SA LRT Surgery

Question 1

1. What is thoracocentesis?
2. Considerations for thoracocentesis.

Answer 1

1. Procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes.
2. Ensure patient receiving O2 supplementation.
   Avoid lateral recumbency e.g. for diagnostic imaging.
   Consider T-FAST.
   Condition onset could have been gradual, allowing for adjustment, or rapid, meaning less able to cope.
   Want to know if unilateral or bilateral.
   - Bilateral could suggest compromised mediastinum.
   Liquid or air?
   Low for liquid, dorsally for air.

Question 2

Thoracocentesis equipment.

Answer 2

O2.
Sterile prep.
Sterile gloves.
LA.
Butterfly catheter.
3-way tap +/- extension tubing.
+/- sedation.
2ml and 20ml syringes.
Kidney dish (and/or jug).
Refractometer (e.g. high SG - pyo, low SG - CHF).
Plain blood tube (culture).
Heparin blood tube (biochem).
EDTA blood tube (cyto).
Microscope slides.
Microscope slide container.

Question 3

Thoracocentesis technique.

Answer 3

Prep skin and apply local.
Choose intercostal space (7th to 9th).
Choose dorsal / middle / ventral third.
Insert butterfly just cranial to rib at a 45 degree angle.
Redirect bevel so sharpest part does not impact the lung.
Aspirate air/fluid.
Take samples.

Question 4

When to place a chest drain.

Answer 4

When thoracocentesis is not enough.
As part of treatment e.g. pyothorax.

Question 5

1. Types of chest drain.
2. Sizes.
3. Chest drain selection depending on placement method.

Answer 5

1. Large-bore trocar chest drain.
   Narrow-bore chest drain - placed using Seldinger technique e.g. MILA.
2. Size depends on patient.
3. Closed chest e.g. draining pneumothorax.
   Open chest e.g. thoracic surgery just performed.

Question 6

1. Selecting site of chest drain placement.
2. Why do we pre-measure chest drain before insertion.
3. Considerations for connectors during chest draining.
4. Securing and protecting the chest drain.

Answer 6

1. Depends if unilateral or bilateral.
   If bilateral, depends if mediastinum intact.
   - if mediastinum not intact, only need to place on one side.
2. To ensure tube placed far enough into the chest so all fenestrations in the tube are well within the chest.
3. Can leak/come loose/become disconnected - ensure have various connectors to hand before you begin.
4. Sutures. Protect the chest drain from interference e.g. body bandage, buster collar.

Question 7

Consideration for larger chest drains.

Answer 7

Need subcutaneous tunnel for chest drain.
- start skin incision further caudal and then place the chest drain through incision in a cranial direction to get into a further cranial rib space – reduces complications and iatrogenic pneumothorax.
Rigidity of them can make them scary to place

Question 8

1. What is the advantage of a narrow-bore chest drain vs a large-bore.
2. Disadvantage of narrow-bore chest drain compared to large-bore

Answer 8

1. Do not require GA for placement.
   - Lower cost.
   - Can get drain placed ASAP.
2. Much more likely to block so often needs replacing.
   - expensive.

Question 9

How to secure a chest drain.

Answer 9

• Use in-built anchor flanges and simple interrupted sutures.
• W/ external drain-securing sutures e.g. roman sandal – need larger suture as prone to breaking.

Question 10

Care of a chest drain.

Answer 10

Wound management.
Tube management.
Body bandage.
Nursing care.
Drugs.
Record keeping.

Question 11

Draining a chest drain.

Answer 11

Intermittent drainage w/ syringe at intervals decided based on volumes of fluid/air that is coming out of patient.
Continuous drainage w/ Heimlich valve.
- only good for air – one-way valve.
- OR commercial units that continuously drain the chest of air/fluid.
ALL NEEDS TO BE DONE AS ASEPTICALLY AS POSSIBLE!!

Question 12

Complications of thoracocentesis and/or chest drains.

Answer 12

Failure to place successfully.
Failure to drain after placement.
Patient interference.
Iatrogenic issues.

Question 13

Iatrogenic issues that can arise from chest drains and/or thoracocentesis.

Answer 13

• Haemorrhages/haemothorax.
• Hitting heart/lungs/nerves/vessels.
• Introduction of infection.
• Pneumothorax.
• Minor wound issues.

Question 14

Chest drain removal timing.

Answer 14

Reasons to keep:
- ongoing Tx via the drain.
- clinically significant production of fluid/air.

Reasons to remove:
- complications.
- resolution of the issue.
- Ongoing need for drainage.

Question 15

What is the biggest advantage of a large-bore chest drain over a narrow-bore chest drain?

Answer 15

Better for drainage of pyothorax.

Question 16

Considerations for intercostal / lateral thoracotomy.

Answer 16

Whether perform on the left or right e.g. PDA access from the left.
Which intercostal space e.g. PDA or lobectomy access via 4th or 5th intercostal space.

Question 17

Lateral (intercostal) thoracotomy approach.

Answer 17

Patient in lateral recumbency.
Select appropriate intercostal space.
Lateral skin incision from top of rib to close to sternum.
Dissect between muscles to allow entry between ribs.
Rib in front and behind incision closed w/ suture.
Remaining soft tissue appositional closure as normal.

Question 18

Sternotomy approach.

Answer 18

Dorsal recumbency.
Ventral midline skin incision from thoracic inlet to xiphoid.
Osteotomy of sternum (not whole length, only middle 50%, to avoid instability).
Allows exploration of left and right sides.
- reserved for bilateral conditions or cases of uncertainty.
Sternal closure w/ metal wires or very big suture.
Soft tissue appositional closure as normal.

Question 19

Surgical procedures during thoracotomy.

Answer 19

Exploration.
Debridement.
+/- repair.
+/- FB removal.
+/- lung lobectomy.
Flushing.

Question 20

Complications post-thoracotomy.

Answer 20

Pleural effusion.
Pneumothorax.
Pulmonary atelectasis.
Re-expansion pulmonary oedema.
Lung lobe torsion.
Post-op pain.
Phrenic nerve injury.

Question 21

1. Common chest trauma aetiology.
2. Chest trauma clinical signs.
3. Dx of chest trauma.

Answer 21

1. Accident.
   Attack.
2. Shock!
   Dyspnoea.
3. CE.
   Imaging.

Question 22

1. Chest trauma Tx.
2. Complications of chest trauma.
3. Px of chest trauma.

Answer 22

1. Stabilisation.
   Sx.
2. Infection/inflammation.
   Delayed healing.
   Ongoing effusion/pneumothorax.
3. Dept. on severity.
   Always give guarded Px.
   Dept. on cost.
   PTS may be sensible in some situations.

Question 23

1. Diaphragmatic hernia aetiology.
2. Diaphragmatic hernia clinical signs.
3. Dx of diaphragmatic hernia.

Answer 23

1. Blunt force trauma.
2. None / vague ill-health / dyspnoea / shock.
   Severity according to:
   - speed of onset.
   - herniation.
   - concurrent injuries.
3. Hx / exam / imaging.

Question 24

Types of diaphragmatic tear.

Answer 24

Circumferential tear.
Radial tear.
Combined.

Question 25

Structures that tend to herniate through the diaphragmatic hernia.

Answer 25

Liver.
Stomach.
Omentum.
Spleen.
Intestines.

Question 26

1. Tx of diaphragmatic rupture.
2. Complications of diaphragmatic tear Tx.
3. Px of diaphragmatic rupture.

Answer 26

1. Stabilisation.
   Laparotomy: explore, replace, repair.
2. Adhesions.
   Re-expansion pulmonary oedema.
   Parenchymal organ re-perfusion injuries.
   SARS/MODS/DIC – inflammatory.
3. Good once through Sx.
   Dept. on concurrent injuries.

Question 27

1. Pyothorax aetiology.
2. Pyothorax clinical signs.
3. Dx of pyothorax.

Answer 27

1. Cats - bacterial infection - cat bite or extension of pulmonary infection e.g. burst abscess (typically Pasteurella).
   Dogs - bacterial infection associated w/ FB (typically E.coli).
2. Lethargy / inappetence / PUO.
   Dyspnoea.
3. Imaging / thoracocentesis / lab tests.

Question 28

1. Tx of pyothorax.
2. Complications.
3. Px of thoracocentesis.

Answer 28

1. Medical - conservative e.g. draining, ABX.
   Surgical (dogs - FB).
2. Non-response to medical therapy / relapse.
   Inflammation.
   Thromboembolism.
   Surgical complications.
3. Dept. on severity at presentation.
   Fair to good.

Question 29

1. Pulmonary abscessation aetiology.
2. Clinical signs of pulmonary abscessation.
3. Pulmonary abscess Dx.

Answer 29

1. FB.
   Chronic bronchopneumonia.
   Penetrating wounds.
   Vascular obstruction.
   Neoplasia.
2. Non-specific.
   Respiratory.
3. Imaging / thoracocentesis / lab tests.

Question 30

1. Tx of pulmonary abscessation.
2. Complications.
3. Px.

Answer 30

1. Medical.
   Surgical - lobectomy.
2. Non-response to medical therapy / relapse.
   Inflammation.
   Thromboembolism.
   Surgical complications.
3. Fair w/ successful Sx.

Question 31

1. Pericardial effusion aetiology.
2. Clinical signs.
3. Dx of pericardial effusion.

Answer 31

1. Idiopathic.
   Neoplastic.
2. Cardiac tamponade.
   Dept. on onset speed.
3. Imaging (US) / pericardiocentesis (from RHS through cardiac notch).

Question 32

1. Tx pericardial effusion.
2. Complications.
3. Px.

Answer 32

1. Pericardiocentesis.
   Pericardiectomy.
2. Recurrence.
   Constrictive pericarditis.
   Sx complications.
3. Dept. on underlying reason.

Question 33

1. Pulmonary neoplasia aetiology.
2. Pulmonary neoplasia clinical signs.
3. Dx of pulmonary neoplasia.

Answer 33

1. Benign / malignant, primary / mets.
2. Non-productive cough / dyspnoea.
   Non-specific weight loss.
   Distal limb pain (paraneoplastic).
   None.
3. Imaging / staging / lab work.

Question 34

1. Tx of pulmonary neoplasia.
2. Complications.
3. Px.

Answer 34

1. Palliative.
   Sx.
2. Sx complications.
3. Stage.
   Histo.
   Sx margins.

Question 35

1. Mediastinal mass aetiology.
2. Clinical signs.
3. Dx.

Answer 35

1. Neoplasia.
   Infectious / inflammatory.
2. Space-occupying lesion.
   +/- pleural effusion.
   +/- paraneoplastic syndromes.
   None.
3. Imaging, lab work.

Question 36

1. Mediastinal mass Tx.
2. Complications.
3. Px.

Answer 36

1. Medical e.g. lymphomas.
   Sx e.g. thymomas.
2. Associated w/ treatment.
   Persistence / recurrence.
3. Diagnosis.
   Clean surgical margins.

Question 37

1. Pulmonary blebs and bullae (air bubbles in lungs) aetiology.
2. Clinical signs.
3. Diagnosis.

Answer 37

1. Unknown cause.
2. None.
   Non-specific.
   - lethargy, anorexia, exercise intolerance.
   Respiratory - tachypnoea, orthopnoea, coughing, tension pneumothorax.
3. Imaging / thoracocentesis.

Question 38

1. Tx pulmonary blebs and bullae.
2. Complications.
3. Px.

Answer 38

1. Thoracocentesis / thoracostomy.
   Sx.
2. Surgical.
   Staple failure.
   Recurrence.
3. Excellent post-op.

Question 39

1. Thoracic oesophageal FBs aetiology.
2. Clinical signs.
3. Dx.
4. Sites of FB.

Answer 39

1. Labradoritis / JackRusselloma.
   Fish hooks in cats.
2. Retching/gagging.
   Hypersalivation.
3. Imaging, endoscopy.
4. Level of throat, thoracic inlet, heart base, diaphragm.

Question 40

1. Thoracic oesophageal FB Tx.
2. Complications.
3. Px.

Answer 40

1. Conservative - endoscopy, fluoroscopy to retrieve via mouth or push down into stomach to then do gastrotomy.
   Sx via oesophagus.
2. Oesophageal damage.
   Surgical complications.
   Suture dehiscence.
   Feeding tube.
3. Fair.

Question 41

1. PPDH aetiology.
2. Clinical signs.
3. Dx.

Answer 41

1. Rare, congenital (hereditary?)
2. None / intermittent vague.
   GI.
   Respiratory.
   Cardiac.
3. Imaging, lab work.

Question 42

1. PPDH tx.
2. Complications.
3. Px.

Answer 42

1. Benign neglect.
   Sx.
2. Adhesions.
   Organ damage.
   Sx complications.
3. Good.