Thoracic Surgery

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Thoracic Surgery
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Overview

• What is it ?
• What do you need to know as a junior ?

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What do you need to know as a Junior on the ward ?

• Different pathologies
• Different operations
• Chest drains
• Post operative care

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Different pathologies

• Lung cancer
• Pneumothorax
• Pleural effusions
• Lung biopsies
• Trauma
• Oddities

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Different operations

• Bronchoscopy (oesophagoscopy)
• Mediasteinoscopy
• Mediasteinotomy / Chamberlains
• Thoracoscopy VATS
• Mini thoracotomy
• Full thoracotomy
• Pneumonectomy / Lobectomy / Wedge

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Anatomy

• Trachea
• 2 bronchi
• 2 Lungs
• 2 lobes on left
• 3 lobes on right

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The Right Lung
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The Left Lung
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Bronchial system
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Compartments of the chest
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Lung cancer

• Small cell
• Non small cell
• Squamous
• Adeno
• Large cell
• Undifferentiated

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Lung cancer

• Except for small cell carcinoma of the lung it is
  generally accepted that surgery is the most
  effective therapy for lung carcinoma

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Small Cell Lung Cancer
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Assessment of Patient

• Fitness for surgery
• Operability of the tumour - Staging

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Staging

• TNM
• T size and position of tumour
• N lymph node status
• M metastasis

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Stages

• Stage GroupingTNM Subsets
• Stage 0 (TisN0M0)
• Stage IA (T1N0M0)
• Stage IB (T2N0M0)
• Stage IIA (T1N1M0)
• Stage IIB (T2N1M0, T3N0M0)
• Stage IIIA (T3N1M0), (T(13)N2M0)
• Stage IIIB (T4, Any N, M0) (Any T, N3M0)
• Stage IV (Any T, Any N, M1)

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Survival
Stage 5 year Survival
1 A, B 60-85
II A,B 40-60
III A 10-40
III B lt10
IV lt5
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Fitness for Surgery

• Age
• Pulmonary function
• Cardiovascular function
• Medical conditions
• Nutritional Status
• Performance status

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Assessment of Operability

• CT scan
• Bone scan
• PET scan
• Mediastinoscopy
• Anterior Mediastinotomy
• VATS

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Pleural effusions

• Fluid in chest
• Due to underlying cause
• Usually malignant, but what ?
• Drain for
• Symptoms
• Diagnosis

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Pneumothorax

• What is a pneumothorax ?
• How do you treat them ?
• Who requires surgery ?
• What does surgery entail ?
• Thoracotomy
• Sternotomy
• Mini thoracotomy
• VATS

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Lung biopsies

• Need tissue to diagnose Interstitial lung
  disease

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Bronchoscopy
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oesophagoscopy
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Mediastinoscopy
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Mediastinoscopy
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Mediastinotomy
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Mediastinotomy / Chamberlains
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Thoracoscopy
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Video Assisted Thoracic Surgery
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Thoracotomy
Posterolateral Lateral Anterolateral Mini
thoracotomy Muscle sparing
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Thoracotomy - Posterolateral
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Thoracotomy - Anterolateral
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Mini thoracotomy

• Small incision thoracotomy

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Lung Resection

• Pneumonectomy
• Lobectomy
• Wedge

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Lung Resection Pneumonectomy
Intrapericardial Extrapericardial No
reserve Sputum pO2 Fluid balance Infiltrates Tempe
rature AF
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Lung Resection Lobectomy
3 Lobes on RT RUL RML RLL (not RUL RLL) 2
lobes on LT LUL LLL
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Wedge resection
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Chest drains

• What are they ?
• Why use them ?
• Suction and its role
• What drain do you take out MARK IT

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Function

• Conduit to remove fluid or air from the pleural
  or pericardial spaces
• The fluid may be blood, pus or pleural effusion
• Allow the lungs and heart to work unrestricted

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Spaces That Need Draining Following Thoracic
Surgery

• Only a single pleural cavity opened
• Air and blood may collect in the space
• Two drains
• Apical drain Air
• Basal drain Blood
• Traditionally apical drain is placed anteriorly
  and basal drain at the back

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Chest Drain
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Suction

• What does it do?
• Makes the external pressure negative
• Air or blood drains more easily out of chest
• Dangers
• If on to high tissues may get sucked into the
  drain damaging them
• If connected but not on similar effect to
  clamping the drains
• BEWARE PNEUMONECTOMY

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Does and Donts of Chest Drains

• Do not clamp a functioning drain as this can lead
  to a tamponade or a tension pneumothorax
• If becomes disconnected, reconnect and ask
  patient to cough
• Always keep drain below level of patient
• If raised above patient the contents may siphon
  back into the chest

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Drain Removaland Timing of Drain Removal
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On Expiration

• Pleural pressures at their highest
• But still less than atmospheric pressure
• Difficult to hold breath at full expiration
• Natural reaction to pain is to take a deep breath
  in

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On Inspiration

• Easy to hold breath on maximal inspiration
• Pleural pressure most negative therefore air more
  likely to move into pleural space

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Valsalva Manoeuvre

• Forced expiration against a closed glottis
• Creates a positive intrapleural pressure
• Easy for patient to hold

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Post operative care

• Blood pressure
• Blood gases / saturation
• Urine output
• Bleeding
• Sputum
• Analgesia