Thoracic Surgical Approaches

Thoracic Surgical Approaches

Mediastinoscopy • surgical procedure to examine the upper chest between and in front of the lungs (mediastinum) • Generally used for diagnostic assessment of mediastinal lymphadenopathy and staging of lung CA 05/15/09

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• a small incision is made in the neck just above the breastbone or on the left side of the chest next to the breastbone • (mediastinosco pe) is inserted through the opening. A tissue sample (biopsy) can be collected. 05/15/09

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Chamberlain Procedure

• also known as an anterior mediastinotomy • minimally invasive operation • A related procedure, known as the Jolly Procedure, is also an anterior mediastinotomy. 05/15/09

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• used to biopsy lymph nodes in the center of the chest, or to biopsy a mass in the center of the chest • the Chamberlain procedure differs from a cervical mediastinoscopy by the location of the incision, and the location of the lymph nodes or mass to 05/15/09

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Internal thoracotomy • by continuing the division of internal muscles more interiorly up to the level of internal mammary artery and posteriorly up to the level of the paraspinous tendons 05/15/09

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• Prevents rib fracture during subsequent spreading of the retractor

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Anterolateral thoracotomy • Traditionally used in trauma victims • Allows quick entry into the chest with the patient supine • In hemodynamic instability, it is better than the lateral decubitus position • Gives the anesthesiologist control over the patients 05/15/09 cardiopulmonary system

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Anterolateral thoracotomy

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• Incision is submammary beginning at sternal border extending to the mid axillary line • Pectoralis major muscle and some of pectoralis minor are divided and incision is carried through seratous 05/15/09

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Bilateral anterior thoracotomy • “clamshell “ thoracotomy • Incision with transection of the sternum • Standard operative approach to the heart and mediastinum in certain circumstances • Preferred incision for double-lung 05/15/09

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Median sternotomy • “trap-door” thoracotomy • For access to mediastinal structures • Frequent complication: hypesthetic nipple • Principally used for cardiac operations 05/15/09

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• Increased the risk of infection if tracheostomy is needed • Associated with less pain and less compromise of pulmonary function then a lateral thoracotomy 05/15/09

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Video assisted thoracoscopic surgery/ VATS

• performed using a small video camera that is introduced into the patient's chest via a scope. • view the anatomy along with other surgical instruments that are introduced into the chest 05/15/09

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VATS

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• The basic principle is to position the ports high enough on the thoracic cage to have access to the hilar structures • Endoscopic staplers are used to divide the major vascular structures and 05/15/09

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Postoperative care chest tube management: • Pleural tubes are left for two reasons: 3. To drain fluid (preventing pleura fluid accumulation) 4. To evacuate air if an air leak is present 05/15/09

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• Tube is removed when the volume of drainage decreases and when no air leak is present • A drainage volume of 150 ml or less over 24 hours has been thought necessary in order to safely remove a chest tube 05/15/09

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Use of suction: • suction levels of 20cm H20 have been routinely used after pulmonary surgery to eradicate residual air spaces and control post-op parenchymal air leaks • Atelectasis or collapse: suction used to achieve 05/15/09

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Assessing an air leak:

• Chest tube and its attached tubing should be examined and lack of kinks or external mechanical obstruction verified • Px is asked to voluntarily cough (water seal chamber observed) • Bubbles: air leak 05/15/09 • Stationary fluid level:

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Pain control • Good pain control after posterolateral thoracotomy is critical • Permits px to actively participate in breathing maneuvers designed to clear and manage secretions; promotes ambulation and feeling of well-being 05/15/09

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• 2 most common techniques of pain mgt are epidural and IV • Epidural catheters: T6 level, scapular tip • Combinations of fentanyl with bupivacaine or ropivacaine are used • Ropivacaine: less cardiotoxicity then bupivacaine • 05/15/09

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• IV narcotics via patientcontrolled analgesia can be used in conjunction with ketorolac • Proper pain control with IV narcotics is a balance of pain relief and sedation • Intercostal nerve catheter: alternative to 05/15/09

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• patient is transitioned to oral pain medication on third or fourth post op day

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Respiratory care • Best respiratory care is achieved when Px is able to deliver an effective cough to clear secretions • Post op : proper pain control without over sedation • In Px’s with pre op impaired pulmo function: routine 05/15/09 nasotracheal suctioning

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• Percutaneous transtracheal suction catheter - better alternative at time of surgery (comfortable and allows regular and convenient suctioning) 05/15/09

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Postop complications 1. Postpneumonectomy pulmonary edema • In 1-5% (higher in right) • Sx of respiratory distress appear hours to days after surgery • X-ray: diffuse interstitial infiltration or 05/15/09

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• Related to increased permeability and filtration pressure, and decreased lymphatic drainage from affected lung • Tx: ventilatory support fluid restriction diuretics 05/15/09

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2. Post op air leak and bronchopleural fistula • Air leaks are common after pulmo resection • Occur more often and last longer in px with emphysematous changes (impaired healing) • Prolonged air leaks : Tx by diminishing or discontinuing suction by continuing chest 05/15/09

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• Management for bronchopleural fistula : - continued prolonged chest tube drainage - Reoperation and reclosure - Bronchoscopic fibrin glue application (fistulas less than 4 mm) 05/15/09

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Solitary pulmonary nodule

• “coin lesion” • Single ,wellcircumscribed, spherical lesion • Less than 3 cm in diameter and completely surrounded by normal lung parenchyma • Clinical significance: 05/15/09

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DDX • A new solitary pulmonary nodule on chest x-ray has a 20 to 40% likelihood of being malignant

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causes of pulmo nodules: 1. Infectious granuloma • 70-80% 2. Hamartoma • 10% • Others: congenital, neoplastic, inflammatory, vascular 05/15/09

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• Risk factor for malignancy : - Smoking - Prior neoplastic disease - Hemoptysis - Age over 35

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Imaging: CT scan • Critical in characterizing nodule locations, size, margin morphology, calcification pattern and growth rate • Lesion larger than 3 cm : more likely malignant • Irregular, lobulated or spiculated edges strongly suggest 05/15/09

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• Corona radiata sign (fine linear strands 4-5 mm outward and appearing speculated) : highly cancer-specific • Calcification within a nodule suggest benign lesion 05/15/09

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Patterns of benign calcification 1. 2. 3. 4.

Diffused Solid Central Laminated or popcorn - common in hamartoma • Stippled ,amorphous or eccentric calcfication: 05/15/09

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PET scanning • Increased glucose uptake with increased metabolic activity • F-flouro deoxyglucose (FDG) is used to measure glucose metabolism in cells • Most lung tumors have increase glucose uptake 05/15/09

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Biopsy versus Resection

• Only a biopsy can definitely diagnose a pulmo nodule • Bronchoscopy : 20-80% sensitivity for detecting neoplastic process within a nodule • Transthoracic FNAB - can accurately identify the status of peripheral 05/15/09 pulmonary lesions in up to

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Transthoracic FNAB

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• VATS is often used for excising and diagnosing in determinate pulmo nodules

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THAN K YOU! 

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