1. Thoracic Surgery

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

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

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

5. 12 pairs of ribs
Posteriorly each rib articulates with its corresponding thoracic vertebrae

6. 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)

7. Ribs, cont

8. 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

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

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

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

13. Anatomy

14. 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

15. Mediastinum
Lies between the left and right pleural cavities

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

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

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

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

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

21. 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

22. 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

23. Anatomy
Lungs

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

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

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

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

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

30. 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

31. 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

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

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

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

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

36. 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)

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

38. 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

39. Considerations
Hemothorax
Accumulation of blood in the thoracic cavity

40. Considerations Pneumothorax
Accumulation of air or gas in the thoracic cavity

41. 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

42. 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

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

44. 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

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

46. 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

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

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

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

50. 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

52. 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

53. 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

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

55. 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

56. Thoracoscopy
VATS (video assisted thoracic surgery)

57. 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

58. 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)

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

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

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

62. Thoracotomy

63. 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

64. Thoracotomy Positioning 3 basic approaches Posterolateral Thoracotomy
Anterolateral Thoracotomy
Median sternotomy

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

66. 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

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

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

69. 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

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

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

72. Thoracotomy
Rib Resection
Place chest tube
Absorbable suture
Baileys

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

74. 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

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

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

77. 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

78. 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

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

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

81. 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

82. 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.

83. 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

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

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

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

87. 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

88. 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

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

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