Surgery for Pleural Disease

Question 1

median sternotomy

Answer 1

ventral midline incision through the sternum

orthopedic approach and closure

Question 2

pros/cons of median sternotomy

Answer 2

pros: access to both sides of chest

cons: limited view of dorsal structures, longer healing time, requires orthopedic equipment, positional hemodynamic impacts

can NOT be used for lung lobectomy

Question 3

intercostal thoracotomy

Answer 3

opening the thorax in between the ribs (intercostal spaces)

Question 4

pros/cons of intercostal thoracotomy

Answer 4

pros: ST approach and closure; fewer hemodynamic positional impacts

cons: cannot access opposite side of chest

NO difference in post op pain from median sternotomy

Question 5

thoracoscopy

Answer 5

uses scopes inserted between the ribs and xyphoid

Question 6

pros/cons of thoracoscopy

Answer 6

pros: magnification, flexible accessibility

cons: loss of tactile feedback, decreased ability to manipulate the viscera, limited based on lesion size and amount of adhesions, obstructed view

Question 7

transdiaphragmatic

Answer 7

abdominal approach

ONLY used for diaphragmatic hernia repair

Question 8

considerations for post-op management

Answer 8

• analgesia
• antibiotics (C&S test)
• chest tube
• monitoring
• fluids
• discharge - at home monitoring

Question 9

causes of hemothorax

Answer 9

• trauma
• neoplasia
• lung lobe torsion
• coagulopathy

Question 10

which causes of hemothorax are surgical

Answer 10

• lung lobe torsion - always
• neoplasia - certain bleeding neoplasias
• trauma - only occasionally

coagulopathy - NEVER surgical

Question 11

what type of surgery is performed for lung lobe torsion

Answer 11

lung lobectomy

must be performed WITHOUT untwisting the lobe to prevent reperfusion injury

approach: intercostal thoracotomy

Question 12

steps of pyothorax management

Answer 12

1. thoracocentesis
2. thoracostomy
3. +/- surgical explore
4. antibiotics

if high risk of foreign body - requires surgical explore
- mostly dogs

Question 13

what are indications for surgical exploration for pyothorax

Answer 13

1. failure to respond to medical management
2. presence of foreign body on advanced imaging
3. mass lesions (walled off abscesses)
4. actinomyces identified in effusion

Question 14

what surgical procedure is performed for pyothorax

Answer 14

exploratory thoracotomy
- remove space occupying exudate/tissue
- remove foreign material and necrotic substrate
- establish drainage
- recreate pleural seal

approach: median sternotomy

Question 15

when does chylothorax require surgical management

Answer 15

idiopathic chylothorax
- if no underlying cause can be identified and treated

NOT usually an acute emergency - can do intermittent chest taps until surgery is scheduled

Question 16

what surgical procedure is performed for chylothorax

Answer 16

thoracic duct ligation

ALWAYS do CT prior to surgery to evaluate number and position of ducts leaking

goal is to reroute lymphatic drainage

approach: intercostal or thoracoscopic

Question 17

what is a common outcome of chronic chylothorax

Answer 17

pleural fibrosis

caused by chronic inflammation + restriction of lung expansion

most common in cats

Question 18

subcutaneous pleural ports

Answer 18

used for chronic management of non-infectious pleural fluid that is:
- non-malignant
- non-responsive to other treatments
- or palliation of malignant effusions

less painful than repeated thoracocentesis

Question 19

indication for surgical management of pneumothorax

Answer 19

recurrent or severe/rapid air accumulation after initial chest taps

Question 20

are dogs or cats more prone to pneumothorax requiring surgical management

Answer 20

dogs - usually due to foreign body inhalation and migration

cats - usually due to infectious or inflammatory disease; can resolve pneumothorax with treatment of the primary disease process

Question 21

heimlich valves

Answer 21

provide a mechanism of one way air flow out of the tube without allowing air in

Question 22

autologous blood patch pleurodesis

Answer 22

taking patient’s own blood and injecting it into the chest tube to form a clot against the side of the chest

used for recurrent pneumothorax that is not resolving with medical therapy and owner doesn’t want surgery

Question 23

what is an important consideration of diaphragmatic hernia surgical repair

Answer 23

must use IPPV because if diaphragm is not intact then abdominal incision will cause loss of negative pressure in the chest