Thoracic Surgery
Lec : 5Thoracic Surgical Approaches
Most thoracic operations done with the patient anasthized and Double Lumen endotracheal tube is used which enable separate ventilation of each lung by blocking the ventilation from the side of surgery so that surgeon can work on deflated lung . Another benefit is that secretions and blood from operated lung will not return to the contralateral lung on which we depend during surgery for ventilation.1.Viedo Asisted Thoracic Surgery ( VATS) :- done by using multiple thoracoscopic ports introduced into thoracic cavity through multiple small access incisions.
Advantages:- 1.less pain 2.Early recovery 3.Short hospital stay 4.No muscle cutting incisions is required
VATS can be used to do Lobectomy, Segmental lung resection,Sympathectomy,lung and Pleural biopsy. patient who get benefit from VAST are:-
1. Patients with impaired Cardiopulmonary function.
2. Advanced age.
3. Vascular problem
4. Extrathoracic malignancy
5.Recent or impendig major operation
6. Impaired wound healing. e g D.M
7. Immunosuppression e.g HIV.
2. Posterolateral Thoracotomy:- Is the most frequently used incision for open procedures , the patient is placed in lateral position, the incision begins in the anterior axillary line just below the nipple and extends below the edge of scapula and then up between the vertebral boarder of scapula and spinous process of vertebrae , the Latimus Dorsi and serratus anterior muscles are divided and the chest entered through 5th intercostal space. Aftre completance of required procedure Two chest tubes are inserted before closuer of chest ,the 1st one is called Apical tube which is put through 7th intercostal space at anterior axilllary line and advanced to the apex of Hemithorax and the 2nd one put through 8th interspace at posterior axillary line to the posterinferior part of Hemithorax to drain oozing blood and /or fluid and called the Basal tube.
3. Anterolateral Thoracotomy :- the chest is entered through the 4th interspace as the Pt. is in supine position. It allows quick entery into thoracic cavity and used in emergency conditions with haemodynamic instability especially when cardiac injury suspected.
4. Clam Shell Thoracotomy :- it is combination of bilateral anterior thoracotomy plus Transverse sternotomy used for Double Lung Transplantation.
5. Trap Door Incision :- it is combination of anterior thoracotomy and partial Median sternotomy to gain access to Mediastinal structures in the superior and anterior Mediastinum.
Lung Abcess :- Is localized area of pulmonary paranchymal necrosis with tissue destruction and cavity formation.
Etiology :- 1. Primary Lung Abcess :-
a. Necrotizing Pneumnia caused by Staph. Aureus , Klebsiella , Pseudomonas and Mycobacteria infections.
b. Aspiration Pneumnia occur when consciousness is impaired with suppress of cough reflex as perioprative period ,strock ,abuse of drug and Alcohol.
c. Esophageal disorder like Achalasia , GERD .
d.Immunosuppression in which infection occurs by apportunistic microorganisim as in carcinomas , DM , Steroid therapy , Mulnutrition , Transplantations .
2. Secondary Lung Abcess :-
a. Bronchial obstruction by Tumor , Foreign bodyb.Systemic sepsis as in septic pulmonary embolism , seeding pulmonary infarct.
c.Complications of pulmonary trauma e.g infected hematoma , penetrating injuries.
d. direct extension from extraparanchymal inf e.g Empyma , Subphrenic abcess.
Microbiology :- In community acquired pneumonia is mostly due to Gram Positive organisim while in hospital acquired cases 60- 70% is from Gram negative orgnisim , in immunosuppressed cases infection occur from apportunitic organisim , while in aspiration pneumonia there is polymicrobial cause
Clicical Featuers :- Productive cough , Fever > 38.9c , Chills , Increase WBC count , decrease Weight , Pleuretic chest pain , dysphnia ,Anemia .
Complications:- 1.Massive hemoptasis. 2. Endobronchial spread to other lung. 3. Ruptuer to pleura. 4.Devlopment of payopneumothorax . 5.Septic shock and respiratory failure. 6.Mortality from 5-10% in normal patient reach to 30% in immunocompramised
Chest Film :-
1. Intact Abcess :- Mass with thin wall cavity.2. Ruptuerd Abcess with communication with tracheobronchial tree :- Air Fliud level .
CT Scan :- help to settle Dx and assess associated mass or endobronchial obstruction.
DDx :- 1. Loculated or interlober Empyma . 2. TB , Fungal infection 2.Infected lung cyst or bullae.Sputum for C and S is of limited value due to contamination with upper respiratory tract flora
Bronchoscopy :- help to exclude endobronchial obstruction by tumor or Foreign body ,also to take bronchial wash for C and S.
Percutaneous Trans thoracic FNA for C/ S under U/S or CT guide
Mx :-start with Broadspectrum antibiotics modified later according to results of C / S for 3 -12 Wks till cavity resolve or serial CXR show improvement.
Surgical drain is uncommon it is indicated in :-
1. Failuer of medical treatment 2. Abcess under tension3. increase in size despite treatment 4.Other lung contamination 5.Abcess > 4-6 Cm in diameter 6.inability to exclude cavitary carcinoma
Surgical drain either by :-
1.Chest tube or percutaneous drain cather for abcess in contact with chest wall.
2.Thoracotomy and surgical cavernostomy to remove whole abcess cavity usually by lobectomy especially with bleeding or payopneumothorax
Important intraoperative consideration is to protect the other lung with Double Lumen ETT