Asheville–Buncombe Technical Community College



THORACIC SURGERY II (continued)

• Thoracotomy

← Anesthesia

– CVP (anesthesia preference)

– Arterial line

– Epidural

– Blood available

← Medications

– NS

– Sterile Water

– Antibiotic in the Irrigant

– Local: lidocaine or marcaine. with or without epi

– Bone Wax

– Surgicel, Avitene, Thrombin and Gelfoam

– Focal-Seal, Other Fibrin Sealants such as Bio-Glue, Hema-Myst

← Thoracic Incisions

– Posterolateral thoracotomy

← Lateral chest position for patient

← Maximum exposure to lung, esophagus, diaphragm, and descending aorta

← Anterior submammary fold about nipple level to scapular tip

← May be as high as spine of scapula

← For pulmonary resections (lobectomy, pneumonectomy, wedge resection), hiatal hernia repair, and thoracic esophagus

– Anterolateral thoracotomy

← Supine position

← Support under affected side to shoulder 20 to 45° for posterior incision extension

← Hips may be rotated by buttock padding

← Submammary incision just below breast from anterior midline to mid or posterior axillary line

← Access at fourth intercostal space

← For pulmonary cyst or localized lesion resection or open lung biopsy

– Thoracoabdominal incision

← Lateral position

← Incision from posterior axillary line to abdominal midline

← 7th or 8th intercostal space

← Exposure to upper abdomen, retroperitoneal area, and lower chest

← Repair of hiatal hernia, esophagectomy, espophagogastrectomy, retroperitoneal tumors, and thoracic aneurysm resection

– Median sternotomy

– Other: transaxillary, supraclavicular, cervical mediastinotomy, anterior approach

– Factors influencing thoracic incision location:

← Exposure

← Physiologic intrapleural pressure changes

← Chest movement

← Maintenance of chest wall integrity and diaphragm

← Lung and underlying pleura condition

← Minimizing invasiveness of procedure

←

← Patient Positioning [Posterolateral]

– Operative side up

– Beanbag (surgeon preference) under drawsheet

– Pillow under head, axillary roll (protect brachial plexus)

– Upper arm on padded mayo, lower arm on padded armboard

– Padding under bottom leg, pillows between legs (peroneal nerve) and feet

– Safety strap and tape across mid pelvic area

– Lower body Bair hugger sheet, cover with blanket

← Prep and drape

– Towel drape over epidural catheter

– Base of neck to hips and side to side to bed

– Begin at incision site work around in circle, prepping axilla last

– Usually betadine soap followed by betadine paint

– Towels x 4-5, drying towels, Ioban, Universal or laparotomy sheet(s)

← Equipment

– ECU

– Suction x 2 (1 for surgery & 1 for beanbag)

– Bair Hugger

– Bronchoscopy Cart

– Stapler Cart

← Instrumentation

– CV or Major Tray

– Chest Retractor of Surgeon Choice (Finochettio, Tuffier, Burford)

– Extra long instrument tray

– Doctor specials

– Long medium and large clip appliers

– Chest Tray Instruments

← Davidson scapular retractor Duval Lung clamps

← Allison lung retractor (whisk) Bronchus clamps

← Box cutter, Bethune rib shears, Guillotine Bailey rib approximator

← Doyan raspatories (pigtails) right & left

← Elevators (Cameron, Alexander, periostial, other)

← Supplies

– Basic or cardiovascular pack Minor or major basin set

– Transverse laparotomy or universal drape pack Gowns, gloves, towels

– Chest tubes (various are surgeon preference) Clip cartridges

– For chest tubes, cutting ndls w/ heavy silk ties Bovie with extension

– Magnetic pad/drape Raytex for sponge sticks

– Laparotomy sponges Long umbilical tapes

– Suction tubing, yankauer tip, cell saver (optional) Kittners

– Suture (prolene, silk, heavy fascia/muscle layer suture, vicryl, other nonabsorbable, skin suture)

← Procedure (Thoracotomy with lobectomy or pneumonectomy)

– Incision made with #10 or #20 blade on #3 knife handle (made at 4th intercostal space for UL/5th or 6th for ML or LL)

– Cautery used to bovie bleeders and open the fascia and muscle layer

– Surgeon will used his hand to loosen fascia

– Surgeon assistant will hold a scapular retractor so surgeon can free up entire area

– May want forceps (debakeys) and cautery or metz to open muscle layer

– If removing a rib will use periosteal elevator such as a cameron or alexanders to scrape away fascia and cartilage from rib

– Will use doyan pigtail to completely free rib

– Will cut rib at either end to remove it with a guillotine or rib shear

– Self-retaining retractor of choice is placed after rib removal

– If does not remove a rib will place self-retaining retractor of choice

– May use a burford (short or long blades or one of each) or tuffier or finochettio

– Once retractor is in, will change to long bovie extension tip; give surgeon and assistant long debakeys (may want extra long debakeys/have extra long instrument set available); dissection of target lobe or entire lung begins

– Right angle & 0 silk ties to tie off vein/arteriole branches, also long medium & large clips; maybe silk or prolene suture on a 3-0 or 4-0 taper needle

– Will dissect with long metz alternating with the cautery, debakeys and a long kittner on a long kelly

– Lung retractor (whisk or egg-beater) or sponge stick to the assistant for exposure

– 1-2 Lovelace lung clamps when ready to staple bronchi or lobe tissue

– For lobectomies and pneumonectomies use linear staplers [55mm or 75mm] May want bovine pericardial or synthetic peri-strips applied to stapler (used to reinforce suture line made by the stapler)

– Thoracotomy staplers are U-shaped [35mm, 60mm, and 90mm staple line length]

← 35mm and 60mm may be 3.5mm (blue) or 4.8mm (green) staple width and have reloads in those sizes

← White staple reloads are thicker than the blue or green

← 35mm also come in a vascular style (red) for bronchi

← Manufacturers recommend a new stapler be used after reloading three times (This is often not done for cost saving reasons)

– Once a stapler is fired a 15 blade on a long #3 knife handle will be used to free the tissue from the staple line; several stapler applications may be needed

– Once the wedge, lobe or lung is removed the chest cavity will be irrigated with warm NS or Water using an asepto or cytal pitcher and suction. Irrigant will be left in momentarily to determine air leaks in the suture line (there will be bubbling). Repair suture may be needed (silk or prolene)

– Hemostatic or synthetic sealant agents may be used

– Irrigation

← NS is used when there is no cancer

← Water is used if there is cancer present. Water causes lyses of cancer cells, which can allow those cells to be suctioned out of thorax. NS could lead to metastasis or spreading of the cancer cells to other areas if those cells that are present are not lysed and suctioned out. These patients often will receive radiation or chemotherapy post-hospitalization

– Specimen – always ask before you pass it off. Clarify specimen type and what the specimen is with the surgeon

← If a lobe or wedge is removed, it will be sent for frozen with margins

← NEVER pass off lung tissue or lymph nodes to go in formaldehyde (permanent specimen) unless CERTAIN that is what surgeon wants!

← Waiting will be involved to determine if margins are clear. If margins are not clear, you will go back and remove more lung tissue

– Once the irrigant is suctioned out, chest tubes of the surgeon’s choice will be placed using a 10 blade on a #3 knife handle (incisions are made below the thoracotomy incision), cautery may be used, a tonsil or kelly will be used to pass the chest tube through the chest wall for placement in the thoracic cavity

– These will be sewn in using a large cutting eyed-needle with a #1 silk tie for each chest tube inserted. Chest tubes must be secured with tape or plastic tie bands; may not use any chest tubes with a pneumonectomy. Tubes should be cut for approximately 5 inches of length, a Y connector inserted for two, and hooked up to the pleurevac

– Pleurevac should be filled with NS to appropriate level. Pleurevac is usually water seal drainage with suction. Pneumovac or pneumonectomy pleurevac has pressure control chambers/NO suction and are used only for pneumonectomies. Regular pleurevacs are used for chest drainage for all other chest procedures

– Pericostal closure of the thoracotomy incision will begin with one or two bailey rib approximators for rib reapproximation

– Heavy (#1) absorbable suture (vicryl, dexon, or PDS) on a CTX or TP-1 taper needle for intercostal muscle closure. These are usually interrupted sutures (have mayo scissors ready to cut and hemostats). They are usually placed, needle cut, and tagged with a hemostat. They are tied after they are all placed

– Remaining muscle/fascia closed w/ running #1 PDS or Vicryl on CTX taper ndl

– Subcutaneous tissue closed w/ a 2-0 or 0 Vicryl on a CT-1 or CTX tapered ndl

– Subcuticular layer will be with 4-0 Vicryl or Monocryl on a PS-1 cutting needle

– Skin staples may be used in some institutions

– Dressing is drain sponges or 4x4s for the chest tubes, telfa, 4x4s, and Primapore Other dressing choices may be used

– Watch when patient is being moved to make certain that chest tubes are clear and not pulled out!

• Descending Thoracic Aneurysm Repair

← Anatomy and Physiology of Thoracic Aorta

– Thoracic aorta extends to the diaphragm, supplies chest wall, diaphragm, esophagus, bronchus, and the spinal cord

← Pathology of Aneurysms

– Localized abnormal dilation of an artery resulting in pressure of the blood on the vessel wall that has been weakened. Develop at sites of arterial weakness

– Causes:

← atherosclerosis (primary)

← Congenital weakness -- 2 hereditary disorders that affect the elastic connective tissues which lead to weakening or thinning of the aorta -- Marfan’s syndrome and Ehlers Danlos syndrome

← Trauma

– Types of aneurysm:

← True-arterial wall weakness; aneurysmal sac involves one or all layers of arterial wall

← False-results from trauma, causes leakage into a layer of the arterial wall creating a blood clot or hematoma

← Dissecting-as intima of artery tears, blood escapes which can lead to hemorrhage and sudden death

– Thoracic aneurysm

← Origin point at or below the left subclavian artery

← Depending on extensiveness of aneurysm, can be operative or inoperable

← Most frequent complication is paralysis

← Diagnosis

– Majority are asymptomatic until they become enlarged

– Discovered on routine chest x-rays

– Routine physicals when an abdominal bruit is auscultated or a pulsatile mass is palpable

– Symptoms include neck, chest, lower back, abdominal, or flank pain that extends to the groin

– Depending on aneurysm involvement can cause symptoms associated with structures supplied with blood at that section of the aorta

– Diagnostics:

← Ultrasound CT

← MRI Aortograms

← Anesthesia

– Arterial line

– Swan ganz catheter

– NG tube

– TEE to check placement of bypass cannuli (some places may use C-Arm)

– Epidural Catheter

– BLOOD available (may want in room)

← Medications

– NS irrigation with antibiotic of choice

– Topical hemostatic agents of choice

← Patient Preparation and Positioning

– Shave is anterior and posterior, including anterior thorax, abdomen, bilateral groins, to knees, and the back

– Prep is betadine soap (x 10 minutes if time permits) and betadine paint

– Position is left posterolateral or thoracoabdominal.

– Posterior Lateral Position

← Headrest, axillary roll (prevent brachial plexus injury)

← Beanbag (on bed before patient) with suction

← Padded armboard lower arm; padded mayo upper arm, or airplane arm sling

← Padding under lower leg and pillows between knees and feet

← Will expose left groin by slightly frog legging left leg

← Draping

– Towel Drape over epidural catheter, towels for perimeter of surgical site, drying towels, ioban drape, Universal Drapes or CV Drape (will expose left groin)

← Equipment

– Bair hugger (lower body) Saline Warmer

– Cell saver Bovie

– Extra suction Beanbag

– Bypass machine (partial bypass usually employed) Defibrillator

– Cryothermia Unit (available) surgeon choice

← Instrumentation

– Chest tray & open Heart tray Chest Retractor of surgeon choice

– Cardiovascular tray or Major Tray Extra long instruments

– Aortic clamps (surgeon choice) Long medium and large clip appliers

– Tube holder, allis, or edna clamps to secure bypass tubing

– Internal Defibrillator Paddles (external available) BOTH STERILE

← Supplies

– Cautery Open heart specialty tray

– Major Basin Tray Magnetic Drape

– Miscellaneous prolene suture Misc silk ties

– Straight Woven Dacron Grafts (Misc sizes) Cutting free needles

– Femoral arterial and venous cannuli Tourniquet snares or rommels

– Vessel loops or umbilical tapes Chest tubes

← Medications

– Warm NS with antibiotic of choice

– Heparinized saline

– Topical hemostatic agents

← Procedure: A. Left groin exposure for atrial to femoral bypass by centrifugal pump for lower aortic vessel perfusion

– Scalpel > metz/cautery > Weitlander

– Right angle > Vessel loops or umbilical tapes

– Rommel or tourniquets (if using 18F robnel catheters, cut pc about 3” long during your set-up)

– Patient is heparinized > peripheral debakeys x 2

– 11 blade [arteriotomy], arterial cannula, tubing clamps (one for arterial cannula one for pump tubing). Must not introduce air to line, may fill with NS slowly

– Vascular clamp or tonsils x 2 may be used to grab femoral vein, 11 blade venous cannula, tubing clamps (same as arterial sequence)

– May secure cannuli with heavy silk sutures on cutting needles to patient’s skin

← Procedure: B Thoracotomy

– Incision made with #10 or #20 blade on #3 knife handle

– Cautery used to bovie bleeders and open the fascia and muscle layer

– Surgeon will used his hand to loosen fascia

– Surgeon assistant will hold a scapular retractor so surgeon can free up entire area

– May want forceps (debakeys) and cautery or metz to open muscle layer

– If removing a rib will use periosteal elevator such as a cameron or alexander to scrape away fascia and cartilage from rib

– Will use doyan pigtail to completely free rib

– Will cut rib at either end to remove it with a guillotine or rib shear

– Place chest retractor of surgeon choice

– Dissect to aorta

– May isolate with a long polyester tape or 1” penrose and clamp with a kelly

– Will measure aorta to determine graft size needed; obtain graft requested

– Surgeon may request more heparin be given

– Aorta is cross clamped with aortic clamps x 2

– Aortic arteriotomy made with blade of choice on long knife handle

– Aneurysm tissue and clot are removed

– Graft will be sewn in with prolene suture (should have what surgeon uses ready to go (this is a surgery where time is of the essence, you will be MOVING) proximal end then distal end

– Clamps are removed, proximal first

– Suture will be tied down after removal of clamp to allow aorta to vent (avoids air being left in aorta). Surgeon may want his hands wet to tie

– Protamine is given and patient is taken off bypass when stabilized

– Have peripheral debakey clamps and tubing clamps ready, as well as prolene suture to close femoral artery and vein of surgeon choice

– Irrigation of wounds

– Femoral incision packed temporarily with antibiotic soaked raytex until closed

– Chest tube placement with anchor sutures

– Suction them out before connecting to Pleurevac

– Chest will be closed as per thoracotomy incisions (periostium, muscles, fascia, subcutaneous, subcuticular)

– Groin will be closed

– Dressings per surgeon choice

• Other Aortic Aneurysms

• Type I

• Type II

• Type III

• Discussion

•

• Coronary Angioplasty (PTCA)

• Discussion

• Cell Salvage by Cell Saver

• Cell salvage refers to blood recovered during surgery and reinfused. It is directly suctioned, filtered, anticoagulated, and reinfused with little RBC damage.

• May be aspirated directly or via squeezed out sponges into a basin

• Contraindications for Cell Saver

← No hemostatics-may clot blood rendering it useless

← Certain antibiotics (ex. Bacitracin) may lyse cells, damaging them

← No exposure to gastric contents, amniotic fluid, or fluid potentially containing cancerous cells

← No local or systemic infection

• Cardiopulmonary Bypass (CPB)

• Method used to divert blood from the heart and lungs to provide a stationary bloodless field and optimal organ tissue function during heart surgeries. [OPCAB (off pump coronary artery bypass) heart is beating and bleeding; visibility challenging; preferred for patients at risk of complications from CPB; must be to be ready to go on bypass if the patient cannot tolerate CABG procedure without having an arrested heart]

• Procedure

← Blood is removed from the right atrium via the inferior vena cava. Can be accomplished using inferior vena cava cannulation alone or with both SVC and IVC cannulation called bi-caval cannulation

← Blood routed to the CPB machine for oxygenation

← Blood is returned via the aortic cannula or femoral arterial cannula to provide oxygenated blood to the patient’s body

← Heparin is given intravenously for anticoagulation. Cannuli and CPB circuits may also be heparin-bonded

• CPB Machine Components

← Oxygenator-removes carbon dioxide and delivers oxygen

← Heat exchange coil-can heat or cool the blood

← Pump-moves the blood

← Filters-removes particulate, air, microemboli

← Sensors-detect air bubbles, low oxygen saturation, and low blood volume collection

• CPB Perfusionist controls physiologic variables along with anesthesia & surgeon

← Hemodilution ↓ blood viscosity =↓clot

← HCT ↓ = ↓ clotting

← Hypothermia = ↓ cellular oxygen consumption/demand = ↓ chance of organ damage

← Core temperature is ↓ from 28 to 30° C

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