[AC] Thoracic Surgery

Question 1

Insertion of an intercostal catheter (chest drain) enables

Answer 1

Drainage of air or fluid from the pleural space, allowing negative intra-thoracic pressures to be re-established leading to lung re-expansion

Question 2

Bubbling in the underwater seal chamber of a chest drain can indicate

Answer 2

An air leak from the lung and should be evaluated critically

Question 3

Lung cancer makes up over 90% of thoracic surgical procedures. What is the most aggressive kind of lung cancer?

Answer 3

Small cell (2 to 4 months prognosis)

Question 4

Some information on lung cancer in New Zealand?

Answer 4

• NZ Maori; lung cancer is 2.5 to 3 x higher than that in the NZ european population
• Five year prognosis in NZ is POOR compared with the rest of the developed countries
• 8% of lung cancers in NZ occur amongst never smokers

Question 5

Causes of lung cancer?

Answer 5

• Smoking/passive smoking
• Cannabis consumption
• Occupational hazards/materials (i.e. toxic chemicals)
• Atmospheric pollutants/gases
• Genetic predisposition
• Metastatic disease

Question 6

Talk about NMT staging of lung cancer and is there any other way lung cancer is staged?

Answer 6

N - represents the lymph NODES involved by metastasis from the lung tumour
M - describes whether spread to other organs has occurred (METASTASIS)
T - represents the size of the TUMOUR and whether it has invaded into surrounding structures such as the ribs or heart

There is also the stage 1 to 5 for lung cancer; in which stage one is a local tumour with no metastasis with high 5 year survival rate to stage 5 which is distal metastasis, inoperable

Question 7

Thoracotomy is an incision into the pleural space of the chest to gain access to the thoracic organs. The muscles transected may include:

Answer 7

Latissimus dorsi
Serratus anterior
Trapezius
Intercostals
Pectoralis major
Pectoralis minor

Question 8

Post op care following thoracic surgery in brief:

Answer 8

Respiratory care
Shoulder and thoracic cage function
Early mobilisation

Question 9

Inspiratory muscle training is an actual program in which you

Answer 9

load your inspiratory muscles via sucking on a device, increases your work of breathing. Patient builds up to it, i.e. up to 30 minutes twice a day.

Question 10

If a patients Hb is low, we might need to give them blood, why is this relevant for us in terms of ambulation?

Answer 10

The may not have as much oxygen carrying capacity (check Sao2). Exercise uses oxygen, therefore we would like the patient to have a blood transfusion prior to surgery.

Question 11

A type of surgery that enables surgeons to view the inside of a chest cavity with only small incisions is

Answer 11

Video-assisted thoracic surgery (VATS)

Question 12

What is the incision and indications for a Pneumonectomy?

Answer 12

Incision: Thoracotomy
Indications: Carcinoma (cancers that begin in the epithelial tissues)

Question 13

What is the pre-op management for a pneumonectomy?

Answer 13

Patient must be able to tolerate one lung removal, assessed via:
Exercise (SAO2 monitoring)
Pulmonary Function Tests (i.e. FEV/FVC ratio >50%; FEV >2L)

Question 14

What is the post op management for a pneumonectomy?

Answer 14

Patients MUST NOT lie on good side. This is to ensure bronchial stump remains intact. Chest drain clamped and released one minute every hour to control mediastinal shift. No suction. Chest drain removed after about 24 hours and mediastinal space allowed to slowly fibrose

Question 15

Incision & Indications for a Lobectomy?

Answer 15

Incision: Thoracotomy; some do VATS
Indications: Usually Carcinoma, bronchiectasis, lung abscess

Question 16

Procedure Lobectomy?

Answer 16

Resection of one or more lobes. On the right lung the middle and lower lobes are often removed together due to their common lymph drainage. Insertion of apical and basal chest drains usual

Question 17

Post-op care Lobectomy?

Answer 17

02, chest drains on low grade suction. Basal chest drain removed 1-2 days post-op, apical chest drain removed when air leak ceases, approx 4-5 days postop. May lie on either side, but should not lie on thoracotomy side unless necessary

Question 18

Segmental resection incision?

Answer 18

Thoractomy or VATS

Post-op care same as Lobectomy

Question 19

Incision Pleurectomy?

Answer 19

Incision: Thoractomy or VATS

Question 20

Procedure Pleurectomy?

Answer 20

Parietal pleura stripped off the chest wall. As the lung expands adhesions form between the visceral pleura and the chest wall preventing recurrence of a pneumothorax. The patient has one or two chest drains which are removed when air leaks stop.

Question 21

Many thoracic surgical procedures require intercostal drainage. What are the two systems of chest drains?

Answer 21

Open chest drainage system

Closed chest drainage system

Question 22

Apical chest drain vs Basal chest drain in terms of drainage needed?

Answer 22

Apical = Air
Basal = blood (fluids)

Question 23

How many chest drains for a pneumonectomy?

Answer 23

1 chest drain