Chaper 53 - Thoracic & thoracoabdominal vascular exposures

Question 1

Median sternotomy patient position

Answer 1

Supine with arms tucked

Question 2

Steps of median sternotomy

Answer 2

1) incision below sternal notch to tip of xyphoid
2) Divide pectoral fascia
3) Score midline of periosteum
4) Divide interclavicular ligament at top of sternal notch
5) Divide sternum with sternal saw
6) Cautery and bone wax for hemostasis
7) Divide sternopericardial ligament to free pericardium from posterior sternum
8) Free up brachiocephalic vein
9) Oper superior portion of pericardium

Question 3

How to gain more exposure to carotids or subclavian after median sternotomy

Answer 3

Carotid: along anterior border of SCM
Subclavian: supraclavicular incision

Question 4

What to do before using sternal saw to divide stenum

Answer 4

Hold mechanical ventilation

Question 5

What must be divided to free the pericardium from the posterior sternum

Answer 5

Sternopericardial ligament

Question 6

Where is the vagus nerve in relation to the subclavian artery

Answer 6

Vagus anterior; recurrent laryngeal posterior

Question 7

Who and when was ministernotomy developed

Answer 7

Holman and Willett 1949

Question 8

What are the benefits of mini sternotomy

Answer 8

1) decrease sternal instability
2) Decrease ventricular injury and post-op adhesions
3) decrease pain
4) decrease blood loss

Question 9

Types of mini sternotomy

Answer 9

1) Inverse T

2) Upper J

Question 10

What can be used to aid in determining the level or extent of sternotomy needed

Answer 10

TEE

Question 11

Trans-sternal bilateral thoracotomy (Clamshell) disadvantage over sternotomy

Answer 11

Increase need for ventilation support post-op with clamshell

Question 12

Trans-sternal bilateral thoracotomy (Clamshell) Steps

Answer 12

1) Right 4th intercostal mid-clavicular to left anterior axillary line
2) Dissect intercostal muscles
2) ligate IMA’s on both
3) dissed pericardium and pleural away from posterior sternum
4) retract left lung

Question 13

Trans-sternal bilateral thoracotomy (Clamshell) position

Answer 13

Supine with left shoulder and hip raised slightly

Question 14

Left posteriolateral thoracotomy is used for

Answer 14

Thoracic aortic pathologies

Question 15

Left posteriolateral thoracotomy patient needs to tolerate

Answer 15

Single lung ventilation

Question 16

Position for Left posteriolateral thoracotomy

Answer 16

Right lateral decubitus

Question 17

Left posteriolateral thoracotomy steps

Answer 17

1) incision midpoint between medial border sacpula and thoracic spine
2) curvilinear incision into 4th intercostal space
3) flaps created
4) anterior edge of latissimus dorsi incised vertically
5) plane between latissimus and serratus anterior developed
6) Retract latissimus dorsi posteriorly and serratus anteriorly
7) Open pleural sac

Question 18

Thoracoabdominal exposure position

Answer 18

Modified right lateral decubitus with

1) legs flat
2) flex table

Question 19

Thoracabdominal exposure steps

Answer 19

THORACIC

1) divide latissimus dorsi and serratus anterior and rectus
2) Access into pleural space
3) Divide inferior pulmonary ligament
4) retract left lung
5) identify vagus, subclavian, esophagus, phrenic

ABDOMINAL

1) dissect lateral to rectus abdominus
2) divide anterior and posterior sheaths
3) divide obliques laterally
4) plane between transversalis and peritoneum developed
5) retract peritoneum and abdominal cavity to right
6) plane between retroperitoneal fat and psoas developed
7) Gerotas fascia and kidney lifted anterior medially
8) Dissect parietal peritoneam from periaortic fat
9) Identify ureter on back of peritoneal sac
10) ligate reno-lumbar vein
11) divide diaphragmatic crus
12) Divide median arcuate ligament

Question 20

Relationship of esophagus to aorta in the thoracic cavity

Answer 20

Esophagus anterior medial to aorta

Question 21

Where is reno lumbar vein

Answer 21

Beside left renal artery

Question 22

What to do with retro-aortic renal vein when doing retroperitoneal exposure

Answer 22

Ligate renal vein distal to adrenal and gonadal

Question 23

Standard transperitoneal abdominal exposure of visceral aorta

Answer 23

1) Supine, midline xiphoid to pubis
2) Left medial visceral rotation
3) release splenic attachment and mobilize superior medially
4) dissect between spleen and left renal by ligating splenocolic and splenorenal ligaments
5) Mobilize spleen and pancreas away from retroperitoneum
6) Dissect retroperitoneum and periaortic fat and left crus and median arcuate ligament

Question 24

Retroabdominal exposure of visceral aorta

Answer 24

Modified rigth lateral decubitus only need mild 20-30 degress hips if not getting thoracic
curvilinear midline between umbi to pubis lateral to 10th -11th intercostal space

Question 25

Key in retroperitoneal curvilinear incision

Answer 25

Stay in one dermatome

Question 26

What to divide in retroperitoneal exposure if left kidney is left down

Answer 26

Gonadal vein

Question 27

What is injured if retroperitoneal dissection and went before the psoas muscle

Answer 27

1) Ilioinguinal nerve

2) Genitofemoral nerve