Thoracic Surgery

Sternum and costal cartilage Manubrium- Uppermost portion which articulates with the clavicles and the first 2 ribs on each side

Sternum and costal cartilage Gladiolus- Middle portion which articulates with the remaining true ribs (3-7) by separate costal cartilages

Sternum and costal cartilage Xiphoid process- Lower portion of the sternum, and is attached to the diaphragm by the substernal ligament

12 pairs of ribs Posteriorly each rib articulates with its corresponding thoracic vertebrae

12 pairs of ribs Anteriorly the first 7 ribs articulate with the sternum (true ribs) The 8th, 9th and 10th ribs articulate with the costal cartilages of the rib above (false ribs) The 11th and 12th ribs are not fixed to the costal arch (floating ribs)

Ribs, cont

Intercostal Space External and internal intercostal muscles fill the spaces between the ribs An intercostal artery, vein and nerve accompany each intercostal muscle When the nerve must be disturbed a local anesthetic may be injected to prevent postoperative pain

Thoracic Cavity This airtight compartment is enclosed in the root of the neck by Sibson’s fascia, and from the abdomen by the diaphragm

Thoracic Cavity, cont. The cavity is divided into right and left pleural cavities containing the lungs

Thoracic Cavity, cont. Parietal pleura Visceral pleura Lines the inner surface of the chest cavity Visceral pleura Forms a sac around the lung

Anatomy

Pleural cavity Potential space between the parietal and visceral pleurae Pleural fluid A serous secretion that provides lubrication between the pleural membranes to minimize friction

Mediastinum Lies between the left and right pleural cavities

Thoracic outlet Junction bound by the manubrium, the first ribs and the thoracic vertebrae

Thoracic outlet, cont. The great vessels of the head, neck and arm pass through this space

Thoracic outlet, cont. Compression of the structures cause thoracic outlet syndrome

Lungs Organs of respiration Main function is to exchange carbon dioxide for oxygen

Lungs, cont, Base rests on the diaphragm, apex to the base of the neck above the level of the 1st rib

Lungs, cont. Hilum - root of the lung, where the bronchus, nerves, lymphatics, and the pulmonary and bronchial vessels enter and leave the lung, on the mediastinal surface

Lungs, cont. Deep fissures divide the spongy porous lung into lobes Right lung- has upper, middle and lower lobes Left lung- has upper and lower lobes

Anatomy Lungs

Bronchovascular Segments Each lung is composed of 10 major segments, each with its own bronchus and branches of the pulmonary artery and vein

Respiratory Pathway Bronchus- bifurcation- enters lung- lobar bronchi- segmental bronchi- bronchioles- alveolar duct- alveoli surrounded by capillaries

Respiration As the thorax expands (muscles contract) the lungs expand and air is drawn in

Respiration, cont. Negative pressure (vacuum) between the pleura

Respiration, cont. As the thorax relaxes the lungs passively contract and air is expelled

Thoracic Terms Vital capacity Residual volume (or air) The greatest amount of air that can be expelled after a maximum inspiration Residual volume (or air) Volume of gas remaining in the lungs after a maximum expiration

Thoracic Terms, cont. Reserve volume (or air) Tidal volume (or air) Maximum volume of air that can be expired from the resting expiratory level Tidal volume (or air) Amount of air inhaled and exhaled during normal quiet breathing Hypoxia Lack of adequate oxygen content in inspired air

Blood supply Bronchial arteries Arises from the aorta Supplies nourishment to the lungs

Blood supply, cont. Pulmonary arteries Carry the blood to the pulmonary parenchema

Blood supply, cont. Pulmonary veins Carry oxygenated blood to the left atrium

Nerves Part of the autonomic nervous system Regulate constriction and relaxation of the bronchi and the blood vessels within the lungs

Considerations Double lumen endotracheal tube Permits respiration on the unaffected lung and collapse of the affected lung Blood for transfusion should be available Blood may be salvaged during the procedure (Cell Saver)

Considerations Stapling devices may be used on the bronchus or lung tissue

Considerations An open bronchus and its secretions should be considered a contaminated area Maintenance of a dry surgical field is important to prevent aspiration of blood or fluid, which predisposes the patient to postoperative pneumonia

Considerations Hemothorax Accumulation of blood in the thoracic cavity

Considerations Pneumothorax Accumulation of air or gas in the thoracic cavity

Considerations Chest drainage systems Used to reestablish negative pressure in the chest cavity, in the presence of pneumothorax or hemothorax Chest tubes are inserted through stab wounds and are anchored to the chest wall with sutures and tape More that one chest tube may be inserted to evacuate air or fluid

Considerations Skin knife Schnidt or Pean 28-36F chest tube 2-0 or 0 silk or nylon on a cutting needle Adsons with teeth if needed Suture scissors

Considerations Chest drainage systems Drainage system must be sterile Drainage system may be disposable (pictured), or a reusable bottle system

Considerations Chest drainage systems Bottle one Bottle two Collects drainage Bottle two Provides the water seal Bottle three Provides suction control as determined by the level of water

Considerations Chest drainage systems Connections between the drainage unit and the chest tube must be physically tight and securely taped or banded

Considerations Chest drainage systems Drainage system must be kept below the level of the body to prevent backflow of air or fluid Chest tubes are generally removed within 5-7 days

Considerations Collapse of the Lung Results from positive pressure in the pleural cavity

Considerations Collapse of the Lung May cause the mediastinum and trachea to shift to the unaffected side, which could impair its function as well

Considerations Collapse of the Lung May cause death if the mediastinum becomes mobile

Considerations Paradoxic motion of the chest results from severe instability of the chest wall because of multiple and often bilateral rib fractures With inspiration partial collapse of the thoracic space occurs Blunt injury that caused the rib fractures also causes severe contusions of the lung, which contributes to the impairment of lung function

Surgical Interventions Mediastinoscopy Thoracoscopy Thoracotomy Pneumonectomy Lobectomy Segmental Resection Wedge Resection Lung Transplant Lung Volume Reduction Decortication of the Lung Drainage of Empyema Decompression for Thoracic Outlet Syndrome Excision of a mediastinal Lesion Correction of Pectus Excavatum deformity

Mediastinoscopy Direct visualization and possible biopsy of lymph nodes or tumors Used to view lymph nodes or masses in the superior mediastinum May precede an exploratory thoracotomy in known cases of lung carcinoma Patients with positive findings may be treated with radiation or chemotherapy, as indicated

Mediastinoscopy Setup includes: Minor procedure set (for cut-down) Mediastioscope Light cord Suction tubing Aspirating tubes Biopsy forceps ESU 20g endocardiac needle (8”) Syringe

Mediastinoscopy Cut-down to pretracheal fascia Finger dissection along trachea into the mediastinum Using scope, locate suspicious tissue Aspirate with needle and syringe to verify non-vascular structure Use biopsy forceps to excise specimen

Thoracoscopy VATS (video assisted thoracic surgery)

Thoracoscopy VATS (video assisted thoracic surgery) Endoscopic visualization of the thoracic cavity Used for both diagnosis and treatment Benefits include decreased pain, shortened hospital stay, and reduced morbidity

Thoracoscopy VATS (video assisted thoracic surgery) Used for biopsy of masses, wedge resections, evacuation of blood clots, division of adhesions, and treatment of pleural disease or conditions such as cysts, blebs and effusions (accumulations of fluid)

Thoracoscopy Setup includes: Lens Light cord Camera Graspers Dissectors Scissors Monitors, etc.

Thoracoscopy Incise and insert 12 mm trocar and lens Additional access ports as needed, depending on procedure and instrumentation required

Thoracoscopy A chest tube may be inserted through one of the surgical puncture sites and secured to the skin

Thoracotomy

Thoracotomy Is considered a painful procedure It is coupled with muscular injury, which may affect functional capacity Local anesthetic may be injected at wound closure for postoperative pain management

Thoracotomy Positioning 3 basic approaches Posterolateral Thoracotomy Anterolateral Thoracotomy Median sternotomy

Thoracotomy Positioning, cont. Padding!!! Lower leg flexed Need 4 people minimum to move Padding!!! Lower leg flexed Dependent arm Free arm Safety strap

Thoracotomy Draping Square with towels Transverse laparotomy drape Magnetic instrument pad Helps prevent instruments from falling from the field when the patient is in the lateral position

Thoracotomy Rib Resection Incision is made over the selected rib, usually the 5th (#10 on #3)

Thoracotomy Rib Resection Periosteal elevator is used to separate the periosteum from the front and sides of the rib

Thoracotomy Rib Resection A Doyen rib rasparatory may be used to scrape the undersurface of the rib Rib shears of choice are used to resect the rib

Thoracotomy Rib Resection Sauerbruch rib rongeurs or a rasp may be used to trim the bone edges Periosteal bleeding may be controlled with electrocautery

Thoracotomy Rib Resection Marrow bleeding may be controlled with bone wax Bone wax used on sternum may be removed prior to closure

Thoracotomy Rib Resection Place chest tube Absorbable suture Baileys

Pneumonectomy Removal of an entire lung, usually to treat malignant neoplasms

Lobectomy Excision of one or more lobes of the lung Performed to remove metastatic involvement when the tumor is peripherally located and the hilar nodes are not involved, or for large, centrally located benign tumors

Segmental resection Resection of a bronchovascular segment of the lung. May be done for benign lesions

Wedge resection Removal of a wedge shaped section of parenchyma that includes the identified lesion, without regard for intersegmental planes

Wedge resection Used for small, peripherally located benign tumors May be done using a stapling device May use 2 or 3 rows of clamps and sutures

Lung transplant May be single or double Thoracotomy approach Patient is prepped from chin to knees If instability occurs femoral arteriovenous bypass may be needed

Lung Volume Reduction Surgery For patients with chronic pulmonary emphysema Surgical staplers are used, frequently with strips of bovine pericardium on the staple lines

Decortication of the Lung Removal of any fibrinous deposit or restrictive membrane on the visceral or parietal pleura that interferes with pulmonary ventilatory function.

Decortication of the Lung Results in blood loss and trauma and should only be used if the underlying lung is healthy Performed via a posterolateral Thoracotomy incision

Drainage of Empyema Removal of an accumulation of pus in the pleural space Prolonged intrapleural infection results in chronic empyema, which can create mediastinal shift, difficulty in swallowing, respiratory limitations, etc.

Drainage of Empyema Removal of an accumulation of pus in the pleural space Anterolateral incision with a catheter Talc poudrage- application of powder into the pleural space of the lung in order to produce pleural adhesions

Decompression for Thoracic Outlet Syndrome Partial or entire removal of the first rib

Excision of a Mediastinal Lesion Removal of lesions using a median sternotomy approach Sternal saw, bone wax, and sternal wires

Correction of Pectus Excavatum Excavatum (funnel chest - more common) Caused by an elongation of the costal cartilages, which pushes the sternum toward the spine

Correction of Pectus Excavatum Correction may be delayed until adolescence or adulthood May be corrected for respiratory distress, pressure on the heart, or for cosmetic appearance

Correction of Pectus Excavatum Usually done in the supine position Costal cartilages are disconnected from the sternum, resected or straightened The sternum is mobilized, and is restored to normal position

Correction of Pectus Excavatum Carinatum (Pigeon chest) Forward projection of the chest Correction criteria from excavatum apply

This now concludes the Thoracic Lecture… Have a SUPER Day!  This now concludes the Thoracic Lecture…