Thoracic Surgery Flashcards by Kate Guiremand

most common surgical approach of thorax

lateral thoracotomy

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what procedure is seen here

lateral/intercostal thoracotomy

less painful than median sternotomy

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how is a lateral thoracotomy closed

circumcostal sutures

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indications for median sternotomy

bilateral thoracic exploration

cranial mediastinal masses

cranial thoracic trachea

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what should be left intact with median sternotomy

manubrium or xiphoid

can cut both if necessary - be extra careful when closing

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minimally invasive approaches

used with lateral approach only

thoracoscopy

video assisted

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special considerations for thoracic surgery

positive pressure ventilation

chest tube(s) commonly required post op

24 hour post op monitoring

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what is a pneumonectomy

removal of all lobes of one lung

rarely performed, indicated for cases where disease is diffuse through multiple lung lobes (neoplasia, abcess, trauma, infiltrative inflammatory disease)

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total lung lobectomy vs partial lobectomy

depends on disease process and location of lesion within the lobe

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suture technique for partial lobectomy

suture proximal to clamps - 1-2 rows or continuous suture pattern

guillotine suture may be used for biopsies and very small peripheral masses

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suture technique for complete lobectomy

triple ligation of vessels - cut between middle and distal ligatures

pre-place horzontal mattress sutures and tie prior to transection

oversew transected end of bronchus

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advantages of stapling technique for partial/complete lobectomy

decreased anesthesia and surgery time

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disadvantage to stapling technique for partial/complete lobectomy

standard devices too large for very small patients

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prior to closure of pulmonary surgery

check for:

bleeding/hemorrhage

air leakage

chest tube placed vis separate intercostal incision

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surgical diseases of pulmonary parenchyma

spontaneous pheumothorax

bronchoesophageal fistulas

lung lobe consolidation and abscessation

bronchiectasis

lung lobe lacerations

lung lobe torsions

neoplasia

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bleb

localized collection of air between internal and external layer of visceral pleura

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bullae

non epithelialized cavities produced by disruption of intra-alveolar septae

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cyst

closed sacs lined by epithelium filled with fluid or air (often secondary to pulmonary contusions)

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cysts, bullae, and blebs

can be secondary to blunt trauma (cysts) or traumatic rupture of alveoli secondary to underlying lung disease

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complications or cysts, bullae and blebs

abscessation

rupture

spontaneous pneumothorax (atelectasis)

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conservative treatment of cysts, bullae and bleds consists of

thoracostomy tubes for 48-72hrs

high recurrence rate

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when is surgical intervention recommended for cysts, bullae, and blebs

when medical management has failed

pre-op CT may be helpful in ID-ing lesions; partial or complete lung lobectomy, pleurodesis?

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what breed is the poster child for lung lobe torsion

afgans

large, deep chested dogs and pugs are most commonly affected*
large dogs: right middle or left cranial lung lobe*
pugs: left cranial lung lobes*

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clinical signs of lung lobe torsion

acute onset

dsypnea, tachycardia, C+, exercise, intolerance, hemoptysis

pyrexia, pale mm, decreased lung sounds ventrally on PE

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diagnostics for lung lobe torsion

thoracocentesis - serosanguinous or chylous effusion imaging - rads or CT

T/F surgical treatment of lung lobe torsion includes untorsing the lobe

**False** ***DO NOT** untorse lung, avoid release of cytokines and endotoxins - REPERFUSION INJURY!*

what is the initial treatment at patient stabilization

thoracocentesis O2 supplementation IV fluids

post op care for lung lobe torsion

thoracic drainage for 3-5 days analgesia and antibiotics

T/F the prognosis for pugs with lung lobe torsion is fair to guarded while other breeds have a good prognosis

**False** * good prognosis for pugs, fair to guarded for other breeds* * 50-61% survival rate, second torsion can occur*

survival with primary pulmonary neoplasia is associated with

lack of LN involvement location size of mass lack of clinical signs

most common type of primary pulmonary neoplasia

bronchiolar or alveolar carcinoma

what is the most common cause of thoracic wall trauma

hit by car

most thoracic wall truama requires surgical intervention

**false**

what should be done before removing a penetrating chest wound

radiographs or CT ## Footnote *thoracotomy for removal of object*

what is flail chest

multiple segemental rib fractures ## Footnote *flail segment moves paradoxically with shest wall during respiration*

why do you see hypoxemia with flail chest

hypoventilation secondary to pain V/Q mismatch secondary to pulminary contusions

what is the most common cause of chylothorax

idiopathic

what is a posible long term consequence of chylothorax

fibrosing pleuritis

what is the treatment for idiopathic chylothorax

**surgical** * thoracic duct ligation* * cysterna chyli ablation* * subtotal pericardectomy* * +/- omentalization, pleuralpport placement*

what can be done to improve visualization of lymphatic structures

injection of methylene blue into mesenteric LN

surgical correction of thoracic duct ligation

cats: L 10th ICS dogs: R 10th ICS transdiaphragmatic approach, dorsal to aorta ventral to sympathetic trunk, ligation/clip individual branches or perform en bloc ligation ligate/ clip as close to diaphragm as possible

what is performed with thoracic duct ligation to maximaize success of surgery

subtotal pericardectomy

what can be done with a TD ligation or TD ligation + pericardectomy

cisterna chyli ablation

cisterna chyli ablation results in

re-routing of abdominal lymphatic drainage to major abdominal vessles

dogs have a \_\_\_\_\_\_outcome compares to cats

**improved** *~ 80-90% effusion free \> 15 months post-op*

what is the most common cause of diaphragmatic hernia

trauma

acute diaphragmatic hernia presentation

respiratory distress (tachypnea, dyspnea, cyanosis) shock other injusies may be present (fractures, wounds, etc)

chronic presentation of diagraphmatic hernias

**respiratory and GI signs most common** dyspnea, exercise intollerance, lethargy V+, regurgitation, inappetance pleural/peritoneal effusion

what is the most accurate diagnostic imaging modality for diagnosing diaphragmatic hernias

Ultrasound (93% accurate) ## Footnote *rads - 66% accurate*

when is surgery emergent with diaphragmatic hernias

if the stomach is herniated

complications with diaphragmatic herniorrhaphy

re-expansion pulmonary edema - close control of PPV during Sx is nesscesary! associated with rapid expansion of perviously atelectic lung persistent pneumothorax hemorrhage failure of repair and re-herniation loss of domain

prognosis for diaphragmatic hernia

excellent if patient survive 24 hours post-op

peritoneopericardial diaphragmatic hernia (PPDH)

congenital communication between pericardium and peritoneal cavity commonly associated with other congenital defects

presentation of PPDH

may be incidental finding presentation at middle age signs can be respiratory, GI, cardiac or neurologic system

breeds predisposed to PPDH

weimaraners cocker spaniels DLHs Himalayans

pentology of defects: congential cranial abdominal wall and diaphragmatic defects

cranial abdominal wall defect caudal sternal fusion defect pericardial defect diaphragmatic defect intracardial defects (VSD most common)

breeds predisposed to pentalogy of defects

cocker spaniels weimeraners dachshunds collies

exam findings with pentology defects

muffled heart sounds ascites murmur +/- concurrent ventral abdominal wall defect

radiographic findings with PPDH

enlarged cardiac silhouette dorsal elevation of trachea overlap of heart and diaphragmatic hernias gas filled structures in pericardial sac sternal defects

when should surgery be performed with PPDH

ASAP - between 8-16 weeks ideally

T/F the pericardial sac should be closed separately with PPDH repair

**False** does not need to be closed separately - use simple continuous pattern

what is the most common congenital cardiac defect in dogs

patent ductus arteriosus

a patent ductus arteriosus is present when the ductus remains patent _______ after parturition

**\> 3 days**

PDA shunts bood from _____ to _____ side of the heart

PDA shunts bood from **_left_** to **_right_** side of the heart *severe volume overload of L heart that progresses to left sided failure*

what is a reverse PDA

Eisenmenger's syndrome ## Footnote *right to left shunting, occurs in face of severe pulmonary hypertension*

what clinical signs can be seen with reverse PDA

differential cyanosis exercise intollerance pelvic limb collapse polycythemia

PE findings with PDA

continuous murmur hyperkinetic pulses (BB shot, waterhammer) +/- stunted growth

T/F occluding of the defect is recommended in all PDA cases because most die before 1 year if not treated

**False** *occluding of R→L shunting is contraindicated*

complications with surgical ligation of PDA

severe hemorrhage secondary to PDA rupture bradycardia (branham reflex) residual ductal flow long term: recanalization

prognosis for PDA

excellant for animals \< 6 months at time of surgery poor to grave for reverse PDA

what is the most common cardiac neoplasia in dogs

HSA of right auricle

which course of treatment offers the best prognosis with right auricular HSA

excision of right auricular mass followed by pericardiectomy followed by chemotherapy

thickening of pericardium or rapid raise in pericardial pressure results in \_\_\_\_\_\_\_

cardiac tamponade

pericardial diseases

pericardial rupture and secondary pericardial contraction and scarring pericardial effusion comstrictive pericarditis

PE findings with pericardial disease

muffled heart sounds weak femoral pulses +/- pulsus paridoxicus +/- cardiogenic shock

diagnostics for pericardial disease

thoracic imaging complete database electrocardiogram pericardiocentesis +/- abdominal imaging

T/F pericardectomy can be curative or palliative depending on underlying disease process

**True**

what is the most common type of PRAA

PRAA with left ligamentum arteriosum

what is the most common breed with PRAA

german shepards ## Footnote *diagnosed via imaging between 2-6 months of age*

what do you have to be aware of when isolating ligamentum arteriosum

dont penetrate the esophagus!