L21: Respiratory and Thoracic Surgery (Ellison)

Question 1

upper airway obstruction in brachycephalic breeds (brachiocephalic syndrome)

Answer 1

-presenting complaint = respiratory distress-stertorous breathing, gagging/regurg, cyanosis or collapse (22%)

Question 2

6 components of brachiocephalic syndrome***

Answer 2

stenotic nares
elongated soft palate
everted laryngeal saccules
laryngeal collapse/stenosis (arytenoid cartilages come together)
hypoplastic trachea (cartilage ring overlaps, narrowing diameter)
enlarged tonsils

Question 3

pre-surgical considerations for brachiocephalic syndrome

Answer 3

• tracheostomy site prep

- minimize swelling: perioperative steroids (ie. short-acting hydrocortisone)

Question 4

Caudal Wedge Technique

Answer 4

• lifts and lateralizes skin folds around nose to correct stenotic nares
• if done in puppyhood, can prevent buildup of negative pressure in nasopharynx and overlengthening of soft palate later in life

Question 5

Elongated Palate Resection: Cut and Sew technique

Answer 5

• stay sutures on either side and then shorten palate and use monocryl or biosyn (absorbable) to suture oral and nasal tissues
• give steroids to prevent swelling

Question 6

Elongated Palate Resection: CO2 laser

Answer 6

• no sutures needed
• creates good hemostasis
• traction added then tip of elongated soft palate removed

Question 7

correction of everted laryngeal saccules

Answer 7

tenotomy scissors used to excise laryngeal saccules and open up more space to breathe

Question 8

chars. of laryngeal paralysis

Answer 8

• hereditary or idiopathic acquired form (latter more common)
• older large breeds; Labs most common. Huskies have genetic component
• bilateral paralysis usually needs correction. Can get along with unilateral paralysis
• dx: visual exam w/ propofol and laryngoscope

Question 9

Geriatric Onset Laryngeal Paralysis and Paresis

Answer 9

-progressive, SYSTEMIC condition that includes laryngeal paralysis, neuro signs, megaesophagus, and muscle wasting

Question 10

Arytenoid Lateralization

Answer 10

• tie-back procedure
• corrects laryngeal paralysis
• atrophied cricoid arytenalis dorsalis m. is elevated using nonabsorbable prolene suture
• aspiration pneumonia most common complication (10%), less commonly: suture pullout, fracture of cartilage

Question 11

Collapsing Trachea

Answer 11

• mini/toy breeds
• avg. age 7yr
• cartilage hypocellular and deficient in glycoprotein and GAG content
• CS: “goosehonk” cough, severe resp. distress, cyanosis
• tx: stent, medical management (cough suppressant, tranquilizers), extraluminal ring

Question 12

Temporary Tracheostomy

Answer 12

• make permanent opening in neck
• incision b/w 3rd and 4th cartilage rings
• put loose ligature around cranial and caudal tracheal ring
• tolerated well for first 24hrs, then get inflamm. and mucus production
• larger dogs tolerate better than small dogs/cats

Question 13

post-op management of tracheostomy

Answer 13

• observation
• oxygen
• suction q2-4hrs
• can put nebulizer up tracheostomy

Question 14

Dx of Tracheal collapse

Answer 14

-CS
-inspiratory and expiratory rads
-fluoroscopy
-tracheoscopy under general anesthesia to evaluate laryngeal fx!!
+/- transtracheal wash and culture

Question 15

lifespan of stent

Answer 15

2-3yr (for collapsing trachea); esp. doesn’t work well if there is collapse of mainstem bronchus

Question 16

common surgical disease of thoracic cavity

Answer 16

• neoplasia
• lung lobe torsion
• lung lobe abscess
• chylothorax
• vascular ring anomaly
• PDA
• pericardial effusion
• pneumothorax
• tracheal collapse (and cervical)

Question 17

suture material for thoracic sx

Answer 17

prolene
PDS or Maxon
Silk - good for ligating vessels; good knot security

Question 18

instruments used in thoracic sx

Answer 18

finochietto
DeBakey tissue forceps (used a lot in GI sx)
Right Angled Mixters (good for clamping vessels)
Hemoclips (bleeding vessels, PDA, lung lobectomy cats, thoracic duct ligation)

Question 19

Approaches to Thoracic cavity

Answer 19

• lateral/intercostal thoracotomy (intercostal most common)
• median sternotomy
• L 4th intercostal space used a lot
• elevate latissimus dorsi, incise through seratus ventralis

Question 20

closure of thoracic wall muscles

Answer 20

have to wrap encircling sutures around the ribs or it won’t hold
-can use PDS (not rapidly absorbable)

Question 21

what approach for pericardectomy? Large masses such as thymoma?

Answer 21

median sternotomy`

Question 22

principles of individual ligation

Answer 22

• tie off pulmonary a. first, then v. (v. is red, a. is blue!)
• use horizontal mattress, oversew
• Prolene, PDS

Question 23

principles of lung lobectomy

Answer 23

• ligate vessels, sew bronchus

- can use thoracoabdominal (TA) stapling device

Question 24

what approach allows exploration of entire thorax?

Answer 24

median sternotomy

Question 25

approach for PDA (DNK?)

Answer 25

Left 4th

Question 26

appreach for PRAA (DNK?)

Answer 26

left 4th

Question 27

approach for cranial lung lobe (DNK?)

Answer 27

R or L 4th

Question 28

approach for cranial mediastinum (DNK?)

Answer 28

R or L 2nd or 3rd

Question 29

approach for caudal mediastinum (DNK?)

Answer 29

R or L 8th or 9th

Question 30

approach for middle and caudal lung lobes (DNK?)

Answer 30

R or L 5th or 6th?

Question 31

approach for thoracic duct (DNK?)

Answer 31

dog: R 8-10th
cat: L 8-10th