Thoracic Surgery

Question 1

What are the indications for a median sternotomy?

Answer 1

Cutting in thru the sternum…

can do combined abdominal and median sternotomy
(lesions on both sides of diaphragm)
or need more exposure (i.e. liver surgery)

Bilateral thoracic exploration
Cranial mediastinal masses
Cranial thoracic trachea
*leave manubrium OR xyphoid intact*

closed w/figure8 polypropylene
(synthetic, non-abs., monofilament, high TS, low reactivity) sutures
or orthopedic wire

Question 2

What are some special considerations for thoracic surgery?

Answer 2

Positive pressure ventilation (ventilator vs. manual bagging)

Chest tube(s) commonly required post-op: Allows for monitoring and removal of air and fluid, provides access to pleura for infusion of local anesthetic

24-hour post-op monitoring: pain mgmt, respiratory monitoring

Question 3

If you had to do a unilateral pneumonectomy, which side would be better for the prognosis of the animal?

Answer 3

Left;
​less lobes on the left side

Question 4

Pulmonary surgery considerations prior to closure?

Answer 4

Check for:
Bleeding, Air leakage
(fill thoracic cavity with saline and look for bubbles during PPV, ventilate up to 25-30cm H2**O)

Chest tube placed via separate intercostal incision

Question 5

How do we treat spontaneous pneumothorax?

Answer 5

Surgical intervention is recommended:
Pre-operative CT for ID’ing lesions;
Median sternotomy —>Partial/complete lung lobectomy

Question 6

T or F:
in the rare case of a lung lobe torsion, we simply need to untwist the lung manually.

Answer 6

FALSE:
avoid release of cytokines and endotoxins (reperfusion injury);
DO NOT UNTWIST THE LUNG!!
Take the whole thing;
lung lobectomy via intercostal thoracotomy if affected lung lobe is known

Question 7

What is the morphological description of chylous effusion as a result of impaired or disrupted lymphatic drainage into the thoracic cavity?

Answer 7

Idiopathic chylothorax

Question 8

How do we diagnose idiopathic chylothorax?

Answer 8

Thoracocentesis: chylous effusion

Question 9

How do we surgically treat Idiopathic chylothorax and what is our goal?

Answer 9

Thoracic duct ligation vs. en bloc ligation Pericardectomy Cisterna chyli ablation Goal: find thoracic duct—> thoracic duct (all lymphatics go thru) becomes leaky so we need to do contrast (intestinal lymphangiography: oil/cream per os) —> LIGATE thoracic duct to prevent the dumping of chyle into the chest cavity

Question 10

How can we describe diaphragmatic hernia?

Answer 10

Loss of continuity of diaphragm resulting in movement of abdominal organs into thoracic cavity

Question 11

How can blunt trauma to the thorax/abdomen result in a diaphragmatic hernia?

Answer 11

Rapid deflation of lungs with open glottis; large peritoneal pressure gradient —> muscle and ventral portions of diaphragm most susceptible to tears

Question 12

Surgery is emergent if which organ is herniated?

Answer 12

Stomach!

Question 13

What is the approach for Diaphragmatic Herniorraphy (repair of the hernia)?

Answer 13

Ventral midline abdominal: we need to be able to visualize and have access to the diaphragm -replace organs into abdomen in correct orientation *may need to extend into median sternotomy

Question 14

What type of suture/patterns do we use to actually repair the hernia?

Answer 14

Simple continuous pattern for apposition; Long-lasting absorbable: PDS Non-absorbable: Prolene

Question 15

Term for congenital communication between pericardium and peritoneal cavity?

Answer 15

Peritonealpericardial diaphragmatic hernia (PPDH)

Question 16

Why do we see an enlarged cardiac silhouette on radiograph in PPDH?

Answer 16

Because the pericardium is filled with things (liver, intestines, etc.) — you can also sometimes see the communication of the enlarged cardiac silhouette with the abdominal cavity

Question 17

How do we approach surgery for PPDH?

Answer 17

Ventral midline abdominal approach; same as traumatic diaphragmatic hernia - dont need to close the pericardium - just get everything back into the abdominal cavity and close up the diaphragmatic defect

Question 18

What is a flail chest?

Answer 18

Numerous ribs in communication that have been fractured (compressed) and portions of the ribs are moving paradoxically with breathing

Question 19

What is the term for the condition involving a congenital deformity where there is inward concavity of the sternum?

Answer 19

Pectus Excavatum (Tx: external splintage w sutures that encircle the sternum and pull sternum twd splint)

Question 20

A 10yo MN Labrador has been diagnosed w/Laryngeal Paralysis based on upper airway exam. What is the recommended treatment that you will discuss with the owner?

Answer 20

Unilateral Arytenoid Lateralization

open up airway to give them a bigger rima glottidis so they can breathe.
You can do medical management but that’s not recommended…

Question 21

What do we examine in the pleural effusion & chylous effusion to say that it’s “chylous”?

Answer 21

Triglycerides!

Question 22

If a dog has torsed a lung lobe, what would you expect to see on thoracocentesis diagnostics?

Answer 22

Serosanguinous/ chylous effusion

Question 23

Which dogs are most commonly affected by Lung Lobe Torsion?

Answer 23

large, deep chested dogs & pugs!
(Afghans are one of the big ones)
Shiba inu

if you see a pug that is having respiratory distress, and it’s not because of the upper airway (of course you want to make sure; that’s why chest radiographs are always important), it may have a lung lobe torsion.

Question 24

What is Intestinal Lymphangiography?

Answer 24

Lymphatic drainage in the abdomen: cysterna chyli

next up, is the thoracic duct within that chest cavity
so we need to outline that - inject lymph node w/contrast agent & then you can see that thoracic duct/associated lymphatics— you may not see them unless they are filled w/ a fatty material! —> oil or cream per os

then the lymphatics are very bright!!

if that doesn’t work, you can inject methylene blue into a lymph node (but that’s in the abdomen, & we need to be in the thoracic cavity, so we have to make a couple different approaches)