Open Chest Surgery Outline - PowerPoint Presentation

Slide1

Open Chest SurgerySlide2

Outline

A & P of descending aorta

Pathology

Diagnosis

Anesthesia

Medications

Patient preparation (positioning, prep, draping)

Equipment, Instrumentation, Supplies

Thoracotomy for descending thoracic aneurysm (groin incision for femoral bypass)

Other Aortic Aneurysm Types (I, II, III)

PTCA

CPB

Cell SalvageSlide3

Anatomy & Physiology

of the

Thoracic Cavity

Refer to Thoracic I Lecture NotesSlide4

Pathology

Lungs

Carcinoma=a new growth or malignant tumor

Lung cancer #1 cause of death r/t cancer

Tumors Divided into 4 Groups:

Small Cell Carcinoma or Oat Cell (malignant)

Large Cell Carcinoma (malignant)

Adenocarcinoma (malignant)

of bronchi = primarily smokers

of bronchioles = 50%smokers & 50%nonsmokers

Squamous Cell Carcinoma (benign) formed from epithelial or squamous cells which line mucous membranes)

90% malignant lung cancers r/t smokingSlide5

Pathology

All tumor types with the exception of small cell (oat cell), have a good prognosis with medical and or surgical intervention

Surgical Interventions include

:

Wedge/Tumor Resection with margins

Lobectomy

Pneumonectomy

Medical Interventions include

:

Chemotherapy

RadiationSlide6

Initial Diagnosis

Cytology of sputum sample

Will determine the type of cells that are present in the respiratory system

Will show presence of cancer cells but

not

where they

actually came from in the lungs

Most preliminary of all tests

Chest X-ray must follow to narrow down location of tumor or mass Slide7

Initial Diagnosis

Chest X-ray

may be found on routine exam (asymptomatic)

may be ordered after presents with symptoms:

Cough

Bloody sputum (hemoptysis)

Dyspnea Slide8

Diagnosis

Cell type determines the course of treatment

Tumors are looked at in terms of “staging”

Staging means,” how developed is the tumor”?

Is it in the lymph nodes, has it metastasized to another area, or is it localized

Staging is accomplished by sending a tissue sample to pathology and having it analyzed for type

Tissue samples are obtained by biopsy

Tissue samples can be of lymph nodes or lung tumor, done with a biopsy needle or actual wedge resections of the lung

Biopsy can be done by bronchoscopy or mediastinoscopySlide9

Specimens

Specimens must be handled appropriately

Mishandling could damage a sample causing it to not be analyzable

There are two types of tissue samples in the OR related to node or tissue:

Fresh frozen

PermanentSlide10

Specimens

Fresh Frozen

Identifies type of tumor

Determines margins

Will entail waiting on path report

Depending on path report may be done and close or have to reopen or proceed

Sent when tumor has not been previously identified by mediastinoscopy, bronchoscopy, or needle biopsySlide11

Permanent

Must ID the type of tumor before it can be stained to determine staging

There are different stains required for different types of tumors

Would send a wedge or lobe for permanent if the tumor type had already been Identified by a previous biopsy (from mediastinoscopy, bronchoscopy, or needle biopsy)Slide12

Specimens

Sometimes may hear “send this for

Fresh

” and the doctor will want cytology run

Cytology identifies an infectious process:

Fungal

Bacterial

AFB (acid fast bacillus) checks for TBSlide13

Other Diagnostic Tests for Review

CT scan or MRI

Shows location of tumor so that if a thoracotomy is done, the surgeon knows where to operate to excise the lesionSlide14

Preoperative Patient Preparation

Chest X-ray, MRI, AND or CT Scans should be in the OR before the patient arrives. They May accompany the patient. They should be displayed in the x-ray box for the surgeon.

Type & cross should be done in the event that the patient experiences extreme blood loss and needs blood replacement during surgery

These procedures are risky (large vessels are present in the thorax & mediastinum, and could be accidentally injuredSlide15

Anesthesia

CVP (anesthesia preference)

Arterial line

Epidural

Blood availableSlide16

Medications

NS

Sterile Water

Antibiotic in the Irrigant

Local:

Lidocaine

Marcaine

With or without Epi

Bone Wax

Surgicel

Avitene

Thrombin and Gelfoam

Focal-Seal

Other Fibrin Sealants:

Bio-Glue

Hema-MystSlide17

Thoracic Incisions

Posterolateral Thoracotomy

Anterolateral Thoracotomy

Thoracoabdominal Incision

Median Sternotomy

Alternative: Transaxillary, supraclavicular, cervical mediastinotomy, anterior approachSlide18

Thoracotomy

Surgical incision into the thorax or chest wall:

Two Types:

Posterolateral Thoracotomy

Anterolateral ThoracotomySlide19

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 Slide20

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 biopsySlide21

Thoracoabdominal Incision

Lateral position

Incision from posterior axillary line to abdominal midline

7

th

or 8

th

intercostal space

Exposure to upper abdomen, retroperitoneal area, and lower chest

Repair of hiatal hernia, esophagectomy, espophagogastrectomy, retroperitoneal tumors, and thoracic aneurysm resectionSlide22

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 procedureSlide23

Patient Positioning

Posterolateral

Operative side up

Beanbag (surgeon preference) under drawsheet

Pillow under head

Upper arm on padded mayo

Lower arm on padded armboard

Axillary roll (protect brachial plexus)

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 blanketSlide24

Prep

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 paintSlide25

Draping

Towels x 4 or five

Drying towels

Ioban

Universal sheet or laparotomy sheetSlide26

Equipment

ECU

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

Bair Hugger

Bronchoscopy Cart

Stapler CartSlide27

Instrumentation

CV or Major Tray

Chest Tray

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

Extra long instrument tray

Doctor specials

Long medium and large clip appliersSlide28

Chest Tray Instruments

Bronchus clamps

Duval Lung clamps

Allison lung retractor (whisk)

Davidson scapular retractor

Doyan raspatories (pigtails) right & left

Elevators (Cameron, Alexander, periostial, other)

Box cutter, Bethune rib shears, Guillotine

Bailey rib approximatorSlide29

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

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

For chest tubes, cutting needles with heavy silk ties

Magnetic pad/drape

Bovie with extension

Suction tubing, yankaur tip, cell saver (optional) Slide30

Supplies Continued

Kittners

Raytex for sponge sticks

Laparotomy sponges

Long umbilical tapesSlide31

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

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

(made at 4

th

intercostal space for UL/5th or 6

th

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 shearSlide32

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

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 bovie tip to long extention tip and give the surgeon and his assistant long debakeys (may want extra long debakeys/have extra long instrument set available)

Will begin dissection of lobe to be removed or entire lungSlide33

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Will use right angle and 0 silk ties to tie off vein and arteriole branches, as well as long medium and large clips

May also request 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

May request lung retractor (whisk or egg-beater) and or a sponge on a stick to the assistant for exposure

Will request one or two lovelace lung clamps when ready to staple bronchi or lobe tissue Slide34

Staplers used for Lobectomies and Pneumonectomies

Linear staplers

(old name GIA)

Come in 55mm and 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)

Come in 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)Slide35

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

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 usedSlide36

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-hospitalizationSlide37

Specimen

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

Clarify specimen type and what the specimen is with the surgeon

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

Ask before you pass it off

Waiting will be involved to determine if margins are clear

If margins are not clear, you will go back and remove more lung tissueSlide38

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

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

These 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

Chest tubes must be secured with tape or plastic tie bandsSlide39

Pleurevacs

Pleurevacs (water seal drainage with suction)

Pneumovac or pneumonectomy pleurevac (pressure control chambers/NO suction)

Pneumonectomy pleurevacs are used only for pneumonectomies

May not use

any

chest tubes with a pneumonectomy

Regular pleurevacs are used for chest drainage for all other chest proceduresSlide40

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

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 placedSlide41

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Remaining muscle/fascia will be closed with a running #1 PDS or Vicryl on a CTX taper needle

Subcutaneous tissue will be closed with a 2-0 or 0 Vicryl on a CT-1 or CTX tapered needle

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!Slide42

Descending Thoracic Aneurysm

Anatomy and Physiology of Thoracic Aorta

Thoracic aorta extends to the diaphragm

Thoracic aorta supplies chest wall, diaphragm, esophagus, bronchus, and the spinal cordSlide43

Aneurysm

Localized abnormal dilation of an artery resulting in pressure of the blood on the vessel wall that has been weakenedSlide44

Pathology of Aneurysms

Develop at sites of arterial weakness

Causes: 1. Atherosclerosis 1° cause

2. Congenital weakness

Marfan’s syndrome

Ehlers Danlos syndrome

(both are hereditary disorders that affect the elastic connective tissues which lead to weakening or thinning of the aorta)

3. Acquired

TraumaSlide45

Aneurysms

Three types:

True

-arterial wall weakness aneurysmal sac involves one or all layers of the 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 deathSlide46

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 Slide47

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 aortaSlide48

Diagnostics/Preoperative Testing

Confirmed with:

Ultrasound

CT

MRI

Aortograms Slide49

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)Slide50

Medications

NS irrigation with antibiotic of choice

Topical hemostatic agents of choiceSlide51

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 thoracoabdominalSlide52

Posterior Lateral Position

Headrest

Axillary roll (prevent brachial plexus injury)

Beanbag (on bed before patient) with suction)

Padded armboard for lower arm

Padded mayo for 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 legSlide53

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)Slide54

Equipment

Bair hugger (lower body)

Cell saver

Bovie

Extra suction

Beanbag

Defibrillator

Bypass machine (partial bypass usually employed)

Saline Warmer

Cryothermia Unit (available) surgeon choiceSlide55

Instrumentation

Chest tray

Cardiovascular tray or Major Tray

Aortic clamps (surgeon choice)

Open Heart tray

Long medium and large clip appliers

Extra long instruments

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

Chest Retractor of surgeon choice

Internal Defibrillator Paddles (external available) BOTH STERILESlide56

Supplies

Cautery

Open heart specialty tray

Major Basin Tray

Magnetic Drape

Miscellaneous prolene suture

Miscellaneous silk ties

Cutting free needles

Straight Woven Dacron Grafts (Miscellaneous sizes)

Femoral arterial and venous cannuli

Tourniquet snares or rommels

Vessel loops or umbilical tapes

Warm NS with antibiotic of choice

Heparinized saline

Topical hemostatic agents

Chest tubesSlide57

Procedure

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 will have cut short about three inches long during your set-up)

Patient is heparinized

Peripheral debakeys x 2

11 blade for arteriotomy, arterial cannula, tubing clamps (one for arterial cannula one will be on pump tubing)

Care is taken to

NOT

introduce air to line, may fill with NS slowlySlide58

Procedure

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 skinSlide59

Procedure

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 shearSlide60

Procedure

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 removedSlide61

Procedure

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 choiceSlide62

Procedure

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 choiceSlide63

Other Aortic Aneurysms

Type I

Type II

Type III

DiscussionSlide64

Coronary Angioplasty (PTCA)

DiscussionSlide65

Cell Salvage by Cell SaverSlide66

Cell Salvage

Blood recovered during surgery and reinfused

Is directly suctioned, filtered, anticoagulated, and reinfused with little RBC damage

May be aspirated directly or via squeezed out sponges into a basinSlide67

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 infectionSlide68

Cardiopulmonary BypassSlide69

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 patient’s 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 heartSlide70

CPB Process

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

Is 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 Slide71

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 collectionSlide72

CPB Continued

Heparin is given intravenously for anticoagulation

Cannuli and CPB circuits may also be heparin-bondedSlide73

CPB Perfusionist

Control many physiologic variables along with anesthesia and the surgeon:

Hemodilution

↓ blood viscosity =↓clot

HCT ↓ = ↓ clotting

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

Core temperature is ↓ from 28 to 30° CSlide74

Summary

A & P of descending aorta

Pathology

Diagnosis

Patient preparation (positioning, prep, draping)

Equipment, Instrumentation, Supplies

Thoracotomy for descending thoracic aneurysm (groin incision for femoral bypass)Slide75

Summary Continued

Other Aortic Aneurysm Types (I, II, III)

PTCA

CPB

Cell Salvage