Cardiothoracic Surgery Dr.Mohammed - PowerPoint Presentation

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Cardiothoracic Surgery

Dr.Mohammed

J.

Jameel

FIBMS.Th.CVS.Senior

Lecturer.

Department of Surgery, College of Medicine,

Al-

Mustansiriyah

University, Baghdad,

Iarq

.

Thoracic Surgery

Lec

: 5

Thoracic 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. Extra thoracic malignancy

5. Recent or impending 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 5

th

intercostal

space. After

completance

of required procedure Two chest tubes are inserted before

closuer

of chest ,the 1

st

one is called Apical tube which is put through 7

th

intercostal

space at anterior

axilllary

line and advanced to the apex of

Hemithorax

and the 2

nd

one put through 8

th

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

haemoptysis

. 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 tension

3. 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