Thoracic Surgery - Instrumentation and Thoracotomy

Question 1

What is the preferred approach to thoracic surgery?

Answer 1

Intercostal thoracotomy

Question 2

Possible thoracic surgery complications? (7)

Answer 2

Haemorrhage
Infection
Ostomyelitis
Seroma
Ipsilateral FL lame
Wound complication
Rib #

Question 3

When are thoracic surgery complication more likely?

Answer 3

Median sternotomy

Question 4

What are the 5 approaches to thorax surgery?

Answer 4

Interostal
Median sternotomy
Rib resection
Transsternal
Trans diaphragmatic

Question 5

Suction tips:
1. Fine surgery?
2. General surgery?
3. Pyothorax?

Answer 5

1. Frazier
2. Yankauer
3. Poole

Question 6

Forceps good for thorax surgery?

Answer 6

DeBakey
Duval Lung grasping forceps

Question 7

Thorax surgery retractors?

Answer 7

Finochietto

Question 8

Thorax surgery scissors?

Answer 8

Metzenbaum

Question 9

Artery forceps for thorax surgery?

Answer 9

Mixter

Question 10

Thorax surgery haemorrhage control?

Answer 10

Dithermy unit

Question 11

What % of Complication in patients undergoing both intercostal and median sternotomy?

Answer 11

39%

Question 12

What % of Complication in patients undergoing median sternotomy?

Answer 12

71%

Question 13

What % of Complication in patients undergoing both intercostal sternotomy?

Answer 13

23%

Question 14

What % of Complication in patients undergoing median sternotomy have post op pain?

Answer 14

50%

Question 15

How to avoid seroma formation?

Answer 15

sternebrae should be sectioned longitudinally without being broken, and the manubrium and xiphoid should be left intact if possible.

Question 16

How should a seroma be managed if the wound remains closed?

Answer 16

Conservatively

Question 17

How should a seroma be managed if dehiscence present?

Answer 17

Open management
- vacuum assisted

Question 18

When is the intercostal approach not the most appropriate?

Answer 18

• General explore of both cavities (e.g. pyothroax non responsive to medical)
• Mediastinal mass e.g. thymoma

Question 19

Which muscle should be preserved during intercostal thoracotomy?

Answer 19

Latissimus Dorsi

Question 20

How should a patient be positioned for intercostal thoracotomy?

Answer 20

Lateral recumb, FLs tied cranially

Question 21

What nerve block for intercostal thoracotomy?
How is this done?

Answer 21

An intercostal nerve block should be performed using bupivacaine injected just caudal to the ribs, in the dorsal third, at the level of the proposed surgical site and including two ribs cranially and caudally (i.e., five rib spaces in total).

Question 22

How is the incision and approach made? (Intercostal)

Answer 22

A skin incision is made at the appropriate level in a dorsoventral direction from the hypaxial musculature to the sternum, and the subcutaneous tissue is incised down to latissimus dorsi. Latissimus dorsi is undermined and retracted dorsally using Langenbeck retractors. The scalenus muscle can be seen ventrally attaching to the fifth rib and is incised to expose the underlying serratus ventralis muscle.

Question 23

What are advantages of leaving latissimus dorsi intact? (3)

Answer 23

• Rapid closure
• Reduced post op pain
• Reduced post op lame

Question 24

What are the disadvantages of leaving latissimus dorsi intact? (1)

Answer 24

Reduced access to thoracic cavity

Question 25

What are the ways to identify correct intercostal space number? (20

Answer 25

-Counting ribs caudally from the J-shaped first rib, or -By identifying the fifth rib from attachments of the caudal end of the scalenus muscle and the cranial end of the external abdominal oblique muscle.

Question 26

What step is taken deep to serratus ventralis?

Answer 26

Deep to the serratus ventralis lies the external and internal intercostal muscles and the pleura, which are transected using Metzenbaum scissors midway between the ribs to avoid damage to the neurovascular bundles (sited caudal to the rib). Care should be taken when puncturing the pleura to identify and avoid any adhesions between pleura and lung.

Question 27

Where should the pleural incision not extend beyond: A. Ventrally? B. Dorsally?

Answer 27

A. internal thoracic vessels (which lie laterally and parallel to the sternum and can be identified by palpation) B. Cotochondral junction

Question 28

What is the risk if the pleural incision extends dorsally beyond costochondral junction?

Answer 28

epaxial muscle and intercostal arterial damage

Question 29

What is placed following intrathoracic procedure?

Answer 29

Thoracostomy tube

Question 30

How is a thoractomy wound closed?

Answer 30

Preplaced circumcostal polydiaxonone sutures

Question 31

What is the aim of the Preplaced circumcostal polydiaxonone sutures?

Answer 31

maintain anatomic rib position and reduce tension on the soft tissue repair, not to oppose or immobilise the ribs:

Question 32

What is the risk if high tension on closing sutures?

Answer 32

Rib #

Question 33

How are the muscle layers closed in lateral intercostal thoracotomy?

Answer 33

he serratus ventralis and scalenus or external abdominal oblique muscles are apposed using an absorbable monofilament suture and latissimus dorsi is released and apposed ventrally.

Question 34

What muscle inserts on 5th rib

Answer 34

Dorsal scelenus m

Question 35

When closing lateral intercostal thoracotomy, what anatomy must be avoided?

Answer 35

Intercostal a

Question 36

How is a patient positioned for median sternotomy?

Answer 36

Dorsal recumb, legs tied cranially

Question 37

How is the incision made for median sternotomy?

Answer 37

Manubirum to xiphoid on midline

Question 38

What is used for full thickness cutting through sternum? What must be kept in tact?

Answer 38

Oscillating saw Manubrium and xiphoid in tact

Question 39

What must happen to access both hemithoraces?

Answer 39

Mediastinum perforated at the dorsal aspect of sternum

Question 40

How is a median sternotomy closed?

Answer 40

Closure of the sternotomy is achieved using figure-of-eight stainless steel wire or suture (e.g. polydiaxonone or polypropylene). I use polydiaxonone in patients >30 kg: one study investigated sternotomy closure in greyhounds and found that sterna closed with polydioxanone or stainless steel wire has similar mechanical properties.

Question 41

What must be used when using oscillating saw?

Answer 41

Saline

Question 42

How much to drain chest post thoracotomy?

Answer 42

to negative pressure

Question 43

What is the most common complication of median sternotomy?

Answer 43

Seroma

Question 44

Where is a thoracoscopy possibly appropriate?

Answer 44

Thoracic duct ligation Pericardectomy Correcting persistent right aortic arch Lung lobectomy Biopsy intra thoracic lesion