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Surgery of Abdomen and Thorax Cavitities > Thoracic Surgery - Instrumentation and Thoracotomy > Flashcards

Thoracic Surgery - Instrumentation and Thoracotomy Flashcards

1
Q

What is the preferred approach to thoracic surgery?

A

Intercostal thoracotomy

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2
Q

Possible thoracic surgery complications? (7)

A

Haemorrhage
Infection
Ostomyelitis
Seroma
Ipsilateral FL lame
Wound complication
Rib #

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3
Q

When are thoracic surgery complication more likely?

A

Median sternotomy

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4
Q

What are the 5 approaches to thorax surgery?

A

Interostal
Median sternotomy
Rib resection
Transsternal
Trans diaphragmatic

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5
Q

Suction tips:
1. Fine surgery?
2. General surgery?
3. Pyothorax?

A
  1. Frazier
  2. Yankauer
  3. Poole
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6
Q

Forceps good for thorax surgery?

A

DeBakey
Duval Lung grasping forceps

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7
Q

Thorax surgery retractors?

A

Finochietto

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8
Q

Thorax surgery scissors?

A

Metzenbaum

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9
Q

Artery forceps for thorax surgery?

A

Mixter

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10
Q

Thorax surgery haemorrhage control?

A

Dithermy unit

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11
Q

What % of Complication in patients undergoing both intercostal and median sternotomy?

A

39%

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12
Q

What % of Complication in patients undergoing median sternotomy?

A

71%

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13
Q

What % of Complication in patients undergoing both intercostal sternotomy?

A

23%

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14
Q

What % of Complication in patients undergoing median sternotomy have post op pain?

A

50%

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15
Q

How to avoid seroma formation?

A

sternebrae should be sectioned longitudinally without being broken, and the manubrium and xiphoid should be left intact if possible.

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16
Q

How should a seroma be managed if the wound remains closed?

A

Conservatively

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17
Q

How should a seroma be managed if dehiscence present?

A

Open management
- vacuum assisted

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18
Q

When is the intercostal approach not the most appropriate?

A
  • General explore of both cavities (e.g. pyothroax non responsive to medical)
  • Mediastinal mass e.g. thymoma
19
Q

Which muscle should be preserved during intercostal thoracotomy?

A

Latissimus Dorsi

20
Q

How should a patient be positioned for intercostal thoracotomy?

A

Lateral recumb, FLs tied cranially

21
Q

What nerve block for intercostal thoracotomy?
How is this done?

A

An intercostal nerve block should be performed using bupivacaine injected just caudal to the ribs, in the dorsal third, at the level of the proposed surgical site and including two ribs cranially and caudally (i.e., five rib spaces in total).

22
Q

How is the incision and approach made? (Intercostal)

A

A skin incision is made at the appropriate level in a dorsoventral direction from the hypaxial musculature to the sternum, and the subcutaneous tissue is incised down to latissimus dorsi. Latissimus dorsi is undermined and retracted dorsally using Langenbeck retractors. The scalenus muscle can be seen ventrally attaching to the fifth rib and is incised to expose the underlying serratus ventralis muscle.

23
Q

What are advantages of leaving latissimus dorsi intact? (3)

A
  • Rapid closure
  • Reduced post op pain
  • Reduced post op lame
24
Q

What are the disadvantages of leaving latissimus dorsi intact? (1)

A

Reduced access to thoracic cavity

25
Q

What are the ways to identify correct intercostal space number? (20

A

-Counting ribs caudally from the J-shaped first rib, or
-By identifying the fifth rib from attachments of the caudal end of the scalenus muscle and the cranial end of the external abdominal oblique muscle.

26
Q

What step is taken deep to serratus ventralis?

A

Deep to the serratus ventralis lies the external and internal intercostal muscles and the pleura, which are transected using Metzenbaum scissors midway between the ribs to avoid damage to the neurovascular bundles (sited caudal to the rib). Care should be taken when puncturing the pleura to identify and avoid any adhesions between pleura and lung.

27
Q

Where should the pleural incision not extend beyond:
A. Ventrally?
B. Dorsally?

A

A. internal thoracic vessels (which lie laterally and parallel to the sternum and can be identified by palpation)
B. Cotochondral junction

28
Q

What is the risk if the pleural incision extends dorsally beyond costochondral junction?

A

epaxial muscle and intercostal arterial damage

29
Q

What is placed following intrathoracic procedure?

A

Thoracostomy tube

30
Q

How is a thoractomy wound closed?

A

Preplaced circumcostal polydiaxonone sutures

31
Q

What is the aim of the Preplaced circumcostal polydiaxonone sutures?

A

maintain anatomic rib position and reduce tension on the soft tissue repair, not to oppose or immobilise the ribs:

32
Q

What is the risk if high tension on closing sutures?

A

Rib #

33
Q

How are the muscle layers closed in lateral intercostal thoracotomy?

A

he serratus ventralis and scalenus or external abdominal oblique muscles are apposed using an absorbable monofilament suture and latissimus dorsi is released and apposed ventrally.

34
Q

What muscle inserts on 5th rib

A

Dorsal scelenus m

35
Q

When closing lateral intercostal thoracotomy, what anatomy must be avoided?

A

Intercostal a

36
Q

How is a patient positioned for median sternotomy?

A

Dorsal recumb, legs tied cranially

37
Q

How is the incision made for median sternotomy?

A

Manubirum to xiphoid on midline

38
Q

What is used for full thickness cutting through sternum?
What must be kept in tact?

A

Oscillating saw
Manubrium and xiphoid in tact

39
Q

What must happen to access both hemithoraces?

A

Mediastinum perforated at the dorsal aspect of sternum

40
Q

How is a median sternotomy closed?

A

Closure of the sternotomy is achieved using figure-of-eight stainless steel wire or suture (e.g. polydiaxonone or polypropylene). I use polydiaxonone in patients >30 kg: one study investigated sternotomy closure in greyhounds and found that sterna closed with polydioxanone or stainless steel wire has similar mechanical properties.

41
Q

What must be used when using oscillating saw?

A

Saline

42
Q

How much to drain chest post thoracotomy?

A

to negative pressure

43
Q

What is the most common complication of median sternotomy?

A

Seroma

44
Q

Where is a thoracoscopy possibly appropriate?

A

Thoracic duct ligation
Pericardectomy
Correcting persistent right aortic arch
Lung lobectomy
Biopsy intra thoracic lesion

Surgery of Abdomen and Thorax Cavitities (10 decks)

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