Thoracic Surgery 1 Flashcards
Name the 6 surgical approaches for the thoracic cavity
Surgical approaches of thorax
- Lateral thoracotomy
- Median sternotomy
- Combined Abdominal & Median Sternotomy
- Transdiaphragmatic
- Rib resection / Pivot Lateral thoracotomy
- Minimally invasive (Thoracoscopy & video assisted)
MOST common surgical approach for the thoracic cavity:
Lateral Thoracotomy
Surgical approach that can access BOTH sides of the diaphragm
Combined abdominal & Median Sternotomy
Surgical approach that allows access to thoracic cavity during celiotomy (incision into abdominal cavity for abdominal procedure)
Transdiaphragmatic
Surgical approach that can remove or pivot rib to increase exposure or remove masses too large to exteriorize through standard lateral thoracotomy.
Rib resection / Pivot lateral thoracotomy
Which is least painful:
Lateral thoracotomy OR Medial sternotomy
Lateral thoracotomy
Suture used to close a lateral thoracotomy:
Circumcostal sutures are used to close a lateral thoracotomy
Surgical approach where side & IC space can depend on surgical procedure ( sx of choice for directed approach to a specific structure)
Lateral/ intercostal thoracotomy
- incise layer by layer; new method is to dissect the latissimus dorsi muscle margin and reflect muscle (Best way).
- use origins & insertions of muscles as anatomic landmarks
Surgical approach used for:
- thoracic duct ligation
- portoazygous EHPS ligation
- -epicardial cardiac pacemaker lead implantation
- caudal esophagus sx
- intra-operative CPR/cardiac massage
Transdiaphragmatic
Surgical approach used for:
- bilateral thoracic exploration
- cranial mediastinal masses
- cranial thoracic trachea
Median sternotomy
Suture used to close median sternotomy:
Figure 8 pattern with:
- polypropylene suture (small pt.)
- -orthopedic wire
3 tools used in a median sternotomy:
- Lebsche sternal knife
- Oscillating saw (safety factor- cuts only hard stuff)
- Osteotome (small pt., tedious)
— leave manubrium OR xiphoid intact = stabilization. less pain on post op.
Name the 2 minimally invasive approaches:
- Thoracoscopy
- - Video assisted
Which minimally invasive approach describes the characteristics below:
- intercostal and transdiaphragmatic subxiphoid portals
- side and IC space will depend on surgical procedure
- requires specialized training and equipment
Thoracoscopy
Which minimally invasive approach describes the characteristics below:
- small incision approach combining use of thoracoscopy telescope for light & visualization but allowing use of either standard surgical instruments or endoscopic instruments,
- a “hybrid” technique that is easily mastered.
- examples: Pericardectomy & lung biopsy/ lobectomy
Video assisted
What type of procedure does Dr. Pope love to use a video assisted approach in:
Pericardectomy
3 important considerations for thoracic sx:
- Positive Pressure Ventilation is required
- Chest tubes commonly required post op
- 24 hr post op monitoring (pain & resp monitoring)
Benefits of having a chest tube in post op of thoracic sx:
- Allows for monitoring & removal of air and fluid.
- Provides access to pleura for infusion of local anesthetic
–use rads for chest tube placement
Term used to refer to removal of all lobes of one lung:
Pneumonectomy
What is indicated for cases where disease is diffuse through multiple lung lobes (Neoplasia / abscess / trauma/ infiltrative inflammatory dz).
Pneuomonectomy
T/F: Pneumonectomy is performed through a LATERAL intercostal approach
True
In a total lobectomy, you need access to the hilus for complete lobectomy. Which surgical approach is utilized:
Lateral thoracotomy OR thoracoscopy
– rads or CT - help guide surgical approach
Total or partial lobectomy depends on disease process & location of lesion in the lobe. Name the ICS associated with lung lobe.
Left Cranial =
Right Cranial =
Right Middle=
Name the ICS associated with lung lobe.
Left Cranial = L 5th
Right Cranial = R 5th
Right Middle= R 5th
Left Caudal = L 7th
Right Caudal = R 7th
2 suture techniques for partial lobectomy
- Suture proximal to clamps
2. Guillotine suture
Type of suture technique for partial lobectomy used for biopsies & very small peripheral masses:
Guillotine suture
T/F: For most lung procedures, ligate the artery FIRST. For lung tumors, ligate vein FIRST.
True
– sometimes in lung tumors the vein is ligated first to prevent emboli knock off
For a complete lobectomy, a triple ligation of vessels is needed (cut between middle & distal ligatures). What sutures a pre-places to collapse the bronchus?
Pre-placed Horizontal mattress
Tool used for stapling for a partial/complete lobectomy:
Thoracoabdominal Stapler (TA)
- isolate hilus of lobe or affected portion of lung lobe.
- staple entire pedicle (vessels & bronchus)
- ensure adequate margins for partial lobectomy
- excise lobe distal to staples
Pros & Cons for stapling technique for partial/complete lobectomy:
Pros & Cons for stapling technique
- –Pro: decreased anesthesia & sx time
- –Con: standard devices too large for very small patients. (endoscopic staplers may be an option).
During pulmonary sx, affected tissue should be isolated with ____________ to decrease risk of contamination
– moistened lapratomy sponges to decrease risk of contamination
Before closure of pulmonary sz, what 3 things do you check for:
- bleeding/hemorrhage
- Air leakage
- Chest tube placed via separate intercostal incision
How do you check for air leakage before closing in pulmonary sx:
- – fill thoracic cavity with saline & look for bubbles during PPV
- Ventilate up to 25-30 cm H20
- very small leaks will likely seal within 24-48 hrs
3 things that occur with spontaneous pneumothorax:
- Cysts
- Bullae
- Blebs
Term for a localized collection of air between internal and external layer of visceral pleura:
Bleb
Term for non-epithelialized cavities produced by disruption of intralveolar septae.
Bulla
Types:
- thin walled bulla
- – subpleural bulla
- –large bulla
- – large bulla (occurs within pulmonary parenchyma)
Term for closed sacs lined by epithelium filled with fluid or air (often secondary to pulmonary contusions)
Cyst
Cyst / Bulla/ Bleb: Which one can be secondary to blunt trauma or traumatic rupture of alveoli secondary to underlying lung disease
Cyst
Complications of cyst:
- – Abscessation
- – rupture
- – spontaneous pneumothorax – atelectasis
Treatment for cyst/bulla/bleb:
Conservative tx with thoracostomy tubes for 48-72 hrs ===> HIGH recurrence rate
if medical management fails, surgical intervention is recommended (CT before)
- – partial or complete lung lobectomy
- –pleurodesis: trying to get the lung to fuse to the body wall
Pleurodesis can be used as tx for cysts/ bulla/ and blebs. What is Pleurodesis?
Pleurodesis: trying to get the lung to fuse to the body wall so that there is no more area where the air is able to accumulate.
Pleurodesis does not work well in cats & dogs (not good adhesion)
7 surgical diseases of the pulmonary parenchyma:
- spontaneous pneumothorax
- Bronchoesophageal fistulas
- lung lobe consolidation and abscessation
- bronchiectasis
- bronchiectasis
- lung lobe lacerations
- Lung lobe Torsions
- Neoplasia
Rare condition resulting in rotation of lung lobe on its hilus
Lung lobe torsion
Results in:
- venous & lymphatic congestion
- consolidation
- pleural effusion
Lung lobe torsion causes:
- Pleural effusion
2. Partial collapse of lung lobe
Common dogs to get lung lobe torsions:
Large, deep chested dogs & pugs
also reported in cats
Name the lobe of the lung effected in each dog:
Large dogs: _______
Pugs: _______
Name the lobe of the lung effected in each dog:
Large dogs: Right middle or left cranial lung lobe
Pugs: left cranial lung lobe
Clinical signs associated with lung lobe torsion:
Acute onset:
- —-Dyspnea
- —-Tachycardia
- —-cough
- —-exercise intolerance
- —-hemoptysis
PE findings:
- —-Pyrexia
- —pale mm
- — decreased lung sounds ventrally
Diagnostics for lung lobe torsion:
- Thoracocentesis (serosanguineous or chylous effusion) – rarely see evidence of sepsis on cytology
- Imaging (rads or CT)
FIRST form of treatment for lung lobe torsion:
PATIENT STABALIZATION
- – Thoracocentesis
- – Oxygen supplementation
- – IV fluids
T/F: After the patient is stabilized, a lung lobectomy can be achieved, by intercostal thoracotomy, if the affected lung lobe is known.
True
TA stapler is typically used
Thoracic drainage typically required for 3-5 days.
Analgesia & antibiotics
Most important thing to remember in treating lung lobe torsion:
DO NOT UNTORSE THE LUNG
– avoid release of cytokines and endotoxins “ REPERFUSION INJURY”
Prognosis for lung lobe torsion in:
Pugs: ______
Other breeds: ______
Prognosis for lung lobe torsion in:
Pugs: Good prognosis
Other breeds: fair to guarded —- 50-60% survival rate. Second torsions can occur (Postop monitoring)
2 most common lung tumors are:
2 most common lung tumors are:
- —-Adenocarcinoma
- — SCC
Which has the better prognosis: Adenocarcinoma or SCC?
Adenocarcinoma
Adenocarcinomas = near lung periphery SCC = located at the hilus = BAD prognosis
Single mass located on a lung lobe; what are the 3 top differentials?
Fungal
Infection
Neoplasia
Primary pulmonary neoplasia is common in what age group:
Middle aged - senior dogs & cats
2 most common types of Primary Pulmonary Neoplasia’s:
Bronchiolar carcinoma
Alveolar carcinoma
Diagnostics for primary pulmonary Neoplasia:
- Preliminary diagnosis on 3 view thoracic rads
- CT provides additional info regarding LN involvement and invasiveness of masses
- Ultrasound guided FNA can be helpful for providing cytologic diagnosis
In Primary pulmonary neoplasia, the survival is associated with:
Survival time associated with primary pulmonary neoplasia is lack of LN involvement, location, and size or mass, and lack of clinical signs.
– intraoperative staging/ LN biopsy
T/F: Lung lobectomy is the treatment for all primary pulmonary neoplasia as treatment
*************
FALSE !!
– lung lobectomy is only indicated for peripheral tumors NOT involving the hilus
– Adenocarcinoma can be treated with lung lobectomy
__ SCC can NOT be treated with lung lobectomy because it involves the hilus
T/F: Most thoracic wall trauma does NOT require surgical intervention
TRUE
Most common cause of thoracic wall trauma is:
Hit by car
injuries can involve:
- – thoracic cage
- – resp tract
- – cardiovascular system
- –pleural space
1st thing to do when dealing with an animal with a penetrating chest wound:
STABALIZE THE PATIENT
- cover wound with sterile dressings until patient is stable for surgical repair
- – mild wounds may not require surgical explore
- – thoracocentesis / thoracostomy tube as needed to treat pneumothorax
Penetrating chest wound common causes:
Penetrating wound causes:
- – bite wound
- – stab wound
- – gunshot wound
- – impalement
Most important thing to remember about treating penetrating chest wounds:
DO NOT REMOVE OBJECTS PENETRATING THE CHEST WALL
– rads or CT should be performed to determine location of object
— thoracotomy for removal of object
Debride any severely damaged muscle
Repair intercostal lacerations (stabilize ribs with circumcostal sutures)
Place thoracostomy tube
What is used for the removal of an object from a penetrating chest wound:
Thoracotomy – for removal of object
- –Debride any severely damaged muscle
- —Repair intercostal lacerations (stabilize ribs with circumcostal sutures)
- —Place thoracostomy tube
Term that refers to multiple segmental rib fractures where the flail segment moves paradoxically with chest wall during respirations.
Flail Chest
Common clinical sign for flail chest:
Hypoventilation secondary to pain causing hypoxemia,
– V/Q mismatch secondary to pulmonary contusions
Tx for flail chest:
Treat conservatively unless rib fractures are severely displaced.
- splinting may be considered to improve comfort.
- primary repair: holds lung into position.
- -external splint – suture around ribs then attach them to a splint on the outside to hold the flailed segment into position
Most common cause for Chylothorax:
IDIOPATHIC
Term referred to chylous fluid draining into the thoracic cavity secondary to impaired or disrupted lymphatic drainage (Fibrosing pleuritis may be long term consequence)
Chylothorax
T/F: Chylothorax is seen in both cats and dogs
True
Diagnosis for chylothorax:
TRIGLYCERIDES of fluid > serum
Serum > Cholesterol
Cytologic evaluation of pleural effusion
– Modified transudate, lymphocytic effusion
Is chylothorax a exudate or modified transudate
Modified transudate = Chylothorax
Tx for IDIOPATHIC chylothorax:
Surgical for idiopathic chylothorax
- Thoracic duct ligation
- Subtotal pericardectomy
- Cysterna Chyli ablation
Name the ICS space for thoracic duct ligation in each animal:
Cat: ______
Dog:_______
Name the ICS space for thoracic duct ligation in each animal:
Cat: L 10th ICS
Dog: R 10th ICS
Surgical approach used for thoracic duct ligation:
Transdiaphragmatic approach = thoracic duct ligation
- allows access to abdomen and thorax
- dorsal to aorta, ventral to sympathetic trunk
- ligate/ clip individual branches or perform en block ligation
Which sx for idiopathic chylothorax, is performed with thoracic duct ligation to maximize success of surgery:
Subtotal Pericardectomy
Name the 3 types of pericardiectomy
- Subtotal pericardiectomy
- Total pericardiectomy
- Pericardiectomy window
Name the pericardiectomy used when removing all of the pericardium ventral to the phrenic nerves all the way around.
Subtotal Pericardiectomy (most common)
- excise VENTRAL to phrenic nerve
- submit for histopathology +/- culture
What surgery, in the treatment of idiopathic chylothorax, can use all the surgical approaches below:
- Intercostal
- –Median Sternotomy
- –Transdiaphragmatic approach
Subtotal Pericardiectomy
Location of the cysterna chyli
Dorsal to the aorta
Behind the diaphragm
– In order to work with the cysterna chyli you must be working in the abdomen.
What surgery, in the treatment of idiopathic chylothorax, results in re-routing of abdominal lymphatic drainage to major abdominal vessels.
Cysterna Chyli ablation
– removing a big enough area so that the chyle continues to drain into the abdomen to be absorbed by other structures.
T/F: Cystern chyli ablation + TD ligation has a better success rate than TD ligation + Pericardiectomy
FALSE
– Cysterna Chyli ablation + TD ligation and TD ligation + Pericardiectomy have the SAME success rate.
T/F: All 3 procedures (TD ligation / Subtotal Pericardiectomy/ Cysterna Chyli abalation) can be performed concurrently
TRUE
What approach allows access to the abdomen AND thorax
**********
Transdiaphragmatic approach
– Pope has said this twice, KNOW IT
T/F: Omentalization is the preferred surgical treatment for idiopathic chylothorax.
FALSE
– not very good results bc the omentum usually tends to turn into a ball and not function very well
Term that refers to taking the omentum and placing it up in the chest allowing the omentum to absorb some of the chyle.
Omentalization
– poor success
What can be used to improve visualization of lymphatic structures:
Lymphangiography or injection of methylene blue into mesenteric LN
When do you use thoracostomy tube or pleuralport for thoracic drainage post op:
Chylothorax tx
Post op Chylothorax complications include:
- Persistent chylous or non-chylous effusion
- lung lobe torsion
- pneumothorax
T/F: Cats have a better outcome than dogs for chylothorax tx post op.
False
Dogs have improved outcome compared to cats (80-90% free > 15 months post op)
