Thoracic Surgery By Mike Poullis

Overview What is it ? What do you need to know as a nurse on the ward ?

What do you need to know as a nurse on the ward ? Different pathologies Different operations Chest drains Post operative care

Different pathologies Lung cancer Pneumothorax Pleural effusions Lung biopsies Trauma Oddities

Different operations Bronchoscopy (oesophagoscopy) Mediasteinoscopy Mediasteinotomy / Chamberlains Thoracoscopy VATS Mini thoracotomy Full thoracotomy Pneumonectomy / Lobectomy / Wedge

Anatomy Trachea 2 bronchi 2 Lungs 2 lobes on left 3 lobes on right

The Right Lung A brief review of the lobar architecture of both lungs is necessary to better understand the bronchial and segmental anatomy presented later in detail. Right Lung: right upper lobe (RUL) occupies the upper 1/3 of the right lung. Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib. The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum. The right lower lobe (RLL) is the largest of all three lobes, separated from the others by the major fissure. Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Review of the lateral plain film surprisingly shows the superior extent of the RLL; there is considerable overlap between the more anterosuperiorly located RUL and the RLL. Similarly, the deep posterior gutters extend considerably inferiorly; with full inspiration, the lower lobe can extend may as low as L2, becoming superimposed over the upper poles of the kidneys. Grossly, these lobes can be separated from one another by two fissures which anatomically correspond to the visceral pleural surfaces of those lobes from which they are formed. The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes. The minor fissure is oriented horizontally, extending ventrally from the chest wall, and extending posteriorly to meet the major fissure. Generally, the location of the minor fissure is approximately at the level of the fourth vertebral body and crosses the right sixth rib in the midaxillary line. The right major fissure is more expansive in size than the minor fissure, separating the right upper and middle lobes from the larger right lower lobe. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body. The major fissure extends anteroinferiorly, intersecting the diaphragm at the anterior cardiophrenic angle.

The Left Lung The lobar architecture of the left lung is slightly different than the right. Because there is no defined left minor fissure, there are only two lobes on the left; left upper and left lower lobes. These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe. It is important to understand that in most individuals, interlobar fissures are usually not completely formed; in some individuals there may be complete absence of a fissure thus losing the demarcation between lobes on gross examination. Review of autopsy materials have revealed that complete development of the minor fissure is seen less than 20% of the time. Similarly, complete development of the right major fissure is seen in less than 30% of the population. Conversely, approximately 1% of individuals have complete absence of an interlobar fissure. Furthermore, at the level of the hilum (or pulmonary root) the pulmonary lobes are not routinely separated from one another, again due to incomplete development of the interlobar fissures medially. In general, fissures are not readily identifiable on plain films, with only small portions typically visualized at best. This is because fissures which are composed of only two layers of visceral pleura, may not present a significant radiographic interface and will not produce a shadow. However, if there is fluid within the pleural space or if the visceral pleura is thickened, fissures may be seen in their entirety. Neither the major or minor fissures are definitively demonstrated on CT. In fact, because of the axial orientation of the right minor fissure, exact delineation of the border between the right middle and upper lobes is almost impossible on CT. The approximate locations of the major fissures are inferred from areas of relatively sparse pulmonary vascularity. While separation of pulmonary lobes solely on the basis of fissure location remains rather difficult even on CT, fissural anatomy is not helpful at all in the identification of bronchopulmonary segments. For these reasons, an understanding of bronchial anatomy is the easiest and most reliable way to identify individual pulmonary segments.

Bronchial system It is now time to turn our attention to the specific bronchial supply for each lobe and segment. Individual segmental bronchi are named after the particular pulmonary segment which it supplies, and are given numerical designations, using the letter "B" for bronchus. For example, the B10 bronchus supplies the S10 segment (posterior basal segment). B10 can also be referred to more formally as the posterior basal bronchus. It should be pointed out that considerable anatomical variation may exist between individuals. Often, two or three bronchi may arise from a common trunk rather than having separate and discrete origins.

Compartments of the chest

Lung cancer Small cell Non small cell Squamous Adeno Large cell Undifferentiated

Lung cancer Except for small cell carcinoma of the lung it is generally accepted that surgery is the most effective therapy for lung carcinoma

Small Cell Lung Cancer

Assessment of Patient Fitness for surgery Operability of the tumour - Staging

Staging TNM T size and position of tumour N lymph node status M metastasis

Stages Stage Grouping—TNM Subsets Stage 0 (TisN0M0) Stage IA (T1N0M0) Stage IB (T2N0M0) Stage IIA (T1N1M0) Stage IIB (T2N1M0, T3N0M0) Stage IIIA (T3N1M0), (T(1–3)N2M0) Stage IIIB (T4, Any N, M0) (Any T, N3M0) Stage IV (Any T, Any N, M1)

Survival Stage 5 year Survival 1 A, B 60-85% II A,B 40-60% III A 10-40% III B <10% IV <5%

Fitness for Surgery Age Pulmonary function Cardiovascular function Medical conditions Nutritional Status Performance status

Assessment of Operability CT scan Bone scan PET scan Mediastinoscopy Anterior Mediastinotomy VATS

Pleural effusions Fluid in chest Due to underlying cause Usually malignant, but what ? Drain for Symptoms Diagnosis

Pneumothorax What is a pneumothorax ? How do you treat them ? Who requires surgery ? What does surgery entail ? Thoracotomy Sternotomy Mini thoracotomy VATS

Lung biopsies Need tissue to diagnose “Interstitial lung disease”

Bronchoscopy

oesophagoscopy

Mediastinoscopy

Mediastinoscopy

Mediastinotomy / Chamberlains

Mediastinotomy

Thoracoscopy

Video Assisted Thoracic Surgery

Thoracotomy Posterolateral Lateral Anterolateral Mini thoracotomy

Thoracotomy - Posterolateral

Thoracotomy - Anterolateral

Mini thoracotomy Small incision thoracotomy

Lung Resection Pneumonectomy Lobectomy Wedge

Lung Resection – Pneumonectomy Intrapericardial Extrapericardial No reserve Sputum pO2 Fluid balance Infiltrates Temperature AF

Lung Resection – Lobectomy 3 Lobes on RT RUL RML RLL (not RUL & RLL) 2 lobes on LT LUL LLL

Wedge resection

Chest drains What are they ? Why use them ? Suction and its role What drain do you take out MARK IT

Function Conduit to remove fluid or air from the pleural or pericardial spaces The fluid may be blood, pus or pleural effusion Allow the lungs and heart to work unrestricted

Spaces That Need Draining Following Thoracic Surgery Only a single pleural cavity opened Air and blood may collect in the space Two drains Apical drain – Air Basal drain – Blood Traditionally apical drain is placed anteriorly and basal drain at the back

Chest Drain

Suction What does it do? Air or blood drains more easily out of chest Makes the external pressure negative Air or blood drains more easily out of chest Dangers If on to high tissues may get sucked into the drain damaging them If connected but not on similar effect to clamping the drains BEWARE PNEUMONECTOMY

Does and Don’ts of Chest Drains Do not clamp a functioning drain as this can lead to a tamponade or a tension pneumothorax If becomes disconnected, reconnect and ask patient to cough Always keep drain below level of patient If raised above patient the contents may siphon back into the chest

Drain Removal and Timing of Drain Removal

On Expiration Pleural pressures at their highest But still less than atmospheric pressure Difficult to hold breath at full expiration Natural reaction to pain is to take a deep breath in

On Inspiration Easy to hold breath on maximal inspiration Pleural pressure most negative therefore air more likely to move into pleural space

Valsalva Manoeuvre Forced expiration against a closed glottis Creates a positive intrapleural pressure Easy for patient to hold

Post operative care Blood pressure Blood gases / saturation Urine output Bleeding Sputum Analgesia

Any Questions ?