Thoracic Surgery Flashcards
define atelectasis
collapsed or underinflated lung
define centesis
sampling of fluid
define hernia
passage of organ/tissue through a normal opening in the body
define exudate
pus
define flange
side tabs that allow for simple suturing of narrow bore chest drains to skin
define hyperpnoea
increased breathing effort
define hypoventilation
reduced oxygen exchange within the lungs
define hypoxaemia
low O2 in the blood
define ipsilateral
the same side
define modified transudate
fluid formed by leakage from normal/non-inflamed vessels (high protein content)
define orthopnea
where an animal adopts a particular positional orientation in order to breathe - often sternal with forelimbs, head and neck extended
define parenchymal
tissue of an organ (not including connective tissue)
define radiolucent
transparent to x-rays
define radioopaque
xrays cannot pass though
define tachypnoea
more rapid breathing than normal
define TFAST
thoracic focussed assessment with sonography for trauma
define pure transudate
passive fluid accumulation
how may signalment affect the assessment of thoracic conditions?
age, species and breed, lifestyle can all predispose patients to different diseases
what thoracic disease is more often seen in older animals?
neoplasia
what thoracic condition are cats predisposed to?
mediasteinal masses
what thoracic condition are yorkies predisposed to?
tracheal collapse
what thoracic condition are pugs predisposed to?
lung lobe torsion
what thoracic condition are afgans predisposed to?
chylothorax
what thoracic condition are ESS predisposed to?
lung FB
what must be considered when assessing a patient with thoracic disease?
signalment
onset (acute or chronic)
progression (slow or rapid)
what are the clinical signs that may raise suspicion of thoracic conditions?
tachypnoea
abnormal breathing
cough
pale mm or cyanosis
exercise intolerance
collapse
may have injuries
may be systemically unwell
what abnormal breathing may be seen with patients with thoracic conditions?
orthopnoea
hyperpnoea
dyspnoea
abdominal breathing
is a cough always seen with thoracic conditions?
no
what is involved in the preliminary management of patients with thoracic conditions?
minimise deterioration
monitor patient closely
what is the key area involved in minimising deterioration of patients with thoracic conditions?
oxygen
what should be involved in the monitoring of patients with thoracic conditions?
recording every 5-10 minutes initially
assessing for any upward or downward trends
is there any downside to providing oxygen to patients with thoracic conditions?
no - just expensive!
what are the options for O2 administration?
flow by
nasal cannula
face mask
oxygen collar
oxygen cage
intubation
what aids the decision around what oxygen delivery method to use?
patient stress levels and how much handling they can cope with
what should be done with any wounds seen on thoracic patients?
assess and record
flush if contaminated
protect from ongoing damage
why may it be necessary to assess the temperament of patients with thoracic conditions?
deciding on O2 delivery
would mild sedation be of benefit
why is it essential to monitor progression of thoracic patients?
identification of trends according to treatment being given
status of these patients can change quickly
what diagnostics should be prepared for for thoracic patients?
bloods
thoracocentesis
imaging
what must be considered when imaging a patient with thoracic disease?
restraint for radiography can be life threatening as the patient may not be able to breathe in lateral
what can be done before the vet arrives to aid prioritisation of case?
TFAST by nurse
what is essential when performing thoracocentesis?
ensure all samples are taken before placing any fluid into non-sterile dishes
what imaging may be needed for thoracic patients?
xray
ultrasound
or both
what should be considered about imaging modality of thoracic patients?
radiography of dyspnoeic patients may be dangerous
ultrasound can rpovide a vidio
what can be identified on thoracic imaging?
pneumothorax
pleural effusion
foreign bodies
soft tissue masses
trauma
what are the main presentations of pneumothorax?
unilateral or bilateral
small or large volume
may be open or closed
is thoracocentesis required for pneumothorax?
yes
what are the main presentations of pleural effusion?
unilateral or bilateral
small or large volume
is thoracocentesis required for pleural effusion?
yes - samples needed
how may foreign bodies be identified on imaging?
may be radiolucent or radioopaque
what would indicate neoplasia on xray?
normal structures in the thorax with abnormal appearence
what would indicate torsion on xray?
normal structures in the thorax with abnormal appearence
what would indicate diaphragmatic hernia on xray?
abnormal structure in thorax
what may be seen on imaging of trauma patients?
broken ribs
may or may not have broken skin
diaphragmatic hernia
what is flail chest?
whole section of ribs broken on both ends which then moves with the lung during breathing and can cause trauma
what are the main surgical thoracic conditions?
pneumothorax
chest and lung trauma
pulmonary blebs and bullae
diaphragmatic rupture
pleural effusion
pyothorax
pericardial effusion
pulmonary neoplasia
is pneumothorax always accompanied by obvious trauma?
no
what approach is used for diaphragmatic rupture surgery?
abdominal
what are the reasons for pleural effusion?
many - CHF, FIP
what types of fluid are seen in pleural effusion?
many e.g. transudates, exudates, blood, chyle
what is pyothorax?
pus in the chest
what is pericardial effusion?
fluid around the heart that may accumulate over time or acutely
why is sampling essential for pleural effusion?
many different causes
what are the two types of pneumothorax?
internal or closed
external or open
what is an internal or closed pneumothorax caused by?
leak caused by something inside the chest
where may a closed pneumothorax originate from?
oesophagus
respiratory tract (trachea or small airways)
how does the presentation of open and closed pneumothorax differ?
internal or open is more rapid and become sicker quicker
how can an open or external pneumothorax be identified?
more obvious due to hole in chest
what can open or external pneumothorax be caused by?
chest trauma
iatrogenic
what are the iatrogenic causes of open pneumothorax?
lung lobectomy
diaphragmatic rupture
complications of thoracocentesis or throacostomy
what are the clinical signs of pneumothorax?
dyspnoea
lethargy
cough
exercise intolerence
how is pneumothorax diagnosed?
imaging
thoracocentesis
why may unilateral pneumothorax lead to bilateral?
if pressure in one side of the chest increases enough the mediasteinum could rupture and air could flood both sides
why may bilateral chest drains be needed for bilateral pneumothorax?
if mediasteinum is intact
how is pneumothorax treated?
chest drain
thoracotomy
when is a chest drain used to treat pneumothorax?
conservative management if air leak may spontaneously heal
when is a surgery used to treat pneumothorax?
if air leak is massive or if ongoing and not sealing
how may chest and lung trauma be caused?
accident (RTA/cliff)
attack (dog, human)
what should be done if you suspect trauma to a patient was non-accidental?
reporting following practice policy
what are the clinical signs of chest/lung trauma?
shock
dyspnoea
soft tissue damage
ortho damage eg. rib fracture
what affects the prognosis of patients with chest and lung trauma?
soft tissue and ortho damage
what types of soft tissue damage may be seen with chest and lung trauma?
open and may be extensive
bruising or crush injuries which progress
what ortho damage may be seen with chest and lung trauma?
rib fractures including flail chest
other fractures round the body whcih may complicate patient management
how should patients with chest and lung trauma be managed?
stabilised before surgery with oxygen
what are the main complications seen with chest and lung trauma patients?
infection or inflammation
issues with healing
ongoing effusions
pneumothorax
what does the prognosis of patients with chest and lung trauma depend on?
severity of injuries - can be costly to treat
what can influence risk of infection/inflammation in chest and lung trauma patients?
reason for trauma
degree of contamination
presence of devitalised tissue
what are blebs?
bubbles seen on edges of lobes where air has risen to the surface
what are lung bullae?
bubbles within lobes where alveoli coalesce
what is the signalment for blebs and bullae?
large breed, deep chested dogs
what is the cause of blebs and bullae?
unknown
may be some link to underlying disease
what clinical signs may be seen with blebs and bullae?
none
non-specific
respiratory
when may a patient with blebs and bullae not show clinical signs?
if none have ruptured
what non-specific signs may be seen with a patient with blebs and bullae?
lethargy
anorexia
exercise intolerance
what respiratory signs may be seen with a patient with blebs and bullae?
sudden onset dyspnoea with no trauma history
progressive tachypnoea, orthopnoea and coughing
what is indicated by peracute closed, tension pneumothorax of patients with blebs and bullae?
they ruptured
how are blebs and bullae diagnosed?
imaging - xray or CT
what is xray useful for in patients with blebs and bullae?
diagnosis of pneumothorax
what is xray not useful for in patients with blebs and bullae?
showing which lobes are affected
what is CT useful for in patients with blebs and bullae?
assessment of lung lobes are affected so useful before surgery
how are blebs and bullae treated?
thoracocentesis with possible chest drain
thoracotomy and lung lobectomy
what is involved in surgical treatment of blebs and bullae?
open sternotomy or thorascopy as unsure which lobes are affected
lobectomy if not too many lobes affected
how effective is conservative management of blebs and bullae with thoracocentesis or thoracostomy?
only 50% respond
where does air accumulate within blebs?
outside or above inner layer of visceral pleura
where does air accumulate within bullae?
inside or underneath inner layer of visceral pleura
what can cause diaphragmatic rupture?
blunt force trauma (RTA/fall)
how does diaphragmatic rupture occur as a result of blunt force trauma?
increased intrabdominal pressure with a closed glottis
diaphragm is weakest structure and ruptures so abdominal contents can move into chest
what are the clinical signs of diaphragmatic rupture?
none
vague ill health
dyspnoea or shock
tachypnoea
orthopnoea
what may increase the severity of diaphragmatic rupture?
speed of onset of symptoms
degree of herniation
concurrent injuries
what may the onset of symptoms of diaphragmatic rupture be like?
peracute
acute
chronic
what effect does the degree of herniation have on the severity of diaphragmatic hernia?
organs involved (if any)
any torsion
compression of thoracic contents
size of tear
what may improve dyspnoea in diaphragmatic rupture patients?
elevation of thorax to release pressure of abdominal organs on thorax
what concurrent injuries may be seen with diaphragmatic rupture?
ortho injuries
what is PPDH?
peritoneopericardial diaphragmatic hernia - contents of gut within pericardium
when is PPDH seen?
congenital
how is diaphragmatic rupture treated?
stabilisation
laporotomy
what is involved in stabilisation of patients with diaphragmatic rupture?
O2
analgesia
IVFT
what is involved in surgery to manage diaphragmatic hernia?
exploration of chest and abdomen
repositioning of abdominal contents or removal if bad torsion / devitalisation
repair
debride as necessary
what must be placed following diaphragmatic rupture repair surgery?
chest drain due to iatrogenic open pneumothorax
what may pleural effusion be caused by?
many reasons
what are the clinical signs of pleural effusion?
varied
dyspnoea
lethargy
cough
exercise intolerence
how is pleural effusion diagnosed?
imaging
thoracocentesis
lab tests
what does treatment of pleural effusion depend on?
diagnosis
what lab tests may be performed on pleural fluid?
SG
cytology
culture and sensitivity
what can specific gravity of effusion samples tell?
what type of fluid it is (e.g. transudate or exudate)
what medical conditions may lead to pleural effusion?
CHF
pyothorax
how may pyothorax be managed?
conservative management in cats
likely surgical in dogs as conservative is unlikely to work
what is pyothorax caused by?
almost always bacterial infection
what are the clinical signs of pyothorax?
mild to severe
lethargy
inappectance
PUO
dyspnoea
how is pyothorax diagnosed?
labs
imaging
what is pyothorax most often caused by in cats?
idiopathic (bites, chronic pneumonia)
what is pyothorax most often caused by in dogs?
FB
oesophageal tear
what bacteria often causes pyothorax in dogs?
e coli
what bacteria often causes pyothorax in cats?
pasturella
what lab tests are used to diagnose pyothorax?
cytology
culture
how is pyothorax treated?
medical management
sternotomy
what is involved in medical management of pyothorax?
systemic antibiotics
chest drain
+/- lavage
what animal is conservative management of pyothorax useful in?
cats
what is involved in surgical management of pyothorax?
sternotomy to explore chest, remove exudate and flush
why is sternotomy for pyothorax done early in dogs?
high percentage of FB
what are the main causes of pericardial effusion?
idiopathic in young dogs
neoplastic
what do the clinical signs of pericardial effusion depend on?
speed at which fluid forms which is linked to cause of disease as this affects whether the pericardium will have stretched
what are the clinical signs of pericardial effusion?
cardiac tamponade
collapse
what is cardiac tamponade?
pericardial effusion fills pericardium so heart is unable to expand adequetely
how much fluid is seen with idiopathic pericardial effusion?
lots - happens over time so pericardium can stretch
how much fluid is seen with neoplastic pericardial effusion?
little - acute onset and so pericardium cannot stretch
how is pericardial effusion diagnosed?
radiography
ultrasound (echocardiogram)
advanced imaging
labs
pericardiocentesis
what is the purpose of lab analysis of fluid in pericardial effusion?
indicates if there is neoplasia which has poorer prognosis
how is pericardial effusion treated?
repeat pericardiocentesis
pericardectomy
chest drain
what is the purpose of pericardectomy?
allows fluid to convert to pleural effusion and prevents cardiac tamponade
is the creation of pleural effusion through pericardectomy of concern?
no - very little fluid and can be absorbed by pleura
what are the complications seen with pericardial effusion?
recurrence after draining and surgery
repair of pericardium as insufficient window taken
adhesions from long standing effusion
what is the prognosis of pericardial effusion?
varied due to cause
what is the aetiology of pulmonary neoplasia?
malignant more common than benign
secondary more common than primary
what are the clinical signs of pulmonary neoplasia?
non productive cough
haemoptysis
dyspnoea
weight-loss
exercise intolerance
anorexia
lameness
none (25%)
why is lameness sometimes seen in patients with pulmonary neoplasia?
due to hypertrophic pulmonary osteopathy
what is hypertrophic pulmonary osteopathy
paraneoplastic syndrome where new bone forms on extermities due to over production of parathyroid hormone
how is pulmonary neoplasia diagnosed?
lab work
imaging
what is involved in lab tests for pulmonary neoplasia?
minimum database
+/- cytology
what imaging is needed for diagnosis of pulmonary neoplasia?
advanced to see masses under afew mm
inflated x ray for masses over 1cm
how is pulmonary neoplasia treated?
palliative care
surgery (open or thoracoscopic)
what are the complications associated with pulmonary neoplasia treatment?
as for any thoracotomy
what does prognosis of pulmonary neoplasia depend on?
presence of mets
histopathology
surgical margins
what is involved in pre and perioperative management of thoracotomy patients?
multimodal analgesia
management of hypothermia
IPPV
what should be monitored about the thoracotomy patient post op?
TPR
pain score
what is involved in drug choices for thoracotomy patients?
depends on presence of drain / underlying issues
what needs very careful management following thoracotomy?
wound and surgical site
drain if present
why may body bandages be used on thoracotomy patients?
increased comfort
reduced infection risk
reduced patient interference
what nursing care may be required for thoracotomy patients?
assistance with basic functions - DUDE
IVFT
U cath if struggling to mobilise
feeding tubes if anorexic
what should be considered if patient is pain scoring high?
basic functions accommodated (e.g. do they need to wee!)
temperament
define thoracocentesis
procedure involving the puncture of the pleural space for diagnostic and theraputic purposes
what patient prep is needed for thoracocentesis?
sterile skin prep
what may be needed to support the patient during thoracocentesis?
oxygen therapy
is thoracocentesis a sterile procedure?
yes
what does the equipment needed for diagnostic thoracocentesis depend on?
whether plan is for sampling or draining as much fluid as possible
what equipment is needed for diagnostic thoracocentesis?
oxygen
short acting local anaesthetic
sterile prep equipment
needle / catheter
assistant
3 way tap
20ml syringe
extension set
kidney dish
what medication may be needed for thoracocentesis?
anxiolytic
LA
what size butterfly catheter will be needed for thoracocentesis in cats and small dogs?
20/22G
what size butterfly catheter will be needed for thoracocentesis in dogs?
18/20G
are IV catheters or butterfly needles better for thoracocentesis?
IV catheters mean that the sharp isn’t left in the patient’s body but the collectin system can only be attached once the stylet is out
butterfly catheters leave a sharp in the patients chest throughout use but can have collection set pre attached
what size syringe is needed for thoracocentesis?
small (2ml) for sampling
then larger (20ml) for draining fluid
what will syringe size affect during thoracocentesis?
amount of suction applied and speed of aspiration
what is essential when collecting samples during thoracocentesis?
samples remain sterile so go straight into sample tubes
what samples may be taken during diagnostic thoracocentesis?
EDTA
heparin
plain/serum
culture
cytology - fresh smear and serum
SG
what lab equipment is needed for diagnostic thoracocentesis?
refractometer
blood tubes
microscope slides
culture sample tube
what is a chest drain?
tube placed into the pleural space to allow ongoing, continuous or intermittent therapeutic drainage
what is the decision to place a chest drain based on?
underlying disease and its effect on fluid or air production
quantity of air/fluid produced
patient temperament
treatment plan
what can be used for therapeutic thoracocentesis?
butterfly catheter and intermittent drainage
may not be appropriate if frequent or larger volume
chest drain then used
why is a chest drain usually placed?
intermittent thoracocentesis not working
following thoracotomy
if long term pleural drainage is needed
trying to avoid surgery
instillation of medication
why may intermittent thoracocentesis not work?
too much air or fluid produced
fluid too thick to come through butterfly
too risky - causing lung trauma
why is a drain needed following thoracotomy?
removal of fluid / air introduced during surgery
detection of fluid / air produced due to underlying condition
detection of fluid / air produced due to surgical complication
when may long term pleural drainage be needed?
pneumothorax due to underlying lung disease
pleural effusion
what medication may be placed through a chest drain?
LA
saline
antibiotics
chemotherapy
why may saline be placed through a chest drain?
lavage of pyothorax
what are the types of chest drain categorised by?
size
placement method
what size of chest drains are available?
large bore
narrow bore
what are the placement techniques for chest drains?
trocar
seldinger / guidewire
what are the main considerations when selecting a chest drain?
type
size
placement method
site
connectors
securing
protection
what will inform the type of chest drain used?
material it is draining (air or fluid)
types available in practice
what are trocar chest drains made of?
silicone or PVC
what does the size of drain depend on?
reason for drainage and amount expected
what sizes of chest drain are available?
6Fr to 20 Fr
what is french scale?
3x outside diameter of the tube in mm
under what conditions may a chest drain be placed?
chest open or closed
what does the site of a chest drain depend on?
unilateral or bilateral condition
if mediasteinum is intact
where should the end of a chest drain sit?
cranioventral but not too close to thoracic inlet
what must you ensure when measuring length of chest drains before placement?
all fenestrations are sat genuinely within the chest
what can happen if chest drain fenestrations are not all within the chest?
iatrogenic PT
incorrect measurement of air drained
what part of a chest drain is the most likely location of complications?
connectors
what must be ensured about chest drain connectors?
appropriate ones to allow for efficient and safe drainage without risk of iatrogenic PT
what does how a chest drain is secured depend on?
drain type
how are trochar drains secured?
roman sandal sutures
how are seldinger drains secured?
built in anchor flanges to facilitates securing to the body wall with simple sutures
how can chest drains be protected from patient interference?
24 hour nursing care
gate clamps
secure sutures
body bandage
buster collar
can trochar drains be placed under sedation of GA?
most likely GA
what types of stylet often come with trochar drains?
sharp
blunt
what can be done during trochar drain placement to prevent air leaks?
subcutaneous tunnel created before entering chest cavity
what are the benefits of trochar chest drains?
lots of different sizes
versatile - useful for air or fluid
large bore and so less likely to block
robust and dont collapse
easy to place once technique learned
most are transparent so easy to see if blocked
rigid so easy to place where required
what are the negatives of trochar chest drains?
need GA to place
higher complication rate than narrow bore
needs careful training to place
good suture technique required to ensure they stay in place
less comfortable than narrow bore
what type of chest drain is more expensive?
seldinger may cost more for actual drain but cheaper overall if no GA needed
is a subcutaneous tunnel needed for a seldinger drain?
no as placement technique is less invasive and so air leaks are less likely
what are the benefits of seldinger chest drains?
no GA
easy to place
easy to secure
versatile
more comfy
what are the downsides of seldinger chest drains?
may not cope with pleural fluid
smaller sizes can be difficult as there may be too much within the chest or outside the chest
not as rigid so can end up with strange placement
may not be able to do SQ tunnel if needed as introducer catheters are not that long
what is the issue with to much drain inside the chest?
prone to kinking
what is the issue with to much drain outside the chest?
vulnerable to patient interference
when is a pleuraport used?
palliative care where long term drainage is needed
how are pleuraport drains placed?
surgical placement
what needles are used to drain a pleuraport?
huberpoint needles
what equipment is needed to place a chest drain in a closed chest?
sterile prep
anaesthetic equipment and monitoring as needed
assistant
chosen chest drain, pre measured
scalpel and blade
suture kit
fenestrated drape
3 way tap
syringes (size dependant on volume to be drained)
extension set
kidney dish
suture
how can a chest drain be secured?
built in anchor flanges and simple interrupted sutures
external drain securing sutures (e.g. roman sandal)
what is crucial about trochar drain securing?
must be done very carefully as risk of premature removal and pneumothorax is high
what are the main ways of draining a chest drain?
intermittent
continuous
what is particularly important if chest drain is being used intermittently?
connectors must be secure
how often should a chest drain be drained?
vet decision but usually every 4-8 hours
what does the frequency of chest drainage depend on?
RR
presence of dyspnoea
what are the main continuous chest drainage options?
Hemlich valve
commercial drainage unit that uses continuous suction
what cases is continuous chest drainage used for?
large air leak pneumothorax
why must care be taken over suction level with continuous thoracic drainage?
can collapse tube and/or aspirate tissue that could be damaged or block the drain
how can you reduce the risk of infection for a patient with a chest drain?
aseptic technique at all times
good bandage hygiene
change all soiled bandages
early identification of infection and treatment
culture before treatment with antibiotics
potentially early removal
what analgesia may be utilised for a hospitalised patient with a chest drain?
LA around drain site
systemic opioids
LA down drain itself
CRI
paracetamol
what analgesia may be utilised for a patient who has been discharged following placement and removal of a chest drain?
NSAID
paracetamol (only in dogs)
what is the negative aspect of using opioids in thoracotomy patients?
can affect breathing
what are the main complications associated with chest drains?
failure to place
failure to drain
patient interferance
iatrogenic
introduction of infection
what are the main issues seen with chest drain placement?
unable to place
incorrect placement
what are the main ways a chest drain may be incorrectly placed?
went caudal not cranial
didn’t enter thorax
stuck in mediasteinum
what should be done following chest drain placement to check position?
xray
why may a chest drain fail to drain following placement?
inadvertent or accidental removal
tube disconnection
tube obstruction
tube kinking
tube slipped out from chest a little
how may a patient interfere with a chest drain?
removal or chewing either part of or entire drain
what iatrogenic problems can there be with chest drains?
haemmorhage / haemothorax
heart or lung damage
inappropriate or premature removal
nerve damage
pneumothorax
pyothorax
seroma
subcutaneous emphysema
how can you check to see if pleural fluid from a chest drain is fresh blood and so indicative of haemorrhage?
PCV
see if it clots (only fresh blood will)
what nerve may be damaged by chest drain placement?
phrenic
how can iatrogenic pneumothorax be prevented in a patient with a chest drain?
check connectors
check fenestration
how can iatrogenic pyothorax in a chest drain patient be prevented?
aseptic technique
what is seroma often caused by in chest drain patients?
high volume effusion - usually resolves
where is subcutaneous emphysema often seen in chest drain patients?
around skin incision
what can be used to treat / manage subcutaneous emphysema in chest drain patients?
antibiotic ointment around incision site
how can subcutaneous emphysema be prevented in chest drain patients?
care with incision size
check fenestration position
removal of drain leading to resolution
who makes the decision about chest drian removal?
vet
why may a chest drain remain in place?
ongoing treatment needed via drain
clinically significant production of fluid/air
what level of drain fluid production may suggest removal of the drain?
2ml/kg/h or a downward trend towards 25% of original production
what are the reasons for chest drain removal?
unacceptable complications where risk of tube staying in is greater than risk of removal
once volume has reduced sufficiently that removal is unlikely to be a risk
swapping to pleuraport for long term palliation
when may a chest drain be removed in a patient with pyothorax?
fluid out is of simular volume to fluid going in
documentation of reduction in signs of infection (e.g. bacteria or neutrophils)
what type of chest drain is this?
trochar with gate clamp, stylet removed and one way connector
what type of chest drain is this?
trochar with stylet and gate clamp
what type of chest drain is this?
seldinger
what type of chest drain is this?
pleuraport
what is involved in stabilising a patient for thoracotomy?
ASA grading and risk assessment
IVFT
drugs
O2
bloods
what must be managed about IVFT in thoracotomy patients?
not too much
use BP and PQ to assess
what are the analgesic considerations for thoracic surgery?
pre-eptive
multimodal
rescue required in theatre
what are the antibiotic considerations for thoracic surgery?
is the patient already on them
is there a plan for intra operative antibiotics
what are the surgical considerations for thoracic surgery?
approach
kit needed
specialised instruments
predicted complications and their management
what are the 4 main approaches for thoracic surgery?
left thoracotomy
right thoracotomy
sternotomy
thoracoscopy
how is the location of thoracotomy described?
numbered rib space incision is made at
what are the benefits of thoracotomy?
less painful than sternotomy
what must be clarified before a thoracotomy is performed?
condition can be treated with unilateral approach
need to be sure of side to approach
need to be sure of intercostal space to use
what does the side the thoracotomy is performed on depend on?
side affected
where the organ is more accesible
what structures are best accessed from the left side?
oesophagus
PDA
what are the negatives of sternotomy?
more painful
less useful for issues in the dorsal thorax
what are the benefits of sternotomy?
good for bilateral conditions
better for exploratory thoracotomy
what are the benefits of thorascopy?
least painful
rapid recovery
what are the negatives of thorascopy?
steep learning curve
specalised equipment
not often seen
limitations to procedures which can be completed using a scope
what position must the patient be in for thoracotomy?
lateral recumbancy with the side to be explored uppermost
what part of the chest can be assessed with thoracotomy?
ipsilateral side
how is a thoracotomy closed?
sutures
what position must the patient be in for sternotomy?
dorsal recumbancy
what approach is used for sternotomy?
midline
how is the thoracic cavity accessed in sternotomy?
osteotomy with saw
what can be assessed during sternotomy?
left and right sides of the chest
how is a sternotomy closed?
metal wire or sutures
what suture material may be used to close the sternum?
large PDS
what clip is needed for a thoracotomy?
correct side of chest
thoracic inlet to mid abdomen
spine and midline
what clip is needed for a sternotomy?
thoracic inlet to mid abdomen
below axilla on both sides
what clip is needed for a thoracoscopy?
full clip in case need to convert to open
how should a patient be positioned for thoracotomy?
lateral
front and back legs loosely tied out of the way
+/- sandbag beneath chest to ensure it is level
how should a patient be positioned for sternotomy?
dorsal
legs loosely tied out of the way
sandbags on either side to stabilise if necessary
how should a patient be positioned for thoracoscopy?
either lateral or dorsal depending on the procedure
what are the main instruments used for thoracic surgery?
longer handled standard instruments
retractors
tissue forceps
sternotomy saw / equipment
what standard instruments usually have longer handles for thoracic surgery?
tissue forceps
scissors
needle holders
what types of retractors can be used for thoracic surgery?
handheld
self-retaining
what sort of tissue forceps should be used in the thorax?
Give an example
atraumatic e.g. debakeys
what is the role of atraumatic tissue forceps in thoracic surgery?
tissue handling
fine dissection
clamping vessels prior to ligation
what is the role of sternotomy instruments?
break through bone
what are the main handheld retractor used in thoracic surgery?
malleable
langenback
name this instrument
langenbeck retractor
what are the main self retaining retractors used in thoracic surgery?
finochettio
gelpis
name this retractor
finochettio
name this retractor
gelpis
name this retractor
malleable
name this instrument
debakey forceps
what is the function of debakeys?
a traumatic tissue forceps
what clamps may be used in thoracic surgery?
vascular
satinsky
soft palate
what are satinsky clamps used for?
vessels prior to ligation
name this instrument
vaascular clamp
name this instrument
satinsky clamp
name this instrument
right angled clamp
name this instrument
soft palate clamp
what forms do right angled clamps come in?
ratchet and non-racheted
what instruments may be used for a sternotomy?
manual: chisel and hammer
electrical: oscillating saw
what additional items will be needed for thoracic surgery?
lap swabs
wire or thick suture
suction
pre-selected chest drain and connectors
tourniquet
pledget sutures
vessel loops
what suture will be needed to close the sternum?
1 PDS or 0 PDS
what basic electrosurgery equipment is available?
monopolar
bipolar
what is required alongside monopolar?
earth pad under patient to complete the circuit and prevent burns
what advanced electro surgery equipment is available?
Gen11
ligasure
harmonic
what may advanced electrosurgical tools be used instead of?
stapler
what is a partial lung lobectomy?
part of a lobe removed
what is a total lung lobectomy?
full lobe removed
what is a pneumonectomy?
one half of the lung is removed
how may lung be removed?
sutures
staples
what is the advantages of suture for lung lobectomy?
useful if stapler fails
less expensive
what is the disadvantages of suture for lung lobectomy?
slow
technically challenging
higher risk of leakage
what is the advantages of staples for lung lobectomy?
quick
lower risk of leakage
what is the disadvantages of staples for lung lobectomy?
more expensive
initially scary to do!
what must always be performed after lung lobectomy?
leak test
what is a leak test following lung lobectomy checking for?
ensuring that staples have closed bronchus and that there is no risk of pneumothorax
what would indicate a failed leak test?
bubble following IPPV demostrating lung leak
how is a leak test performed?
fill chest with warm saline
IPPV performed
check for air bubbles to ensure no leak
suction fluid out once happy
where should the chest be filled with saline to?
above the level of the lungs
Poster about managing resp system
Look at LP/TC/aspergillosis/FB/BOAS
you fool
