9. Thorax

Question 1

Describe the orientation of intrathoracic structures

Answer 1

Question 2

List the common surgical approaches to the thoracic cavity

Answer 2

1. Intercostal thoracotomy
2. Rib resection thoracotomy
3. Median sternotomy
4. Xiphoid resection thoracotomy
5. Transsternal thoracotomy
6. Transdiaphragmatic thoracotomy
7. Paracostal approach
8. Thoracoscopy

Question 3

Describe the key characteristics of a median sternotomy approach to the the thoracic cavity.

Answer 3

• approach of choice for bilateral exploration of the thoracic cavity
• access to the dorsal mediastinum may be limited
• postoperative morbidity reduced via ensuring sternebrae are sectioned longitudinally without being broken
• may be partial or complete
• leave the manubrium or xiphoid sternebrae intact to facilitate stable closure

Question 4

Describe the steps of a median sternotomy

Answer 4

• dorsal recumbency
• ventral midline incision
• incision of SC tissues
• separation of pectoral muscles down the midline
• cautery used for perforating branches of the internal thoracic artery and vein associated with each sternebrae
• separate pectoral muscles from attachments to ventral surface of the sternum
• determine appropriate line for sternotomy (avoid deviation from midline)
• section sternebrae longitudinally using reciprocating saw, osteotomy, special sternal saw, sternal splinter or bone cutters
• after 1-2 sternebrae have been sectioned may insert gelpi retractors into sternal cartilage to stabilise sternum and produce some tension to facilitate extended incision along the midline
• perforate connective tissue of the ventral thorax

Question 5

What is the typical method of closing a median sternotomy - sectioned sternebrae?

Answer 5

Figure of 8 sutures of stainless steel wire (> 10 kg) or 0 polypropylene (< 10 kg).

At least one suture per sternebra, usually incorporating the costal cartilage.

Figure of 8 wire mechanically superior to double-loop cerclage.

Alternating orientation of sutures (passage from left to right perpendicularly across sternotomy or in oblique manner) recommended to avoid distraction of the dorsal or ventral edge of sternotomy during suture tightening and to maximise bony contact to reduce pain and facilitate healing.

Question 6

Describe the process of a lateral thoracotomy

Answer 6

Question 7

Describe the process of an intercostal thoracotomy

Answer 7

Question 8

What are the goals of thoracic wall reconstruction?

Answer 8

1. Restore integrity of pleural space to allow negative pressure re-establishment
2. Ensure sufficient rigidity of thoracic wall to restore thoracic “bellows”
3. Ensure epithelial coverage

Question 9

What is the “thoracic bellows” mechanism?

Question 10

What muscle can be recruited to close thoracic wall defects?

Answer 10

1. Latissimus dorsi
2. External abdominal oblique
3. Transversus abdominis
4. Diaphragm

Question 11

What criteria deem a muscle suitable for use as a reconstructive flap?

Answer 11

1. adequate thickness
2. easy to mobilise without undue morbidity
3. capable of rotating locally to cover defect with minimal tension
4. has a function that can be taken over by other muscles