Thoracic Surgery

Question 1

Indications

Answer 1

carcinoma of lungs or mediastinum 
benign tumours 
localised bronchiectesis 
severe pulmonary disease 
recurrent pneumothorax 
empyema - where pus gathers between lungs and inner surface of chest wall 
correction of bony deformities

Question 2

Posterolateral Incisions

Answer 2

via 5th intercostal space 
anterior axilla 
involves division of - serratus anterior, lat dorsi, lower traps, rhomboids major and intercostals (many muscles compromised)
division of ribs posteriorly 
may include rib resection

Question 3

Anterolateral Incisions

Answer 3

via 4th intercostal space
sternal border extending to the mid axillary line
involves division of - pec major, pec minor, serratus anterior
less extensive, more rapid entry to pleural cavity, less muscle compromise

Question 4

Mid-Lateral Incision

Answer 4

Follows parallel course of the 5th rib
involves division of - lat dorsi, pec major, serratus anterior
advantages - smaller incision, less muscles affected, less pain

Question 5

Sternotomy

Answer 5

vertical splitting of the sternum
less interference with pulmonary function
no muscles compromised
increased thoracic joint pain

Question 6

WEDGE RESECTION

Answer 6

removal of a wedge of parenchyma
Indications
- small peripheral tumours
- peripheral located inflamamtory siease

Question 7

LOBECTOMY

Answer 7

removal of lobe of lung
can be either video assisted or open lateral thoracotomy
- UL accessed via 4th intercostal space
- ML/LL accessed via 5th intercostal space
ICC post op
remaining space filled by shifting of surrounding structures

CXR

• shift of structures towards the removed lobe
• remaining lobes expand
• elevation of diaphragm on that side
• may have some pleural effusion

Question 8

PNEUMONECTOMY

Answer 8

removal of the whole lung 
Indications 
- carcinoma 
- extensive unilateral bronchiectesis 
- extensive chronic abscess
ICC first 24 hours - doesn't drain all fluid and air as want to keep space filled to prevent movement of other lung 

CXR

• mediastinal shift
• remaining lung hyperinflates
• hemithorax shrinks
• tissue fibrose
• white out where lung used to be

Question 9

PLEURODESIS

Answer 9

when membranes of lungs are stuck together in order to prevent the build up of air and fluid in the pleural space
Indications
- recurrent pneumothorax
- persistent pleural effusion

Question 10

LUNG TRANSPLANT

Answer 10

Indications
- cystic fibrosis
- pulmonary fibrosis
- any condition of end stage respiratory failure
High risk procedure, requires extensive prep
Take 4-8 hours, spend 2-3 weeks in hospital
Can have rejection post op or infection/immunosupression

Question 11

Potential Complications Thoracic Surgery

Answer 11

haemorrhage 
arrhythmias 
myocardial infarction 
stroke 
death 
emyema 
wound infection 
infection/fever

pleural effusion
retained secretions
acute lung injury - widespread infection throughout the lungs
pain - around the ICC and surgical wound
persistent pneumothorax
surgical emphysema

Question 12

Physio Management - Clinical Implications

Answer 12

pain 
reduced lung volumes 
impaired gas exchange 
musculoskeletal dysfunction 
impaired airway clearance 
dyspnoea

Question 13

Physio Management - Intervention

Answer 13

Pain - educate PCA

• supported huff/cough
• appropriate timing interventions
• advocate for patient

Reduced Lung Vol - mobilise

• advice sitting time and bed rest
• TEEs and DBExs

Impaired Gas Exchange
- optimsie O2 therapy
appropriate positioning

Musculoskeletal Dysfunction
- thoracic, cervical and shoulder exercises

Impaired Airway Clearance - mobilise, ACTs, humidification

Dyspnoea - breathing control, positions of breathlessness