Trachea And Thoracic Surgery Flashcards
A cervical ventral midline approach allows access to what structures?
Cranial cervical trachea Sternohyoideus and sternohyoideus mm Recurrent laryngeal n Vagosympathetic trunk R and L common carotid arteries Thyroid glands Esophagus
A median sternotomy allows access to what structures?
Caudal cervical and cranial thoracic trachea
An intercostal thoracotomy through the right 3rd ICS allows access to what structure?
Cranial thoracic trachea
An intercostal thoracotomy through the right 4th ICS allows access to what structure?
Tracheal bifurcation
What are the surgical diseases of the tracheal?
Tracheal collapse Esophagotracheal/esophagobronchial fistual Foreign body Neoplasm Trachea rupture (trauma) Hematoma
How is tracheal collapse managed medically?
Cough suppressants (lifelong) - hydrocodone, or butorphanol
Corticosteroid (pred) to reduce inflammation
Antibiotic if secondary to infection
Sedation for events that cause excessive excitement/stress - acepromazine
Bronchodilator (theophylline) useful in some cases
Lifestyle changes and weight loss
When do we surgically treat tracheal collapse?
Only when medical management has failed
What are possible surgical treatments for tracheal collapse?
External prosthetic tracheal rings - for cervical trachea only
Intraluminal stent
How are external prosthetic tracheal rings placed?
Only in cervical tracheal
Ventral midline cervical approach
Secured to cartilaginous rings
Must start and end ring placement in area of normal trachea
What are complications for external prosthetic tracheal rings?
Laryngeal paralysis. -> damage during surgery or continued trauma from implants
Tracheal necrosis -> secondary to damage to trachea’s segmental blood supply (life threatening)
Pneumothorax -> diffusion of air through mediastinum during surgery
How is an intraluminal stent placed?
Self-expanding nitinol stent
Placed fluoroscopically or endoscopically
Advantages of placing an intraluminal stent?
Minimally invasive
Shortened anesthesia time
Can be used in cervical and thoracic trachea
Immediate improvement in clinical signs
Complications of using intraluminal stenting?
Stent fracture
Stent migration
Tracheitis
Collapse beyond stented region —> mainstream bronchi
Tracheal obstruction secondary to granulation tissue formation —> can respond to treatment with corticosteroid and colchicine
Tracheal rupture
What is internal tracheal trauma usually caused by?
Rupture or necrosis secondary to ET tube (cats > dogs)
Foreign bodies
When is external trachea trauma seen?
Blunt or penetrating injuries
Bite wounds
Lacerations
Clinical signs of tracheal trauma?
SQ emphysema Anorexia Lethargy Stridor Coughing Dyspnea
How are minor treachal tears treated?
Medically
- cage rest
- O2 supplement
- sedatives
- thoracocentesis/thoracotomy for pneumothorax
- temporary tracheostomy (maybe)
If dyspnea persists or worsens —> surgical repair
- primary closure of tear
- simple continuous pattern
- fine absorbable suture
Surgical intervention is indicated for tracheal tears when… ?
Dyspnea persists or worsens with medical management
Pneumothorax persists >2-3 days
Severe damage is visits
What technique is used for tracheal resection/anastomoses?
Split cartilage technique
- results in least amount of stenosis postop
- difficult in small dogs and cats
Can resect 25-50% of trachea in adult dogs, only 20-25% in puppies
Complications for tracheal resection and anastomoses?
SQ emphysema Pneumomediastium and pneumothorax Infection Stricture -> poor apposition of mucosa -> tension -> inflammation
When is a permanent tracheostomy indicated?
Salvage procedure
- untreatable upper airway obstruction
- upper airway treatment failure
What is the long-term care for a permanent tracheostomy ?
Excessive secretions for weeks pot op
Maintenance of opening - clip hair
No swimming
Protection from foreign bodies- plant material
Harness
What is the prognosis for permanent tracheostomies?
Good for indoor dogs if underlying dz in benign
Poor to guarded in cats
-mucous plugs are common
Median survival time is 20-42days
Soft tracheal cartilage may predispose to collapse
What is the most common surgical approach to the thoracic cavity?
Lateral thoracotomy
What surgical approach allows access to the thoracic cavity during celiotomy or other procedures that may require access to the abdominal cavity?
Transdiaphragmatic
What are the indications for a median sternotomy?
Bilateral thoracic exploration
Cranial mediastinal masses
Cranial thoracic trachea
*Leave manubrium/xyphoid intact
How is a median sternotomy closed?
Figure 8 of polypropylene sutures or orthopedic wire
What are minimally invasive approaches for thoracic surgery?
Thoracoscopy
-> can have intercostal or trandiaphragmatic subxiphoid portals
Video assisted
-> uses thoracoscopy telescopes and either standard surgical instruments/ endoscopic
T/F: positive pressure ventilation is required for thoracic surgery
True
Removal of an entire lung is called?
Pnumonectomy
When is a pneumonectomy indicated?
Disease is diffuse through multiple lung lobes (neoplasia, abscess, trauma, infiltrative inflammatory disease)
What is the surgical approach for a pneumonectomy?
Lateral intercostal approach
You are doing a total lung lobectomy on on the left cranial lobe. Which intercostal space do you enter through?
Left 5th
You are doing a total lung lobectomy on on the left caudal lobe. Which intercostal space do you enter through?
Left 7ths
You are doing a total lung lobectomy on on the right cranial lobe. Which intercostal space do you enter through?
Right 5th
You are doing a total lung lobectomy on on the right middle lobe. Which intercostal space do you enter through?
Right 5th
You are doing a total lung lobectomy on on the right caudal lobe. Which intercostal space do you enter through?
Right 7th
What suture technique can be used for partial lobectomy??
Suture proximal to clamps
- one to two rows of continuous suture patter
- excise mass and oversew transection site
Guillotine suture may be used for biopsies and very small peripheral masses
What suture technique is used for complete lobectomy?
Triple ligation of vessels
-cut between middle and distal ligatures
Place horizontal mattress sutures in bronchus
Oversew transacted end of bronchus with simple continuous pattern
What is the stapling technique for portion/complete lobectomy?
Thoracoabdominal stapler (TA) Locate hilus of lobe and stable entire pedicle (vessels and bronchus)
Excise lobe distal to staples
You just did a lobectomy on a dog.. what are you going to check for prior to closing?
Bleeding/hemorrhage
Air leakage
- fill thoracic cavity with saline and look for bubbles
-ventilate up to 25-30cmH2O
-very small leaks will likely seal within 24-48hours
Chest tube placed via separate intercostal incision
What are surgical disease of the pulmonary parenchyma?
Spontaneous pneumothorax Traumatic pneumothorax Brochoesophageal fistulas Lung lobe consolidation and abscessation Bronchiectasis Lung lobe laceration Lung lobe torsions Neoplasia
What is the recommended treatment for spontaneous pneumothorax?
Partial or complete lung lobectomy —> access via median sternotomy
The conservative treatment is by placing thoracostomy tubes but this is associated with a high rate of recurrence
What are causes of lung laceration?
Iatrogenic
- thoracocentesis
- thoracostomy tube
- inadvertent cut during thoracotomy
Rib fractures
Penetrating trauma
When is surgical treatment of a lung laceration indicted?
Uncontrollable or unresolving pneumothorax
Ongoing intrathoracic hemorrhage
What techniques can be used to surgically treat lung lacerations?
Continuous inverting suture pattern (eg lambert)
Deep hemostatic mattress suture with simple continuous closure of laceration
Partial or compete lobectomy
What dogs are most commonly affected by lung lobe torsion?
Large dog, deep chested: middle or left cranial lung lobe
Pug: left cranial lung lobe
What are possible causes of lung lobe torsion?
Pleural effusion
Partial collapse of lung lobe
Lung lobe torsion results in ???
Venous and lymphatic congestion
Consolidation
Pleural effusion
Clinical signs of lung lobe torsion?
Acute
Dyspnea, tachycardia, cough
Exercise intolerance
Hemoptysis
Pyrexia, pale mm, decreased lung sounds ventrally
You have decreased lung sounds ventrally so you do a thoracocentesis, you see serosanguinous or chylous effusion..
and radiographs show a consolidated lung lobe
what is your dx?
Lung lobe torsion
What is your initial treatment for lung lobe torsion?
For patient stabilization
Thoracocentesis
Oxygen supplementation
IV fluids
What is the surgical treatment for lung lobe torsion?
Lobectomy
—> intercostal thoracotomy
*** DO NOT untwist lung —> avoid reperfusion injury
What is the prognosis for lobectomy due to lung lobe torsion?
Good for pugs
Fair to guarded for other breeds
-second torsion can occur
How long are chest tubes required after a lobectomy from lung lobe torsion?
3-5days
You have an idiopathic chylothorax.. how can you visualize the vessels during surgery?
Intestinal lymphangiography
- oil or cream per os
- methylene blue into ileocecal node or water soluble contrast into catheterized lymphatic
What are the surgical options for idiopathic chylothorax ?
MUST DO: Thoracic duct ligation or En bloc ligation
Can do these added on..
Pericardectomy
Cisternii chylii ablation
Pleuroperitoneal shunt
How is an idiopathic chylothorax surgery managed post op?
Chest tube or pleuroport placement for continued drainage
Complications of surgery for idiopathic chylothorax?
Continues/recurrent effusion
Lung lobe torsion
Prognosis for surgical treatment of idiopathic chylothorax?
60-100% resolution
Worse in cats
What is a diaphragmatic hernia?
Loss of continuity of diaphragm resulting in movement of the abdominal organs into the thoracic cavity
T/F: congenital diaphragmatic hernias are most common
False
Traumatic are most common
T/F: Most tears in the diaphragm are seen in the ventral portion
True
Most common presenting signs with chronic diaphragmatic hernia?
Respiratory and gastrointestinal signs
- dyspnea, exercise intolerance, and lethargy
- vomiting, regurg, inappetence
Muffled lung sounds Borborygmi auscultated in the thorax Tachycardia Tachypnea Empty abdomen on palpation
Dx?
Diaphragmatic hernia
You want to do diagnostic imaging to confirm a diaphragmatic hernia, what method will you use?
Radiographs with Positive contract celiography
- inject dilute sterile contrast into abdomen
- look for contrast in thoracic cavity
- false negative results due to fibrin sealing diaphragm defect with chronicity
Ultrasound (93% accurate)
Treatment for diaphragmatic hernia?
Stabilize first
- consider pleural effusion in chronic cases (US thoracocentesis)
- O2 therap
- prop patient to move organs caudally
When is a surgery for a diaphragmatic hernia an emergency??
If stomach is herniated
What is the method used for a diaphragmatic herniorraphy ??
Ventral midline abdominal approach
Organ resection
- adhesions in chronic hernia
- liver lobe torsion
Replace organs into abdomen
Repair tear with continuous suture pattern
-PDS or proline
-large defects with meth or muscle flap
Exploratory for organ trauma
Remove air from thoracic cavity
Complications seen with diaphragmatic herniorraphy?
Re-expansion pulmonary edema
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