THORACIC SURGERY
Thoracic Surgery
Lec : 5
Thoracic Surgical Approaches
Most thoracic operations done with the patient anasthized
and Double Lumen endotracheal tube is used which enable
separate ventilation of each lung by blocking the ventilation
from the side of surgery so that surgeon can work on
deflated lung . Another benefit is that secretions and blood
from operated lung will not return to the contralateral lung
on which we depend during surgery for ventilation.
1.Viedo Asisted Thoracic Surgery ( VATS) :- done by
using multiple thoracoscopic ports introduced into thoracic
cavity through multiple small access incisions.
Advantages:- 1.less pain 2.Early recovery 3.Short
hospital stay 4.No muscle cutting incisions is required
VATS can be used to do Lobectomy, Segmental lung
resection,Sympathectomy,lung and Pleural biopsy. patient
who get benefit from VAST are:-
1. Patients with impaired Cardiopulmonary function.
2. Advanced age.
3. Vascular problem
4. Extra thoracic malignancy
5. Recent or impending major operation
6. Impaired wound healing. e g D.M
7. Immunosuppression e.g HIV.
THORACIC SURGERY
2. Posterolateral Thoracotomy:- Is the most frequently used
incision for open procedures , the patient is placed in lateral
position, the incision begins in the anterior axillary line just
below the nipple and extends below the edge of scapula and
then up between the vertebral boarder of scapula and
spinous process of vertebrae , the Latimus Dorsi and
serratus anterior muscles are divided and the chest entered
completance of
After
rcostal space.
inte
th
through 5
required procedure Two chest tubes are inserted before
which is
one is called Apical tube
st
closuer of chest ,the 1
intercostal space at anterior axilllary line
th
put through 7
one put
nd
and the 2
and advanced to the apex of Hemithorax
interspace at posterior axillary line to the
th
through 8
posterinferior part of Hemithorax to drain oozing blood and
/or fluid and called the Basal tube.
the chest is entered through
-
3. Anterolateral Thoracotomy :
is in supine position. It allows
Pt.
s the
a
interspace
th
the 4
quick entery into thoracic cavity and used in emergency
conditions with haemodynamic instability especially when
cardiac injury suspected.
4. Clam Shell Thoracotomy :- it is combination of bilateral
anterior thoracotomy plus Transverse sternotomy used for
Double Lung Transplantation.
5. Trap Door Incision :- it is combination of anterior
thoracotomy and partial Median sternotomy to gain access
THORACIC SURGERY
to Mediastinal structures in the superior and anterior
Mediastinum.
Lung Abcess :- Is localized area of pulmonary paranchymal
necrosis with tissue destruction and cavity formation.
Etiology :- 1. Primary Lung Abcess :-
a. Necrotizing Pneumnia caused by Staph. Aureus ,
Klebsiella , Pseudomonas and Mycobacteria infections.
b. Aspiration Pneumnia occur when consciousness is
impaired with suppress of cough reflex as perioprative
period ,strock ,abuse of drug and Alcohol.
c. Esophageal disorder like Achalasia , GERD .
d.Immunosuppression in which infection occurs by
apportunistic microorganisim as in carcinomas , DM ,
Steroid therapy , Mulnutrition , Transplantations .
2. Secondary Lung Abcess :-
a. Bronchial obstruction by Tumor , Foreign body
b.Systemic sepsis as in septic pulmonary embolism ,
seeding pulmonary infarct.
c.Complications of pulmonary trauma e.g infected
hematoma , penetrating injuries.
d. direct extension from extraparanchymal inf e.g Empyma ,
Subphrenic abcess.
Microbiology :- In community acquired pneumonia is
mostly due to Gram Positive organisim while in hospital
acquired cases 60- 70% is from Gram negative orgnisim , in
THORACIC SURGERY
immunosuppressed cases infection occur from apportunitic
organisim , while in aspiration pneumonia there is
polymicrobial cause
Clicical Featuers :- Productive cough , Fever > 38.9c ,
Chills , Increase WBC count , decrease Weight , Pleuretic
chest pain , dysphnia ,Anemia .
Complications:- 1.Massive haemoptysis. 2. Endobronchial
spread to other lung. 3. Ruptuer to pleura. 4.Devlopment of
payopneumothorax . 5.Septic shock and respiratory failure.
6.Mortality from 5-10% in normal patient reach to 30% in
immunocompramised
Chest Film :-
1. Intact Abcess :- Mass with thin wall cavity.
2. Ruptuerd Abcess with communication with
tracheobronchial tree :- Air – Fliud level .
CT Scan :- help to settle Dx and assess associated mass or
endobronchial obstruction.
DDx :- 1. Loculated or interlober Empyma . 2. TB ,
Fungal infection 2.Infected lung cyst or bullae.
Sputum for C and S is of limited value due to contamination
with upper respiratory tract flora
Bronchoscopy :- help to exclude endobronchial obstruction
by tumor or Foreign body ,also to take bronchial wash for C
and S.
THORACIC SURGERY
Percutaneous Trans thoracic FNA for C/ S under U/S or CT
guide
Mx :-start with Broadspectrum antibiotics modified later
according to results of C / S for 3 -12 Wks till cavity resolve
or serial CXR show improvement.
Surgical drain is uncommon it is indicated in :-
1. Failuer of medical treatment 2. Abcess under tension
3. increase in size despite treatment 4.Other lung
contamination 5.Abcess > 4-6 Cm in diameter
6.inability to exclude cavitary carcinoma
Surgical drain either by :-
1.Chest tube or percutaneous drain cather for abcess in
contact with chest wall.
2.Thoracotomy and surgical cavernostomy to remove whole
abcess cavity usually by lobectomy especially with
bleeding or payopneumothorax
Important intraoperative consideration is to protect the other
lung with Double Lumen ETT