavity help filter the air as it enters the upper respiratory tract.) Which sense are olfactory nerves responsible for? (Smell) Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved The Pharynx and Larynx Pharynx lies behind the oral cavity Divided into three sections Larynx connects trachea to oropharynx Larynx contains the epiglottis What are the three sections of the pharynx? (Oropharynx, nasopharynx, and laryngopharynx) When is the epiglottis closed? (When a person holds his or her breath) Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved The Bronchi Left and right primary Branch off at the carina Become bronchioles Terminate at the alveoli The trachea branches into right and left primary bronchi at the carina. Which lung is inhaled foreign material more likely to enter? Why? (Because the right bronchus is straighter than the left, inhaled foreign material is more likely to enter the right lung.) Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved The Bronchioles The bronchioles are composed of smooth muscle lined with epithelium. From Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, WB Saunders. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved The Lungs Paired organs separated by the mediastinum Enclosed in the pleural cavity Covered by the pleural sac Expand based on negative pressure created by the space between the two layers Break in integrity of pleural cavity causes a collapse How many lobes does each lung have? (The left lung has two, the right lung has three.) What does the alveolus do? (An alveolus exchanges incoming oxygen molecules with carbon dioxide molecules from the blood.) Copyright ©2013 by Elsevier Inc. All rights reserved

Mechanism of Breathing Controlled by the autonomic nervous system Diaphragm contracts, decreasing space between pleural membranes Thoracic cavity is a closed space Breathing is also under voluntary control. Copyright ©2013 by Elsevier Inc. All rights reserved

Factors Affecting Breathing Intact pleural membrane maintains negative space Penetrating trauma causes lungs to collapse Sufficient elasticity of alveoli Intact central nervous system Chest cavity expansion What is a hemothorax? A pneumothorax? (A hemothorax is blood, and a pneumothorax is air.) Name a disease that constricts the alveoli. (Emphysema) Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Diagnostic Testing Pulmonary function Laboratory test Imaging studies Pulmonary function tests measure lung function. What are some of the tests included in this group of procedures? (Tidal volume, vital capacity, and peak expiratory flow rate) What does the arterial blood gases test measure? (In this test, the arterial blood is assessed for oxygen and carbon dioxide levels and pH [acid-base balance].) Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Instruments General surgery instruments Chest wall instruments Lung instruments Bronchus clamps Surgical stapling devices Vascular clamps What thoracic and pulmonary surgery instruments are available at your clinical affiliates? (Answers will vary.) Long instrument shanks must be at least 9 inches for most adult patients. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Instruments (Cont.) Thoracic and pulmonary instrumentation is fine and delicate and must be handled with great care. From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Closed Chest Drainage Closed chest drainage is used to restore negative pressure in the thoracic cavity. If the draining tube comes out, why is gauze immediately placed over the wound? (Fluid flows back into the chest cavity and can collapse the lungs or heart.) From Lewis SM, Heitkemper MM, Dirksen SR: Medical surgical nursing, ed 6, St Louis, 2004, Mosby. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Bronchoscopy What are the indications for bronchoscopy? (Hemoptysis, suspected tumor, infection, evaluation of burn injury, lesions, and aspirated foreign bodies) Describe the patient prep process for bronchoscopy. (The patient is placed in the supine position with the neck slightly hyperextended.) What are the possible complications of rigid bronchoscopy? (An important complication of rigid bronchoscopy is injury to the tracheobronchial structures if the patient moves during the procedure.) What is bucking? How can it be prevented? (The autonomic gag reflex may cause the patient to arch and cough, even during heavy sedation or light general anesthesia. This is called bucking.) From Sugarbaker DJ, Strauss G, Fried MP: Laser resection of endobronchial lesions: use of rigid and flexible bronchoscopes, Operative techniques in otolaryngology—head and neck surgery 3:93, 1992. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Mediastinoscopy Endoscopic examination of the mediastinum through incision Thymus and lymph node biopsy are performed to establish a diagnosis In what position is the patient placed for mediastinoscopy? (Supine position with the neck hyperextended.) Where will the physician stand during a mediastinoscopy? (At the patient's side or by his or her head) Copyright ©2013 by Elsevier Inc. All rights reserved

Video-Assisted Thoracoscopic Surgery Describe the prep margins for a thoracoscopy. (The patient is placed in the lateral position with the operative side up and a general anesthetic is administered through a double-lumen endotracheal tube.) How many ports are placed for a thoracoscopy? (3 or 4) Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Patient Position Lateral with an axillary roll Anesthetic General Trocar placement Dependent upon procedure A thoracoscopy in an adult requires the use of what degree(s) of endoscope? (0-30) What instrument trays are needed to perform a thoracoscopy? (Mayo trays) Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Lung Biopsy Removal of a small portion of lung tissue for pathological examination Performed when other diagnostic tests are inconclusive Completed as a video-assisted procedure What is a wedge resection? (A wedge resection is a large tissue biopsy or the removal of a small peripheral lesion.) The surgeon will carefully inspect the suture line for air leaks by filling the chest cavity with warm saline solution. When the lung is inflated, the suture line will be observed for bubbles. Copyright ©2013 by Elsevier Inc. All rights reserved

Lung Volume Reduction Surgery Patients with chronic pulmonary emphysema may benefit Involves resection of portions of a lung in which air is trapped in emphysematous lung tissue Define emphysema. (A condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness.) Stapling devices are most commonly used to remove lung tissue. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Thoracotomy Open surgery of the thoracic cavity Reference Figure 33-13, Thoracotomy, in the textbook. What indications might cause a surgeon to perform a thoracotomy? (The procedure for opening and closing the chest generally is the same for any thoracotomy. Thoracic emergencies involving open or penetrating wounds with severe hemorrhage may require the thoracotomy to be performed in the emergency department.) Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Thoracotomy (Cont.) If the ribs cannot be fully retracted to provide a clear window to perform the procedure, a rib may be removed. Chest tubes are always required after a thoracotomy procedure. Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Lobectomy Removal of a lobe of the lung to prevent the spread of metastatic cancer or to treat a benign tumor May be performed as video-assisted procedure Lobectomy may be indicated for cysts, localized infection, or trauma to a portion of the lung. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Lobectomy (Cont.) A lobectomy may be performed as an open procedure or as a video-assisted thoracoscopic surgery (VATS) procedure. When performing a VATS lobectomy, all instruments must be counted and readied for a possible conversion to an open procedure. Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Pneumonectomy Procedure involves removal of entire lung Procedure done to Debulk malignant tumor Slow spread of cancer Treat extensive abscess Treat bronchiectasis At conclusion of the procedure, the wound is irrigated with warm saline and any leaks are identified and repaired. Copyright ©2013 by Elsevier Inc. All rights reserved

Rib Resection: Thoracic Outlet Syndrome Thoracic outlet syndrome is compression of subclavian vessels and brachial plexus at superior aperture of thorax Decompression includes partial or entire removal of rib The thoracic outlet is formed by what structures? (The opening of the thoracic outlet is formed by the first ribs, the spine, and the sternum.) Which anatomical structures are being compressed in a patient with thoracic outlet syndrome? (Subclavian vessels and brachial plexus) Copyright ©2013 by Elsevier Inc. All rights reserved

Decortication of the Lung Surgical removal of fibrin layer of the lung to facilitate lung expansion Surgical removal of a portion of the parietal pleura What is empyema? (Chronic inflammation or infection) Curettes may be needed for removal of tough fibrous deposits. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Lung Transplantation Performed to remove diseased, poorly functioning lung and replace with lung from organ donor Why is single-lung transplantation performed most often? (Single-lung transplantation increasingly is used as a way to maximize the allocation of donor lungs.) When is bilateral transplantation indicated? (If both lungs are diseased) Copyright ©2013 by Elsevier Inc. All rights reserved

Lung Transplant Indications Restrictive lung disease Emphysema Pulmonary hypertension Other noninfectious end-stage pulmonary diseases Organ transplants are commonly handled by a procurement team; with the recipient hospital staff used as assistants. Why is speed important when procuring or transplanting an organ? (Limited period of viability) Copyright ©2013 by Elsevier Inc. All rights reserved

Single and Bilateral Lung Transplants In single-lung transplant, surgeon will make three anastomoses: Bronchus to bronchus Pulmonary artery to pulmonary artery Recipient pulmonary veins to donor atrial cuff In bilateral transplant May require cardiopulmonary support Why is the groin prepped for a single-lung transplantation? (Generally, the groin is prepped and exposed in case a femorofemoral bypass is required.) Bilateral lung transplantation often requires the use of cardiopulmonary support. Copyright ©2013 by Elsevier Inc. All rights reserved

Copyright ©2013 by Elsevier Inc. All rights reserved Questions? Copyright ©2013 by Elsevier Inc. All rights reserved