artery when the sternal wires are placed (cid:142)(cid:3) Instability of the sternum (cid:142)(cid:3) Wound infection (cid:142)(cid: 3) Dehiscence of wound (cid:142)(cid:3) Osteomyelitis (rare). CHAPTER 16 Thoracic surgery 712 Lobectomy This is the removal of a single lobe of lung. Occasionally bilobectomy (e.g. midd le and lower lobectomy) is performed. Indications (cid:142)(cid:3) Lung carcinoma (cid:142)(cid:3) Benign tumors (cid:142)(cid:3) Chronic lung abscess (cid:142)(cid:3) Pulmonary tuberculosis (cid:142)(cid:3) Fungal infec tions (cid:142)(cid:3) Bronchiectasis (cid:142)(cid:3) Congenital abnormalities e.g. lung s equestration. Preoperative preparation (cid:142)(cid:3) All patients should undergo bronchoscopy by the o perating surgeon (cid:142)(cid:3) Results of lung function tests, chest radiograph, ECG, an d CT scan must be available (cid:142)(cid:3) The patient should be warned about the possible conversion to pneumonectomy depending on intraoperative findings. Position Right or left lateral. Incision Posterolateral thoracotomy in the 5th intercostal space. Anesthetic General anesthesia with double lumen endotracheal intubation. Postoperative management (cid:142)(cid:3) Nurse the patient on the HDU (cid:142)(cid:3) Mon itor ECG, CVP, BP, oxygen saturation, respiratory rate, and urine output (cid:142)(cid:3) Perform a postoperative chest radiograph on arrival to the HDU (cid:142)(c id:3) Provide analgesia by PCA, epidural or paravertebral block (cid:142)(cid:3) DVT prophy laxis according to local protocols (cid:142)(cid:3) Use regular chest physiotherapy to help expectoration and deep breathing (cid:142)(cid:3) Carry out daily chest radiographs to assess expansion of the remaining lobe (cid:142)(cid:3) Remove the intercostal drains when there is no longer any drainage of flui d or air and chest radiograph appearances are satisfactory (this is usually 24 \200\22348 h ours). Frequently after lobectomy the basal drain can be removed first and the apical one l ater. Confirm air leakage when bubbles appear in the underwater seal bottle when the patien t is asked to cough. Complications (cid:142)(cid:3) Complications related to general anesthesia. (cid:142)(cid:3 ) Hemorrhage. LOBECTOMY1 713 (cid:142)(cid:3) Bronchopleural fistula. (cid:142)(cid:3) Presents as an air leak lasting for more than one week. (cid:142)(cid:3) C onfirmed by the presence of bubbles in the underwater seal bottle during normal respiration or when the patient is asked to cough. (cid:142)(cid:3) If the air leak is minimal the drain may be clamped for a period of one to two hours. A chest radiograph is taken. If the lung is still expanded or a very small pneu mothorax is present the drain may be safely removed. A check radiograph is performed the fo llowing day to ensure the lung remains expanded. (cid:142)(cid:3) As a last resort talc pleurodesis can be performed on the ward using a slu rry of talc mixed with local anesthetic introduced through the chest drain. This induces in flammation resulting in closure of the air leak. (cid:142)(cid:3) Cardiac arrhythmias (most frequently atrial fibrillation). (cid:142)(cid:3 ) Wound infection and empyema. (cid:142)(cid:3) Bronchopneumonia in the remaining lung. (ci d:142)(cid:3) ARDS. (cid:142)(cid:3) Death (3 \200\2234% in the UK). CHAPTER 16 Thoracic surgery 714 Right upper lobectomy Indications See p712. Preoperative preparation See p712. Position Right or left lateral position. Incision Posterolateral thoracotomy in the 5th intercostal space. Anesthetic General anesthesia with double lumen endobronchial intubation. Procedure (cid:142)(cid:3) Carry out a posterolateral thoracotomy in the 5th intercostal sp ace (see pp706 \200\2237). (cid:142)(cid:3) Divide any pleural adhesions to free the lung. (cid:142)(cid:3) Inspect th e whole lung and palpate to ascertain location of the tumor and operability and to make sur e that there are no other nodules in the other lobes of the right lung. (cid:142)(cid:3) Clean the pleural reflection at the top of the right lung. (cid:142)(cid:3 ) Identify the upper pulmonary vein and ligate it with two proximal non-absorbable ligature s and one distal ligature non-absorbable ligature and divide it between the proximal and di stal ligatures. Alternatively, divide the vessel using an Endo GIA 30 vascular stapler (thi s places three rows of staples either side of the cut). (cid:142)(cid:3) Identify the upper pulmonary arterial branches and encircle them with righ t-angle forceps and a non-absorbable ligature. These can also be ligated with two proximal ligatures and one distal ligature and divided or secured using an Endo GIA 30 stapling devi ce. (cid:142)(cid:3) Then pay attention to the posterior aspect of the lung where the pleural reflection onto the bronchus is cleared and identify the upper lobe bronchus. (cid:142)(cid:3) Isolate and staple with the TA 30 4.5mm stapler. Divide the bronchus just distal to the staple line and retract it to expose the recurrent branch of the right upper lobe. This branch is of varying size but is usually quite small; encircle it, ligate it, an d divide it. (cid:142)(cid:3) Now separate the oblique fissure if not complete by dissection or by stapling it and dividing it. (cid:142)(cid:3) Deal with the horizontal fissure, which is invariably incomplete, in one o f two ways, either by using the Endo GIA stapler or by applying traction on the right upper lobe bronchus to allow it to separate from the rest of the lung. This will inevitably leav e a raw surface on the upper part of the middle lobe. (cid:142)(cid:3) Secure haemostasis on this raw surface with diathermy. RIGHT UPPER LOBECTOMY1 715 (cid:142)(cid:3) Expand the remaining lung and test the bronchial staple line by covering it with 0.9% saline solution and increasing the intra airway pressure to 40mmHg. S eal any air leak using tissue glue e.g. Tisseal. (cid:142)(cid:3) Close the chest. (cid:142)(cid:3) Turn the patient into the supine positio n and reverse the anesthetic. (cid:142)(cid:3) Transferred to the HDU for monitoring when t he patient is breathing spontaneously. Postoperative management See p712. Complications See p713. CHAPTER 16 Thoracic surgery 716 Right middle lobectomy Indications See p712. Preoperative preparation See p712. Position Right lateral. Incision Posterolateral thoracotomy in the 6th intercostal space. Anesthetic General anesthesia with double lumen endobronchial intubation. Procedure (cid:142)(cid:3) Perform posterolateral thoracotomy in the 6th intercostal space (see pp706 \200\2237). (cid:142)(cid:3) Free the lung from the chest wall by dividing pleural adhesions. (cid:142) (cid:3) Identify the middle lobe between the horizontal and oblique fissures. (cid:142)(cid :3) Deepen the fissures at the point where the transverse fissure meets the oblique fissure if incomplete, and ligate the branches (usually two) to the middle lobe from the pulmonary artery and divide them between the ligatures. (cid:142)(cid:3) Then retract the lung backwards and clean the upper pulmonary vein. The mi ddle lobe vein usually drains into the lower part of the right up- per lobe vein. The middl e lobe vein is the lowest tributary draining into the upper lobe vein. Identify it, ligate it with two ligatures and divided between the ligatures. (cid:142)(cid:3) Then identify the middle lobe bronchus by finger palpation. Clean it and v isualize it and encircle it. Then staple the middle lobe bronchus using the TA 30 4.5mm sta pler. Divide the middle lobe bronchus just distal to the staple line and the middle lobe sp ecimen removed. (cid:142)(cid:3) Expand the remaining lung and test the bronchial staple li ne by covering it with 0.9% saline solution and increasing the intra airway pressure to 40mmHg. S eal any air leak using tissue glue e.g. Tisseal. (cid:142)(cid:3) Close the chest. (cid:142)(cid:3) Turn the patient into the supine positio n and reverse the anesthetic. (cid:142)(cid:3) Transfer the patient to the HDU for monitori ng when breathing. Postoperative management See p712. Complications See p713. This page intentionally left blank CHAPTER 16 Thoracic surgery 718 Right lower lobectomy Indications See p712. Preoperative preparation See p712. Position Right or left lateral position. Incision Posterolateral thoracotomy in the 6th intercostal space. Anesthetic General anesthesia with double lumen endobroncheal intubation. Procedure (cid:142)(cid:3) Make a posterolateral thoracotomy in the 6th intercostal space (see pp706 \200\2237). (cid:142)(cid:3) Divide pleural adhesions to free the lung. (cid:142)(cid:3) Then inspect t he lung and palpate to ascertain tumor operability and presence of any other lesions. (cid:142)(cid:3) Commence right lower lobectomy by separating the fissures at the point whe re the horizontal fissure meets the oblique fissure. If the fissures are incomplete, carry out dissection at this point inwards until the lower pulmonary artery branches become visib le. Encircle them just below the middle lobe artery branch and ligate twice and divide them or staple with the Endo GIA 30 vascular stapler. (cid:142)(cid:3) Isolate the branch to the apical part of the lower lobe, which lies just a bove and ligate separately with two ligatures and then divide it. Then separate the rest of the oblique fissure. (cid:142)(cid:3) Isolate the lower pulmonary vein and divide it between ligatures, or with Endo GIA 30 vascular stapler. (cid:142)(cid:3) Then clean the lower lobe bronchus by removing lymphatic tissue and stapli ng it just below the middle lobe bronchus take off using the TA 30 4.5mm stapler. Resect th e bronchus distal to the staple line and remove the lower lobe. (cid:142)(cid:3) Expand the remaining lung and test the bronchial staple line by covering it with 0.9% saline solution and increasing the intra airway pressure to 40mmHg. S eal any air leak using tissue glue e.g. Tisseal. (cid:142)(cid:3) Close the chest. (cid:142)(cid:3) Turn the patient into the supine positio n and reverse the anesthetic. (cid:142)(cid:3) Transfer the patient to the HDU for monitori ng when he/she is breathing spontaneously. Postoperative management See p712. Complications See p713. This page intentionally left blank CHAPTER 16 Thoracic surgery 720 Left upper lobectomy Indications See p712. Preoperative preparation See p712. Position Right or left lateral position. Anesthetic General anesthesia with double lumen endobronchial intubation. Incision Posterolateral thoracotomy in the 5th intercostal space. Procedure (cid:142)(cid:3) Perform a posterolateral thoracotomy in the 5th intercostal spac e (see pp706 \200\2237). (cid:142)(cid:3) Divide any pleural adhesions. (cid:142)(cid:3) Inspect the lung (a puckere d appearance on the surface of the lung suggests underlying tumor) and palpate it to assess operability of the lesion by lobectomy. (cid:142)(cid:3) Note any hilar or mediastinal lymphadenopathy. (cid:142)(cid:3) Proceed wi th lobectomy if the tumor is restricted to the lower lobe and there is no infiltration of the upper lobe or other adjacent structures. (cid:142)(cid:3) Clear the upper part of the pulmonary hilum to expose the large blood vessels clearly. (cid:142)(cid:3) Then enter the oblique fissure. If this is incomplete then dissect the fissure out to approach the branches of the left pulmonary artery in its depth. Identify th e lower arterial branch. Then clear the lingular branch, isolate it and ligate it in contin uity and divide it. There are two apical branches which can be quite large. Clear these iso late them and either ligate them between two non-absorbable ligatures or staple them using an Endo GIA 30 vascular stapler. (cid:142)(cid:3) If you encounter difficulty in isolating the apical arterial branches take the upper pulmonary vein first. If there is not sufficient length, open the pericardium, w hich will facilitate ligation or stapling of the vein. (cid:142)(cid:3) Clear the upper bro nchus and its junction with the right main bronchus and demonstrate the right lower bronchu s. Then staple the upper bronchus using the TA 30 4.5mm stapler and divide it distal to the staple line. (cid:142)(cid:3) Separate the remaining oblique fistula, staple it, and divide it and remove the upper lobe. (cid:142)(cid:3) Secure haemostasis using the diathermy cautery. (cid:142)(cid:3) Expand th e left lower lobe and test the bronchial staple line by covering it with 0.9% saline solution and increasing the intra airway pressure to 40mmHg. S eal any air leak using tissue glue e.g. Tisseal. LEFT UPPER LOBECTOMY1 721 (cid:142)(cid:3) Close the chest. (cid:142)(cid:3) Turn the patient into the supine positio n and reverse the anesthetic. (cid:142)(cid:3) Transfer the patient to the HDU for monitori ng when he/she is breathing spontaneously. Postoperative management See p712. Complications See p713. CHAPTER 16 Thoracic surgery 722 Left lower lobectomy Indications See p712. Preoperative preparation See p712. Position Right or left lateral position. Incision A left thoracotomy is performed in the bed of the 6th rib. Procedure (cid:142)(cid:3) Perform a left thoracotomy in the bed of the 6th rib. (cid:142)( cid:3) Divide pleural adhesions if present to free the lung. (cid:142)(cid:3) Inspect the l eft lower lobe and palpate to assess tumor operability. (cid:142)(cid:3) Similarly inspect and palpate the upper lobe to make sure there are no other lesions present. (cid:142)(cid:3) Open the oblique fissure and the pulmonary arterial branches displayed deep within the fissure. (cid:142)(cid:3) Isolate the lower lobe arterial branches and ligate with two ligatures pro ximal and one distal, and divide between the proximal and distal ligatures. Alternatively, divide the branches using the Endo GIA 30 stapler. Isolate the apical branch of the lower l obe similarly, ligate it in continuity, and divide it. (cid:142)(cid:3) Divide the pulmonary ligament up to the lower pulmonary vein. Encircle thi s and either divided between two ligatures or stapled with the endo GIA 30 vascular stapler . (cid:142)(cid:3) Clean the lower bronchus through the bifurcation with the upper bronchus by removing lymphatic material surrounding it. Then staple the lower bronchus usin g a TA 30 4.5mm stapler. Resect the bronchus distal to the staple line flush with the stapl er. (cid:142)(cid:3) Remove the lower lobe specimen. (cid:142)(cid:3) Ensure haemostasis using the diathermy cautery. (cid:142)(cid:3) Expand the left upper lobe and test the bronchial s taple line by covering it with 0.9% saline solution or sterile water and increasing the intra airway pres sure to 40mmHg. Seal any air leak using tissue glue e.g. Tisseal. (cid:142)(cid:3) Close th e chest. (cid:142)(cid:3) Turn the patient into the supine position and reverse the anesthe tic. (cid:142)(cid:3) Transfer the patient to the HDU for monitoring when breathing is spontaneous. Postoperative management See p712. Complications See p713. This page intentionally left blank CHAPTER 16 Thoracic surgery 724 Pneumonectomy Pneumonectomy is necessary for centrally placed tumors and can only be perfor med in fit patients. Indications (cid:142)(cid:3) Lung carcinoma (cid:142)(cid:3) Chronic lung abscess. Preoperative preparation (cid:142)(cid:3) All patients undergo bronchoscopic assessment by the operating surgeon (cid:142)(cid:3) Results of lung function tests, chest radiograph and CT scan must be available (cid:142)(cid:3) ECG. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral position. Postoperative management (cid:142)(cid:3) The patient is nursed on the HDU. (cid:142)(cid:3 ) The drains are connected to a bottle with an underwater seal. A clamp is applied to the d rain which is released for 5min every hour in order to keep the mediastinum central. On no account should suction be applied to the drain. (cid:142)(cid:3) Monitoring of continuous ECG, CVP, BP, oxygen saturation, respiratory rate, and urine output is performed. (cid:142)(cid:3) An immediate postoperative chest X-ray is performed on arrival to the HDU. This will be useful as a baseline in case there is any subsequent change in the patient \200\231s condition. (cid:142)(cid:3) Analgesia is provided by PCA, epidural, or paravertebral block. (cid:142)( cid:3) DVT prophylaxis is prescribed according to local protocols. (cid:142)(cid:3) Regular chest physiotherapy to help expectoration and deep breathing. (cid:142)(cid:3) A repeat ch est X-ray is performed at 24 hours. (cid:142)(cid:3) The intercostal drain is removed after 24 hours providing there is no further blood leak and no air leak and the chest X-ray appearances are satisfactory. Complications following pneumonectomy (cid:142)(cid:3) Complications related to general ane sthesia. (cid:142)(cid:3) Hemorrhage \200\224blood loss over 200ml per hour for 4 consecuti ve hours, or more than 500ml per hour are indications for reopening the chest. (cid:142)(cid:3) Bronchopleural fistula \200\224this may be suspected if the patient develo ps serosanguinous sputum or discharge from the thoracotomy wound. A drop in the fluid level on serial chest radiographs confirms the diagnosis. Immediate management: PNEUMONECTOMY1 725 (cid:142)(cid:3) The patient is turned with affected side dependent so that there is no ove rspill of pneumonectomy space fluid into the good lung. (cid:142)(cid:3) An intercostal drain is inserted. (cid:142)(cid:3) Antibiotics are commenc ed. (cid:142)(cid:3) Suction bronchoscopy is carried out. (cid:142)(cid:3) Following stabilization of the patient: (cid:142)(cid:3) The patient is taken to the operating theater and rigid broncho- scopy performed to suck out secretions or spill over into the good lung, and visualize the fistula. (cid:142)(cid:3) If the fistula is small, treatment is with sodium hydroxide cauterisa- tio n every 2 weeks. This is introduced on a cotton pledget through a rigid bronchoscope and ne utralized with acetic acid. (This works by causing an inflammatory reaction followed by hea ling and fibrosis, which reduces and eventually closes the fistula). (cid:142)(cid:3) If the fistula is large, the fistula is closed with a pedicled muscle flap . (cid:142)(cid:3) If the bronchopleural fistula presents at a later date (weeks after surg ery), diagnosis is made reduction in the fluid level within the pneumonectomy space on seri al chest radiographs. The patient is treated as above. (cid:142)(cid:3) Arrhythmias (most commonly atrial fibrillation). (cid:142)(cid:3) Wound infection and empyema of pneumonectomy space. (cid:142)(cid:3) Bronc hopneumonia in the remaining lung. (cid:142)(cid:3) ARDS (cid:142)(cid:3) Death (mortality in the UK is between 5 \200\2238%). CHAPTER 16 Thoracic surgery 726 Right pneumonectomy Indications (cid:142)(cid:3) Lung carcinoma (cid:142)(cid:3) Chronic lu ng abscess. Preoperative preparation (cid:142)(cid:3) All patients should undergo bronchosc opy by the operating surgeon (cid:142)(cid:3) Results of lung function tests, chest radiogr aph and CT scan must be available (cid:142)(cid:3) ECG. Anesthetic General anesthesia with double lumen endobronchial intubat ion. Position Lateral position. Incision Perform a posterolateral thoracotomy in the right 5th intercostal space. Procedure (cid:142)(cid:3) Perform a posterolateral thoracotomy in t he 5th intercostal space (see pp706 \200\2237). (cid:142)(cid:3) Divide pleural adhesions (if present) and free the lung. (cid:142)(cid:3) Palpate the lung to confirm the position and operability of the tumor and to assess whether any other lesions are present which have not been visualized on CT scan. (cid:142)(cid:3) Inspect the mediastinum for enlarged lymph nodes. (cid:142)(cid:3) Signs o f inoperability: tumor invading adjacent structures e.g. pericardium, left atrium, aorta or esophagus. (Diaphragmatic invasion is not a sign of inoperability as the affected part can be resected and the defect closed directly with non -absorbable sutures or a Dacron patch inserted to restore the diaphragm.) (cid:142)(cid:3) If the lesion is operable: clean the pleural reflection around the hilum, behind the phrenic nerve, below the azygos vein and in front of the esophagus. (cid:142)(cid:3) Then free the superior pulmonary vein and encircle it with a stout non-abs orbable suture using right angled forceps. This provides traction on the vein, which is eit her ligated in continuity with non-absorbable ligatures or stapled and simultaneously divid ed using an Endo GIA 30 vascular stapler. (cid:142)(cid:3) Isolate the lower pulmonary vein, encircle with a non-absorbable ligature and either ligate, divide, or staple it. (cid:142)(cid:3) Then clean the main right pulmonary artery and encircle with a stout non-a bsorbable ligature, which provides traction for application of the Endo GIA 30 vascular sta pler, which staples on both sides and divides the vessel when it is fired. (cid:142)(cid:3) In the event that the pulmonary veins are too short for ligation or stapling then open the pericardium posterior to the phrenic nerve and divide the veins with in the pericardium. RIGHT PNEUMONECTOMY1 727 (cid:142)(cid:3) Clean the right main bronchus by removing the subcarinal lymph nodes. The bronchus is then stapled as close to the main carina as possible using the TA 30 4.5mm stapler. (cid:142)(cid:3) Divide the bronchus distal to the staple line and remove the lung. (cid:14 2)(cid:3) Clip or ligate the bronchial arteries on the posterior aspect of the main bronchus. (cid:142)(cid:3) Remove and submit all visible lymph nodes for histological examination after clear labeling. (cid:142)(cid:3) Secure haemostasis using the diathermy cautery. (cid:142)(cid:3) If the pe ricardium has been opened, suture it with 4/0 Prolene. If the defect in the pericardium is too large for direct closure then suture a Dacron patch in place to close the defect in ord er to prevent herniation and strangulation of the heart. (cid:142)(cid:3) Cover the bronchial stump with adjacent pleura using interrupted 4/0 Prolene sutures. (cid:142)(cid:3) Then test the bronchial stump for air leaks by covering the hilum with 0.9 % saline solution or sterile water and increasing the intratracheal pressure to 40mmHg. Sut ure any air leak with 4/0 Prolene. (cid:142)(cid:3) Insert a single intercostal drain (size 24 \200\22328French, Silastic) thr ough a separate stab incision. Secure it with a heavy non-absorbable suture. (cid:142)(cid:3) Close the chest. (cid:142)(cid:3) Turn the patient into the supine positio n and reverse the anesthetic. (cid:142)(cid:3) Transfer the patient to the HDU for monitori ng when he/she is breathing spontaneously. Postoperative management See p712. Complications See p713. CHAPTER 16 Thoracic surgery 728 Left pneumonectomy Indications (cid:142)(cid:3) Lung carcinoma. (cid:142)(cid:3) Chronic lu ng abscess. Preoperative preparation (cid:142)(cid:3) All patients should undergo bronchoscopy by the o perating surgeon (cid:142)(cid:3) Results of lung function tests, chest radiograph and CT s can must be available (cid:142)(cid:3) ECG. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral position. Procedure (cid:142)(cid:3) Perform a left posterolateral thoracotomy in the 5th intercostal space (see pp706 \200\2237). (cid:142)(cid:3) Divide any pleural adhesions and free the lung. (cid:142)(cid:3) Palpate t he lung to confirm the position and operability of the tumor and to assess whether any othe r lesions are present which have not been seen on CT. (cid:142)(cid:3) Signs of inoperability: tumor invading adjacent structures e.g. pericardium, left atrium, aorta or esophagus. (Diaphragmatic invasion is not a sign of inop erability as the affected part can be resected and the defect closed directly with non-abso rbable sutures or a Dacron patch inserted to restore the diaphragm.) (cid:142)(cid:3) If the lesion is inoperable then take biopsies of the lung tumor and/or th e mediastinal lymph nodes, insert an intercostal drain, and close the chest wall in layers. (cid:142)(cid:3) If the lesion is found to be operable then carry out the pneumonectomy as follows. (cid:142)(cid:3) Clean the pleural reflection around the hilum starting below the arch of t he aorta, posteriorly in front of the esophagus, and anteriorly behind the left phrenic ner ve. (cid:142)(cid:3) Release the pulmonary ligament. (cid:142)(cid:3) Free the lower left p ulmonary vein using sharp and blunt dissection and encircle with a stout non-absorbable ligature. (cid:142)(cid:3) Isolate the upper left pulmonary vein. (cid:142)(cid:3) Once it is clear t hat the lung can be removed without any problems, staple these two veins using an Endo GIA 30 vascular stapler. (cid:142)(cid:3) Clean the left main pulmonary artery, isolate it and retract it with a sto ut non-absorbable ligature. This facilitates the introduction of the Endo GIA 30 vascular s tapler, fire it after ensuring the artery lies between the marks on the anvil of the staple r. LEFT PNEUMONECTOMY1 729 (cid:142)(cid:3) Clear the left main bronchus by removing any subcarinal lymph nodes and st aple it using the TA 30 4.5mm cartridge, and divide it as close to the main carina as possi ble. (cid:142)(cid:3) Remove the lung specimen. (cid:142)(cid:3) Remove any additional lymp h nodes either in the subaortic area or mediastinum. Exercise great care in removing the su baortic lymph nodes because of the course of the left recurrent laryngeal nerve. Use diathe rmy with extreme caution. (cid:142)(cid:3) Secure haemostasis. (cid:142)(cid:3) Ligate or clip bronchial arteries wit h Liga clips. (cid:142)(cid:3) If the pericardium has been opened then suture this either s utured directly or patched using a Dacron patch, in order to prevent herniation and strangu lation of the heart in the postoperative phase. (cid:142)(cid:3) Cover the bronchial stump with adjacent pleura using interrupted 4/0 Prolene sutures. (cid:142)(cid:3) Then test the bronchial stump for air leaks by covering the hilum with 0.9 % saline solution or sterile water and increasing the intratracheal pressure to 5 \200\2236 KPa. Suture any air leak with 4/0 Prolene. (cid:142)(cid:3) Insert a single intercostal drain (size 24 \200\22328Fr., Silastic) throug h a separate stab incision. Secure this with a heavy non-absorbable suture. (cid:142)(cid:3) Close the chest. (cid:142)(cid:3) Turn the patient into the supine positio n and reverse the anesthetic. (cid:142)(cid:3) Transfer the patient to the HDU for monitori ng when he/she is breathing spontaneously. Postoperative management See p712. Complications See p713. CHAPTER 16 Thoracic surgery 730 Right intrapericardial pneumonectomy Indication Lung cancers situated at the hilum encroach ing upon the pulmonary artery or pulmonary veins near the left atrium. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral position. Incision Perform a posterolateral thoracotomy in the 5th intercostal space. Procedure (cid:142)(cid:3) Open the pericardium vertically behind the phrenic nerve to expo se the junction of the pulmonary veins with the left atrium. Encircle the veins and staple or ligate as previously described. (cid:142)(cid:3) Encircle the right pulmonary artery in the recess between the ascending aorta and the superior vena cava and ligate or staple it. (cid:142)(cid:3) Staple the bronchus flush with the tracheobronchial junction as previously described. (cid:142)(cid:3) Close the defect in the pericardium by direct suture or insert a Dacron patch in order to prevent herniation of the heart. (cid:142)(cid:3) Subsequent steps of the operation are as for right pneumonectomy. Postoperative care See p712. Complications See p713. This page intentionally left blank CHAPTER 16 Thoracic surgery 732 Left intrapericardial pneumonectomy Indication Lung cancer at the hilum that has encroached upon the pulmonary artery or pulmonary veins. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral position. Incision Perform left posterolateral thoracotomy in the 5th intercostal space. Procedure (cid:142)(cid:3) Clear the pulmonary artery and obtain further length by dividing the ligamentum arteriosum. Take extreme care during this maneuver to spare the recurrent l aryngeal nerve, which is in close proximity. Do not use diathermy cautery. (cid:142)(cid:3) Make a vertical incision in the pericardium posterior to the phrenic nerve to expose the junction of the pulmonary veins with the left atrium. (cid:142)(cid:3) Isolate the pulmonary veins and staple them flush with the left atrium and divide them. (cid:142)(cid:3) Isolate the left pulmonary artery, staple it and divide it. (cid:142)(cid: 3) Clean the bronchus to its junction with the trachea and staple it. (cid:142)(cid:3) Clos e the defect in the pericardium using a Dacron patch. (cid:142)(cid:3) Subsequent steps of the procedure are as for left pneumonectomy. Postoperative care See p712. Complications See p713. This page intentionally left blank CHAPTER 16 Thoracic surgery 734 Open parietal pleurectomy and bullectomy Indications (cid:142)(cid:3) Non-resolving spontan eous pneumothorax (cid:142)(cid:3) Repeated spontaneous pneumothorax (more than two episode s) (cid:142)(cid:3) First spontaneous pneumothorax in airline pilots. Anesthetic General an esthesia with double lumen endobronchial intubation. Position Lateral position. Preoperativ e preparation Results of lung function tests, chest radiograph, ECG, and CT scan must be av ailable. Incision Posterolateral thoracotomy through the 5th intercostal space. Procedure ( cid:142)(cid:3) After the chest is entered, retract the lung downwards to expose the apex w here one or two thin walled cysts may be present. Sometimes only a scarred area may be visi ble. (cid:142)(cid:3) Remove the cysts using a stapling device endo GIA 30 (blue). (cid:142)(cid :3) Perform parietal pleurectomy by raising and excising the pleura starting at the pleural edge at the upper part of the incision and moving towards the apex of the pl eural space. Excise with great care while the pleura is being stripped off the sympathetic nervous trunk. (cid:142)(cid:3) Control any bleeding points with diathermy. (cid:142)(cid:3) Close the che st. (cid:142)(cid:3) Turn the patient into the supine position and reverse the anesthetic. (cid:142)(cid:3) Transfer the patient to the HDU for monitoring when is breathing spontaneously. Postoperative management (cid:142)(cid:3) Suction is applied to the drainage bottles (5KPa) for 48 hours to encourage the lungs to expand and adhere to the raw surface of the chest wall created by th e pleurectomy. (cid:142)(cid:3) Daily chest radiographs. (cid:142)(cid:3) Regular chest physiotherapy. (ci d:142)(cid:3) Analgesia is provided with PCA, epidural or paravertebral block. (cid:142)(ci d:3) The drains are removed when the drainage of air and fluid stops and the chest radiograph confirms the lung is fully expanded. Complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Prolonged air leak (cid:142)(cid:3 ) Permanent air space (lung not fully expanded) (cid:142)(cid:3) Wound infection (cid:142)( cid:3) Empyema. This page intentionally left blank CHAPTER 16 Thoracic surgery 736 Open lung wedge biopsy Indications Diagnostic for interstitial lung disease. Anesthetic General anesthetic with single lumen endotracheal intubation. Preoperative preparation Results of lung function tests, chest radiograph, ECG, and CT scan must be available. Position (cid:142)(cid:3) Supine (cid:142)(cid:3) A pillow is placed under the shoulder on the side of the operation. Incision (cid:142)(cid:3) Make a small anterolateral thoracotomy (10cm) in the 5th intercos tal space. Procedure (cid:142)(cid:3) After the chest has been opened, divide any pleural adhesions. ( cid:142)(cid:3) Hold the edge of the lung with a Duval forceps and resect a wedge of lung u sing several applications of the Endo GIA 30 stapling device. (cid:142)(cid:3) Remove the specimen. (cid:142)(cid:3) Inspect the staple line for any air or blood leak. If present, suture these with 4/0 Prolene. (cid:142)(cid:3) Introduce an intercostal drain through a separate incision. (cid:142)(cid: 3) Close the chest wall. (cid:142)(cid:3) Connect the intercostal drain to an underwater se al. (cid:142)(cid:3) Send the specimens for histopathology and microbiological examination. Postoperative management (cid:142)(cid:3) Return the patient to HDU for monitoring and pain control. (cid:142)(cid:3) Attach the intercostal drain to suction (5KPa). (cid:142)(cid:3) Perform a chest radiograph as a baseline and at 24 hours. (cid:142)(cid:3) Provide analges ia through PCA, epidural or paravertebral block. (cid:142)(cid:3) Regular chest physiothera py. (cid:142)(cid:3) Remove the drain after 24 hours, if the chest radiograph shows the lung is fully expanded. Complications (cid:142)(cid:3) Pneumothorax (cid:142)(cid:3) Wound infection. This page intentionally left blank CHAPTER 16 Thoracic surgery 738 Open excision of pulmonary nodule Indication Solitary lung nodule on CXR and CT scan. Preoperative preparation Results of lung function tests, chest radiograph, ECG, and CT scan must be available. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral position. Incision Posterolateral thoracotomy in the 5th or 6th intercostal space. Procedure (cid:142)(cid:3) Once the chest is opened, divide any pleural adhesions. (cid:142 )(cid:3) Inspect the lung and palpate for the nodule. (cid:142)(cid:3) Grasp the nodule wit h tissue holding Duval forceps. (cid:142)(cid:3) Excise the nodule and surrounding lung as a wedge by applying the stapler (endo GIA 30) several times. (cid:142)(cid:3) Observe the staple line for air and blood leaks. If present suture these with a 4/0 Prolene. (cid:142)(cid:3) Insert two intercostal drains (24 \200\22328Fr., Silastic) through separat e stab incisions. Direct the anterior drain to the apex of the pleural space and the posterior one to the base of the pleural space. (cid:142)(cid:3) Close the chest in layers as previously described. Postoperative care (cid:142)(cid:3) Return the patient to HDU for monitoring and pain contr ol. (cid:142)(cid:3) Attach the intercostal drain to suction (5KPa). (cid:142)(cid:3) Perfo rm a chest radiograph as a baseline and at 24 hours. (cid:142)(cid:3) Regular chest physiot herapy. (cid:142)(cid:3) Provide analgesia by PCA, epidural or paravertebral block. (cid:14 2)(cid:3) Remove the drain after 24 hours, if the chest radiograph shows the lung fully expanded. Complications (cid:142)(cid:3) Pneumothorax (cid:142)(cid:3) Wound infection. This page intentionally left blank CHAPTER 16 Thoracic surgery 740 Excision of mediastinal mass Indications Any anterior mediastinal mass e.g. thymoma, retros ternal thyroid, pericardial cyst, and germ cell tumors. Position Supine. Anesthetic General anesthesia with endotracheal intubation. Incision Vertical midline from the sternal notch to the xiphisternum. Procedure (cid:142)(cid:3) Perform median sternotomy (see p710). (cid:142)(cid:3) Visualize and palpate the tumor or lesion and excise with care. Cauterize any arteries or veins supplying the tumor with diathermy or ligate them. Seek, id entify, and ligate the thymic vein. (cid:142)(cid:3) In cases suffering from myasthenia gravis the whole thymic gland needs to be removed. This is an \200\230H \200\231 shaped structure and extends upwards into the ne ck as well as downwards to the phrenic nerves on either side of the pericardium. Take great care when the lower part of the thymus is being removed to avoid damage to the phrenic ner ves. (cid:142)(cid:3) Secure haemostasis and introduce a single drain (24 \200\22328Fr, Silastic ) into the mediastinum through a separate stab incision below the sternotomy. (cid:142)(cid:3) If the pleural space has been entered, direct either one of the mediastina l drains into the pleural space or insert a third drain. (cid:142)(cid:3) Suture the drain in place with a heavy non-absorbable suture. Insert a closing stitch. (cid:142)(cid:3) Appose the sternal halves using 6 stainless steel wires, taking care to ensure that there is no bony step. (cid:142)(cid:3) Twist the wires until the sternal edges are firmly approximated. Then cut the wires using wire cutters and bend so that the cut ends point into the sternum. (cid:142)(cid:3) Close the subcutaneous tissues using continuous absorbable sutures e.g. Vicryl. (cid:142)(cid:3) Close the skin using subcuticular continuous absorbable sutures e.g. Monocryl. (cid:142)(cid:3) Connect the drain to a bottle with an underwater and suction commenced (5KPa). (cid:142)(cid:3) Reverse the anesthetic and once the patient is breathing spontaneously, transfer to the HDU. Postoperative care (cid:142)(cid:3) Perform a baseline chest radiograph and repeated at 24 hours (cid:142)(cid:3) Provide analgesia through PCA, epidural or paravertebral block (cid: 142)(cid:3) Regular chest physiotherapy EXCISION OF MEDIASTINAL MASS1 741 (cid:142)(cid:3) Remove the chest drain at 24 hours if the chest radiograph appearances are satisfactory and drainage of blood and air has ceased. Complications (cid:142)(cid:3) Complications of general anesthesia (cid:142)(cid:3) Bleedin g \200\224this can occur following damage to the internal mammary artery when the sternal wires are placed (cid:142)(cid:3) Instability of the sternum (cid:142)(cid:3) Wound infection (cid:142)(cid: 3) Dehiscence of wound (cid:142)(cid:3) Osteomyelitis (rare). CHAPTER 16 Thoracic surgery 742 Thoracic neurogenic tumors These usually lie in the paravertebral region at any level in th e chest and are usually incidental radiological findings. They should be removed because: 1 . They can grow into the intraveterbral foramen and cause spinal cord compression. 2. Sometimes they develop sarcomatous changes. Preoperative preparation (cid:142)(cid:3) A CT scan or MRI scan study is essential to visua lize any intra spinal extension. (cid:142)(cid:3) Neurosurgical input is essential if the tumor encroaches the spinal canal. (cid:142)(cid:3) The patient should be warned of the risk of damage to the sympathetic trunk which may result in postoperative Horner \200\231s Syndrome. Position Lateral. Anesthetic General anesthesia with double lumen endobronchial intubation. Incision Posterolateral thoracotomy in the 4th intercostal space. Procedure (cid:142)(cid:3) Open the chest and deflate the lung and retract it. Incise the p arietal pleural around the margins of the tumor using diathermy. (cid:142)(cid:3) Mobilize the tumor gradually placing traction sutures in the tumor tissue to assist the process. (cid:142)(cid:3) Cauterize and divide numerous blood vessels supplying the tumor. (cid:142) (cid:3) If the tumor rises from the sympathetic chain, the chain may be damaged during mobilization. (cid:142)(cid:3) Carry out the resection all the way round until the tumor is on a stalk at tached to the intravertebral foramen from which it is eased away with care. Ligate any vein s. (cid:142)(cid:3) Use a pack to control any bleeding. Do not use diathermy because of proximity of the spinal cord. (cid:142)(cid:3) Close the chest as previously described. Postoperative management As for thoracotomy (see p712). Complications (cid:142)(cid:3) Horner \200\231s syndrome (cid:142)(cid:3) Bleeding (cid:142 )(cid:3) Complications related to general anesthesia. This page intentionally left blank CHAPTER 16 Thoracic surgery 744