Thoracic Flashcards
Transhiatal + Cervical esophagogastric anastomosis
Upper midline laparotomy and abdominal exploration; assess suitability of stomach as esophageal replacement.
Divide triangular ligament; retract liver to right with table-mounted upper hand retractor.
Mobilize stomach by dividing and ligating high short gastrics, left gastroepiploic and left gastric vessels while preserving the right gastric and right gastroepiploic vessels.
Perform a generous Kocher maneuver.
Perform extramucosal pyloromyotomy.
Insert 14 French rubber jejunostomy feeding tube.
Open peritoneum overlying the hiatus and mobilize the distal 10 cm of esophagus under direct vision, clamping and ligating lateral attachments with long right-angle clamps and dissecting with electrocautery.
Through oblique left cervical incision anterior to the sternocleidomastoid muscle, retract carotid sheath laterally, trachea and thyroid medially, mobilize and encircle cervical esophagus while avoiding direct placement of metal retractors or instruments against the tracheoesophageal groove.
Mobilize the thoracic esophagus from the posterior mediastinum with posterior, anterior, and finally lateral dissections.
Retract 3–4 inches of esophagus into the cervical wound, divide it with a surgical stapler, and deliver the mobilized stomach and attached esophagus out of the posterior mediastinum.
Through the diaphragmatic hiatus, inspect the posterior mediastinum for bleeding and assess integrity of the mediastinal pleura and the need for chest tubes (place now if needed); place gauze packs into the posterior mediastinum through the hiatus from below and the neck incision from above to encourage hemostasis.
Divide stomach 4–6 cm distal to the esophagogastric junction, from lesser toward greater curvature, progressively straightening the stomach by traction on the gastric tip with each application of the stapler; remove the specimen from the field and assess need for frozen section on gastric margin.
Oversew gastric staple suture line and transpose stomach through posterior mediastinum until 3–5 cm of gastric tip is visible in cervical wound.
Loosely narrow diaphragmatic hiatus and suture stomach to edge of diaphragm and left lobe of liver against the hiatus.
Bring jejunostomy tube through left upper quadrant of anterior abdominal wall, suture tube site to anterior abdominal wall and tube to skin, close abdomen
Perform side-to-side or end to end stapled CEGA, place NGT into thoracic stomach and 1/4 inch penrose drain adjacent to the anastomosis, and close cervical wound.
Obtain a portable chest radiograph in the operating room prior to extubation to identify and treat a previously unrecognized hemo- or pneumothorax.
Primary Repair of Perforated Esophagus
Thoracotomy (left neck for cervical perf, right lateral thoracotomy 5th intercostal space for thoracic eso perf, left 7th intercostal posterolateral for distal perf)
Harvest intercostal muscle flap—not required; decision must be made prior to thoracotomy
Debridement of the pleura and mediastinum
Mobilization of the esophagus
Debridement of the esophagus
Perform myotomy to expose entire mucosal injury
Two-layer closure with or without buttressing of repair
Test repair with NGT and then advance into stomach
Establish Enteral access (invasive if needed)
Place drain or chest tube
Potential Pitfalls
Inability to perform primary repair
Presence of a distal obstruction
Severe undilatable reflux strictures
Laparoscopic Heller Myotomy with a Dor Fundoplication
Place a nasogastric tube prior to induction to prevent aspiration.
Five laparoscopic port sites.
Dissect the anterior aspect of the distal esophagus bluntly from the hiatus.
Expose the gastroesophageal junction by removing the gastroesophageal fat pad taking care to preserve the anterior vagus nerve.
Divide the longitudinal and the circular muscle fibers for at least 6 cm onto the esophagus and 2 cm onto the stomach.
Separate the edges of the myotomy from the underlying mucosa for half of the esophageal circumference.
Insufflate the esophagus under water to test for a leak from the myotomy site.
Perform an anterior (Dor) or a posterior (Toupet) fundoplication.
Close the laparoscopic port sites.
Potential Pitfalls
Aspiration of retained food in the esophagus at the time of induction.
Mucosal perforation particularly if there is scarring from previous Botox injections.
Splenic injury due to retraction of the stomach.
Incomplete myotomy due to failure to extend the myotomy adequately onto the stomach
Solitary pulm nodule surgical resection
Place patient in lateral decubitus position
Intubation with double lumen endotracheal tube to allow for single lung ventilation.
Flexible bronchoscopy to confirm correct placement of double lumen endotracheal tube.
Placement of camera port through eighth intercostal space at the anterior axillary line and secondary ports through the fourth intercostal space at the midclavicular line and the sixth intercostal space near the scapula to triangulate the lesion.
5–10 mmHg of CO2 insufflation to facilitate lung collapse
Resection of nodule with endoscopic stapler.
Removal of specimen using endoscopic retrieval bag or through wound protector.
Send for frozen section if there is any concern about margins and if nature of the lesion will change your operative plan (i.e., conversion to lobectomy).
Assessment of staple line for pneumostasis and hemostasis.
Chest tube placement through camera port and closure of remain ports in layers.
Potential Pitfalls
Damage to intercostal neurovascular bundle or intravascular injection of local anesthesia.
Damage to lung/abdominal/mediastinal structures during port placement, especially if adhesions are present.
Improper endotracheal tube placement leading to hypoxemia or poor lung isolation.
Inability to locate nodule or remove with a clean margin.
Failure to remove sample using retrieval bag or wound protector may lead to port site recurrence.
Video-Assisted Thoracoscopic Bleb/Bullae Resection and Pleurodesis
Prepare the patient with general anesthesia and a double-lumen endotracheal tube.
Commence the operation with a thorough bronchoscopy of the tracheobronchial tree.
For the resection, position the patient in the lateral decubitus position with single lung ventilation.
Place the VATS camera port at the 5th intercostal space in the anterior axillary line.
Depending on the location of the pathology, additional ports may be placed in the 4th intercostal space or the 7th intercostal space.
Similar to a wedge resection, grasp the affected tissue and apply the endoscopic stapler across the base of the bullae/bleb. Use a reinforced, linear GIA staple load.
After resection, abrade the parietal pleura through the VATS ports. This can be accomplished by using the electrocautery scratch pad, the electrocautery, or the argon beam coagulator.
Chemical pleurodesis can be accomplished by evenly distributing 1–5 mg of aerosolized sterile talc or 500 mg of powder doxycycline in 50 mL sterile saline to the pleural space.
Upon completion of the procedure, re-inflate lung, check for leak, remove the ports and insert a single chest tube into the inferior VATS port.
