1

Chapter 32Chapter 32

Thoracic and Pulmonary Thoracic and Pulmonary SurgerySurgery

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 2

Thoracic Surgery

Review terms and definitions listed at beginning of chapter

Use your medical dictionary if necessary

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 3

Thoracic Surgery

Lung function Ventilation Diffusion Perfusion

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 4

Thoracic Surgery

Bronchi Left and right primary Branch off at the carina Become bronchioles Terminate at the alveoli

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 5

Thoracic Surgery

Lungs and bronchial tree.(From Herlihy B, Maebius NK: The human body in health and illness, ed 2 Philadelphia, 2003, Saunders.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 6

Thoracic Surgery

Lungs Paired organs separated by the mediastinum Enclosed in the pleural cavity Covered by the pleural sac Expand based on negative pressure created by

the space between the two layers

Lung pressure Break in integrity of pleural cavity causes a

collapse

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 7

Thoracic Surgery

Mechanism of breathing.

(From Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 8

Thoracic Surgery

Diagnostic testing Pulmonary function Laboratory test Imaging studies

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 9

Thoracic Surgery

Instruments General surgery instruments Chest wall instruments Lung instruments Bronchus clamps Surgical stapling devices Vascular clamps

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 10

Thoracic Surgery

A. Thoracotomy instruments. Top, left to right: 1 malleable T retractor, 1 Giertz rib rongeur, 1 Matson rib stripper, and elevator. Bottom left: Burford rib spreader with shallow blade attached; 1 shallow blade; 2 deep blades.(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 11

Thoracic Surgery

Chest Drainage System

(From Lewis SM, Heitkemper MM, Dirksen SR: Medical surgical nursing, ed 6, St Louis, 2004, Mosby.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 12

Thoracic Surgery

Video-Assisted Thoracoscopic Surgery

A, Trocar placement. B, Isolation of lung tissue. C, Insertion of endoscopic stapler. D, Resection of wedge.(Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 13

Thoracic Surgery

Video-assisted thoracoscopic surgery Patient position

• Lateral with an axillary roll

Anesthetic • General

Trocar placement • Dependent upon procedure

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 14

Thoracic Surgery

Thoracoscopy – Lung biopsy Removal of a small portion of lung tissue for

pathological examination Performed when other diagnostic tests are

inconclusive Completed as a video-assisted procedure

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 15

Thoracic Surgery

Lung volume reduction Patients with chronic pulmonary emphysema may

benefit• Involves resection of portions of a lung in which air is

trapped in emphysematous lung tissue

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 16

Thoracic Surgery

Bronchoscopy

A, Top to bottom: Insertion of rigid bronchoscope. Endobronchial obstruction. Flexible scope is placed inside rigid scope for biopsy. B, Removal of mass using forceps. Laser removal.(From Sugabaker DJ, Strauss G, Fried MP: Laser resection of endobronchial lesions: Use of rigid and flexible bronchoscopes, Oper Tech Otolaryngol Head Neck Surg 3:93, 1992.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 17

Thoracic Surgery

Mediastinoscopy Endoscopic examination of the mediastinum through

incision Thymus and lymph node biopsy are performed to

establish a diagnosis

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 18

Thoracic Surgery

Thoracotomy Open surgery of the thoracic cavity

• Thoraco = Chest cavity

• Otomy = Incision into

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 19

Thoracic Surgery

Thoracotomy Open surgery of the thoracic cavity

A, Incision made following the curve of the fifth rib. B, The muscles are divided.(Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 20

Thoracic Surgery

Thoracotomy (cont.)

(Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 21

Thoracic Surgery

(Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby.)

Thoracotomy (cont.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 22

Thoracic Surgery

Lobectomy Removal of a lobe of the lung to prevent the

spread of metastatic cancer or to treat a benign tumor

May be performed as video-assisted procedure

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 23

Thoracic Surgery

Lobectomy

Placement of the proximal bronchus clamp 1.5 to 2 cm from main bronchial trunk.(Modified from Waldhausen JA, Pierce WS, Campbell DB: Surgery of the chest, ed 6, St Louis, 1996, Mosby.)

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 24

Thoracic Surgery

Pneumonectomy Procedure involves removal of entire lung Procedure done to

• Debulk malignant tumor

• Slow spread of cancer

• Treat extensive abscess

• Treat bronchiectasis

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 25

Thoracic Surgery

Cervical rib resection for thoracic outlet syndrome Thoracic outlet syndrome is compression of

subclavian vessels and brachial plexus at superior aperture of thorax

Decompression includes partial or entire removal of rib

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 26

Thoracic Surgery

Decortication of the lung Surgical removal of fibrin layer of the lung to

facilitate lung expansion

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 27

Thoracic Surgery

Decortication of the lung Surgical removal of a portion of the parietal pleura

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 28

Thoracic Surgery

Lung transplantation Performed to remove diseased, poorly

functioning lung and replace with lung from organ donor

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 29

Thoracic Surgery

Lung transplantation (cont.) Indicated for patients with

• Restrictive lung disease

• Emphysema

• Pulmonary hypertension

• Other noninfectious end-stage pulmonary diseases

Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 30

Thoracic Surgery

Lung transplantation (cont.) In single-lung transplant, surgeon will make three

anastomoses:• Bronchus to bronchus

• Pulmonary artery to pulmonary artery

• Recipient pulmonary veins to donor atrial cuff

In bilateral transplant• May require cardiopulmonary support