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 Pectus excavatum repair Characterized by a deep depression of the lower half of the sternum . Indication Surgical treatment in most cases is for cosmetic reasons. Preoperative preparation The patient should be warned that one defect (pectus excavatum) wi ll be replaced by another (a scar). Anesthetic General anesthetic with endotracheal intubation. Position Supine. Incision Make a vertical midline incision from the manubriosternal junction to 5cm below th e xiphoid process. Procedure (cid:142)(cid:3) Divide the skin and subcutaneous tissues in line of the incision . (cid:142)(cid:3) Raise a full thickness flap of skin subcutaneous tissue and pectoral muscles on either side to expose the relevant costal cartilages and ribs. (cid:142)(cid:3) Remove the deformed costal cartilages on both sides, preserving the perichondrium using a periosteal elevator. (cid:142)(cid:3) Then perform two parallel transverse sternal osteotomies using a powered saw. This is V-shaped in cross section with the broad part placed anteriorly so tha t elevation of the sternum results in correction of the deformity. (cid:142)(cid:3) Secure the sternum in its new position using two stainless steel wires passed through the two bits of sternum, which are twisted and tightened. (cid:142)(cid:3) Elevation of the lower sternum is made possible by inserting an Abrams bar of stainless steel under the lower sternum, which is attached on either end to the anterio r end of the 4th or 5th ribs. (cid:142)(cid:3) Insert 2 Redivac vacuum drains. (cid:142)(cid:3) Close the muscle flaps us ing absorbable sutures. (cid:142)(cid:3) Close the subcutaneous tissues and skin using abso rbable sutures. Postoperative management (cid:142)(cid:3) Nurse the patient on HDU. (cid:142)(cid:3) Obtain a baseline chest radiograph. (cid:142)(cid:3) Provide analgesia through PCA epidural or pa ravertebral block. (cid:142)(cid:3) Regular chest physiotherapy. (cid:142)(cid:3) Repeat th e chest radiograph at 24 hours, and if appearances are satisfactory and there is no further drainage of air or fluid, remove the drains. (cid:142)(cid:3) Remove the Abram \200\231s bar after six months under local anesthesia via a 1cm skin incision. PECTUS EXCAVATUM REPAIR1 745 Complications (cid:142)(cid:3) Bleeding \200\224from intercostal or internal mammary artery (cid:142)(cid:3) Pneumothorax (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Scar (hype rtrophic or keloid). CHAPTER 16 Thoracic surgery 746 Pectus carinatum repair This deformity is characterized by prominence of the lower sternum or costal cartilages. Indication Cosmetic. Anaesthestic General anesthesia with endotracheal intubation. Position Supine. Incision Make a vertical midline incision from the manubriosternal junction to 5cm below th e xiphoid process. Procedure (cid:142)(cid:3) Divide the skin and subcutaneous tissues in the line of the inci sion. (cid:142)(cid:3) Reflect the skin, subcutaneous tissues and pectoral muscles off the costal cartilages as a full thickness flap. (cid:142)(cid:3) Resect all the affected costal cartilages on both sides of the sternum leaving behind the perichondrium (from where new cartilage develops). (cid:142)(cid:3) Perform two parallel transverse sternal osteotomies close together using a power saw so that a wedge of sternum which is V-shaped on cross section is removed. The ap ex of the V lies anteriorly, so that the sternum moves inwards when the two edges are appro ximated. (cid:142)(cid:3) Fix the two parts of the sternum together with two stainless stee l wires. These are tightened with the sternum in its new position. (cid:142)(cid:3) Secure haemostasis using diathermy. (cid:142)(cid:3) Insert two Redivac va cuum drains. (cid:142)(cid:3) Close the muscles, subcutaneous tissue and skin layers using absorbable sutures. Postoperative management As for pectus excavatum (p744). Complications As for pectus excavatum (p745). This page intentionally left blank CHAPTER 16 Thoracic surgery 748 Rib resection for empyema Indications (cid:142)(cid:3) When decortication is contraindicate d by a patient \200\231s age or debilitated state (cid:142)(cid:3) The presence of bronchopleural fistula or oesophagopleural fistula. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral position. Procedure (cid:142)(cid:3) Look for the rib level at the most dependent part of the empyema cavity. This is identified on a PA and lateral chest X-ray after contrast material has been injected into the empyema cavity. (cid:142)(cid:3) Make a transverse incision (approx. 10cm) over the chosen rib. Divide the subcutaneous tissues and muscles along the incision and expose the rib. Elevate the periost eum using a periosteal elevator and excise a segment of rib (approx. 8cm). (cid:142)(cid:3) Aspirate through the periosteal bed to confirm the presence of pus. (cid:1 42)(cid:3) Send a pus specimen to microbiology for microscopy, culture and sensitivity. (cid:142)(cid:3) Enter the empyema cavity and remove the outer wall using diathermy. Ligate the intercostal vessels on either side in order to prevent later damage and hemorrhage by erosion from the intercostal drainage tube. (cid:142)(cid:3) Clean and wash out the empyema cavity. (cid:142)(cid:3) Insert a large bor e Silastic drainage tube through the incision about 5cm into the pleural cavity. Then cut the tube short so that approximately 2cm project from the skin edge, and pierce its outer end with a large safety pin and secure it to the skin with adhesive strips. (cid:142)(cid:3) Leave the wound open, as it heals rapidly. (cid:142)(cid:3) Apply a dry dr essing over the wound and drain. This can later be converted to a stoma bag. Postoperative management (cid:142)(cid:3) Transfer the patient to the HDU. (cid:142)(cid:3) Obtain a PA and lateral chest radiographs to ensure that the chest drain is correctly sited. (cid:142)(cid:3) Change the drain dressings/stoma bag daily. When the drainage of pus cease s the drain is gradually shortened and eventually removed. This may take a few months. Complications (cid:142)(cid:3) Complications of general anesthesia (cid:142)(cid:3) Hemorrh age. This page intentionally left blank CHAPTER 16 Thoracic surgery 750 Decortication for empyema Indication (cid:142)(cid:3) Chronic empyema (cid:142)(cid:3) Orga nized and unresolved haemothorax. Contraindications (cid:142)(cid:3) In very elderly and debilitated patients. (cid:142)(cid: 3) In the presence of severe systemic sepsis. Preoperative investigations (cid:142)(cid:3) Chest radiograph \200\224PA and lateral (cid:1 42)(cid:3) CT scan (cid:142)(cid:3) Needle aspiration of fluid for microscopy, culture, and sensitivity (cid:142)(cid:3) Rigid bronchoscopy. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Lateral. Incision Perform a posterolateral thoracotomy in the 5th intercostal space when the empyema is near the apex, or in the 6th or 7th intercostal space when the empyema extends to the d iaphragm. Procedure (cid:142)(cid:3) Enter the chest and spread the ribs. In chronic empyema if the r ibs are crowded it may be necessary to resect the rib to obtain access. (cid:142)(cid:3) Separate the outer wall of the empyema cavity from the chest wall as far as possible, using blunt and sharp dissection. (cid:142)(cid:3) Incise the outer cortex and enter the empyema cavity. (cid:142)(cid:3) Asp irate the pus and fibrin residue within the cavity and following this wash out the sac with sterile water. (cid:142)(cid:3) Dissect the outer wall of the abscess cavity further and remove by sharp dissection. (cid:142)(cid:3) Incise the cortex on the collapsed lung through the layers of the sac using a scalpel with great care. (cid:142)(cid:3) Develop a plane between the lung tissue and the cortex of the empyema sac. (cid:142)(cid:3) Then \200\230peel \200\231 the cortex off the collapsed lung tissue takin g care to preserve the integrity of the visceral pleural surface of the lung as far as possible. Inev itably the superficial layers of the lung will be damaged in this process. (cid:142)(cid:3) Remove as much of the empyema sac cortex as possible. (cid:142)(cid:3) Sco re the bits of cortex, which are very adherent to the lung with a scalpel in a crosshatch pattern. The lung is simultaneously forcibly expanded by the anes thetist so that the lung tissue expands through the incision. DECORTICATION FOR EMPYEMA1 751 (cid:142)(cid:3) When maximum expansion of the lung is obtained there will be both air and blood leakage present. (cid:142)(cid:3) Obtain haemostasis with diathermy cautery. Use a dental mirror to visualize bleeding points on the lateral chest wall. (cid:142)(cid:3) Insert two intercostal drains (24 \200\22328Fr., Silastic), one anteriorly and one posteriorly. The anterior drains to the apex of the chest and the posterior drains to t he base of the chest. Secure these to the skin with stout non-absorbable sutures. The air a nd blood leakage should settle over the next day or two. (cid:142)(cid:3) Connect the drains to suction (7 \200\22313KPa) in order to maintain lung expansion. (cid:142)(cid:3) Close the chest in layers as previously described. (cid:142)(cid:3) Send s pecimens of the contents of the empyema cavity and the wall of the empyema cavity to microb iology for microscopy, culture and sensitivity, and to histopathology. Postoperative management (cid:142)(cid:3) Transfer the patient to the HDU. (cid:142)(cid:3) Daily chest radiographs. (cid:142)(cid:3) Continue suction on the drains until the lung is fully expanded and all air leaks have ceased, at which stage the chest drains are removed. This may take several days. (cid:142)(cid:3) Regular chest physiotherapy. (cid:142)(cid:3) Provide analgesia through PCA, epidural or paravertebral block. (cid:142)(cid:3) Remove th e intercostal drains when there is no longer any drainage of fluid or air and chest radiograph appearances are satisfactory. Complications (cid:142)(cid:3) Complications of general anesthesia (cid:142)(cid:3) Bleedin g (cid:142)(cid:3) Haemothorax (cid:142)(cid:3) If severe, patient may need to be returned to theater for evacuation of blood clots. CHAPTER 16 Thoracic surgery 752 Airway stents Indications (cid:142)(cid:3) Extrinsic airway compression e.g. tumors or othe r structures within the chest (cid:142)(cid:3) Intrinsic airway obstruction from benign or malignant diseases (cid:142)(c id:3) Sealing of airway fistulas (cid:142)(cid:3) Some cases of tracheobronchomalacia. Contraindications In addition to the contraindications for rigid or flexible bronchoscopy ( see pp694, 696), stent insertion should be avoided if nonviable lung is present beyond the obstruction. Types of stent (cid:142)(cid:3) Numerous types (cid:142)(cid:3) Silicone, metal or hybrid ( cid:142)(cid:3) Insertion devices are specific to the stent. Procedure Insert with either flexible or rigid bronchoscope depending on the design of the stent. Radiological screening is sometimes necessary. Postoperative management (cid:142)(cid:3) Humidified oxygen (cid:142)(cid:3) Regular chest physiotherapy. Complications In addition to the risks of flexible or rigid bronchoscopy (see pp695, 697) ( cid:142)(cid:3) Migration of stent (cid:142)(cid:3) Infection (cid:142)(cid:3) Granuloma fo rmation (cid:142)(cid:3) Breakage (cid:142)(cid:3) Haemoptysis (cid:142)(cid:3) Airway obst ruction e.g. due to impaction or granulomas (cid:142)(cid:3) Pain (cid:142)(cid:3) Death. This page intentionally left blank CHAPTER 16 Thoracic surgery 754 Video assisted thoracic surgery (VATS) Key points (cid:142)(cid:3) Patient placed in a late ral position. (cid:142)(cid:3) Position the patient to open the intercostal spaces as much as possible. This can be achieved by breaking the table at the chest level or placing a pil low between the patient \200\231s chest and the operating table. (cid:142)(cid:3) Use a triangular port arrangement. (cid:142)(cid:3) Avoid instrument \200 \230fencing \200\231 (crossing the instruments). (cid:142)(cid:3) Create the ports under di rect vision and ensure adequate haemostasis as bleeding will obscure the view. (cid:142)(cid:3) Using double lumen endobronchial intubation allows deflation of the lung and provides a larger space to work in. (cid:142)(cid:3) Divide all intrapleural adhesions before proceeding. (cid:142)(cid:3) Moni tors should be positioned in front of the operating surgeon. (cid:142)(cid:3) Staples and c artridges must be selected according to the type and thickness of tissue to be divided. Safety points (cid:142)(cid:3) Use bipolar diathermy near the heart, esophagus, and spine. (cid:142)(cid:3) Always make sure the cutting instrument or stapler is positioned properly and in full view before dividing tissue. (cid:142)(cid:3) Ensure a full thoracotomy set is available in the operating room for immed iate conversion to open thoracotomy in the event of severe intraoperative hemorrhage. Location of ports First port: 2cm incision in the 6th intercostal space below the tip of th e scapula \200\224insert the thoracoscopic camera via flexible port. Second port: stab inci sion in the 4th intercostal space anterior to the latissimus dorsi muscle. Third port: stab incision in the 5th intercostal space at the posterior border of the latissimus dorsi musc le. Complications (cid:142)(cid:3) Bleeding. If uncontrolled, may require conversion to an open procedure. (cid:142)(cid:3) Infection of port sites. (cid:142)(cid:3) Complications of general anesthe sia. This page intentionally left blank CHAPTER 16 Thoracic surgery 756 VAT parietal pleurectomy and bullectomy Indications (cid:142)(cid:3) Non-resolving spontane ous pneumothorax (cid:142)(cid:3) Repeated spontaneous pneumothorax on more than two episod es (cid:142)(cid:3) First spontaneous pneumothorax in airline pilots. Anesthetic General anesthesia with double lumen endobronchial intubation. Position of patient Lateral. Procedure (cid:142)(cid:3) Insert ports (see p776). (cid:142)(cid:3) Deflate the lung. (cid :142)(cid:3) Divide pleural adhesions using endoscopic diathermy scissors. (cid:142)(cid:3) Examine the apex of the lung and identify bullae. Grasp these with an endoscopic grasper v ia the second port and stapled across the base using an Endo GIA 30 stapling device inserte d through the third port. (cid:142)(cid:3) More than one staple application may be necessary. (cid:142)(cid:3) Carry out parietal pleurectomy by elevating the pleura with long Roberts forceps, starting at the anterior incision. A sheet of pleura is first rolled onto the forceps and then removed by gentle tracking on the video control. (cid:142)(cid:3) Alternatively the pleura may be abraded using a piece of mesh rolled on Roberts forceps. (cid:142)(cid:3) Aspirate blood in the pleural cavity. Secure haemostasis using diathermy. (cid:142)(cid:3) Insert two chest drains (one apical and one basal) under video vision. Connect the drains to underwater seal bottles, and commence suction (5KPa). (cid:142)(cid:3 ) Inflate the lung. (cid:142)(cid:3) Close the chest in layers with absorbable sutures. (ci d:142)(cid:3) Transfer the patient to the HDU once the anesthetic has been reversed and breathing spontaneously. Postoperative care (cid:142)(cid:3) Obtain a baseline postoperative chest radiograph to ens ure full expansion of the lung (cid:142)(cid:3) Perform daily chest radiographs (cid:142)(cid:3) Regular chest physiothera py (cid:142)(cid:3) Remove the drains when they stop bubbling (no air leak) and the lung has expanded fully on chest radiograph. This page intentionally left blank CHAPTER 16 Thoracic surgery 758 VAT lung wedge biopsy Indication This is a diagnostic procedure for interstitial lung disea se. Preoperative preparation (cid:142)(cid:3) Chest radiograph (cid:142)(cid:3) CT scan (cid:14 2)(cid:3) Respiratory function tests. Anesthetic General anesthesia with double lumen endobronchial intubation. Procedures (cid:142)(cid:3) Insert ports in a triangular configuration. (cid:142)(cid:3) De flate the lung. (cid:142)(cid:3) Introduce the thoracoscope into the middle port (first por t). (cid:142)(cid:3) Divide all pleural adhesions using the endoscopic diathermy scissors. (cid:142)(cid:3) Grasp the portion of lung containing the lung nodule with an endoscopic grasper via the second port. (cid:142)(cid:3) Introduce a stapler via the third port and fire several times around the lesion to remove a wedge of lung. (cid:142)(cid:3) Inspect the staple lines to make sure they are air and blood tight. If there is a leak, this is sutured with 4/0 Prolene. (cid:142)(cid:3) Aspirate blood in the pleural cavity. (cid:142)(cid:3) Place two chest dra ins (one apical and one basal) under video vision. Connect the drains to underwater seal bottles, which are connected to suction (5KPa). (cid: 142)(cid:3) Inflate the lung. (cid:142)(cid:3) Close the chest in layers with absorbable su tures. (cid:142)(cid:3) Transfer the patient to the HDU once the anesthetic has been reversed and breathing spontaneously. Postoperative care (cid:142)(cid:3) Ensure adequate analgesia either by PCA, epidural or in tercostal block (cid:142)(cid:3) Obtain a baseline postoperative chest radiograph to ensure full expansion of the lung (cid:142)(cid:3) Perform daily chest radiographs (cid:142)(cid:3) Regular chest physiothera py (cid:142)(cid:3) Remove the drains when they stop bubbling (no air leak) and the lung has expanded fully on chest radiograph. Chapter 17 759 Principles of plastic surgery P. Baguley Introduction 760 Anatomy of the integument 762 Normal wound healing 764 Abnormal wound healing 766 Keloids and hypertrophic scars 768 Reconstructive ladder 770 Primary and secondary intention healing 772 Skin grafts 774 Split thickness skin graft 776 Full thickn ess skin graft 780 Flaps 782 Types of local skin flaps 784 Free flaps and microsurgery 788 Management plan 790 Plastic surgical technique 792 Lower limb trauma 794 Neoplasia 798 The breasts 802 Burns 806 CHAPTER 17 Principles of plastic surgery 760 Introduction Many branches of surgery have a well-defined anatomical area that they special ize in, whereas plastic surgery is generally a technique based speci- ality. This means tha t there are basic principles that can be used to help innumerable operative situations enco untered. The term \200\230plastique \200\231 was first used in 1798 and is derived from the Greek w ord plastikos, meaning \200\230fit for molding \200\231. Until the turn of the twentieth c entury most procedures were for reconstruction and there is a perceived distinction between esthetic and reconstructive surgery. Sir Harold Gillies even defined the two: reconstructi ve surgery is an attempt to restore the individual to normal and esthetic surgery attempts to surpass the normal. However, it is rare for any procedure not to need at least some degr ee of esthetic consideration, so a sense of form and function as well as esthetic judgment and an ability to conceptualize the final result are all essential to the application of pl astic surgery. As much of the surgery is technique-based then an appreciation of the underlying anatomy, p articularly of skin, as well as factors such as healing and what may have caused the proble m initially are vital. Following this an understanding of some of the basic principles of s urgery must be appreciated. It is only when all factors are considered can a plan of treatm ent be formulated and a successful result be expected. Plastic surgery covers an enormous range of procedures in all aspects of the body. However, in this chapter those aspects of plastic surgery, which are mainly applicable to general s urgery are presented. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 762 Anatomy of the integument The integument consists of skin, subcutaneous fat and fascia. Blood supply (Fig. 17.1) The blood supply to the integument is divided into a number of tra ns- versely arranged plexuses. (cid:142)(cid:3) Subpapillary plexus At the junction of the papillary and reticular layers of the dermis; loops up to epidermis \200\224papillary loops. (cid:142)(cid:3) Subdermal plexus At the lower border of the dermis; gives off branches to the subpapillary plexus and down to fat. The blood vessels that pass to the sub dermal plexus come from the deep fascia. (cid:142)(cid:3) Subcutaneous plexus Within the adipose tissue. (cid:142)(cid:3) Fascial pl exuses There are 2 fascial plexuses: superficial fascial plexus which is minor and cannot s ustain flap and the deep fascial plexus which is dominant. Relaxed skin tension lines There is natural elasticity to the skin because of the elastin f ibers that lie within the dermis. The skin is naturally under tension, as demonstrated by t he gaping of an incised wound or the stretching of a healing wound. The degree of tension i s greatest in one direction and this is termed the relaxed skin tension line (RSTL). An inc ision placed parallel to these lines is therefore subject to minimal tension and usually re sults in a better quality scar. Conversely an incision that transgresses these lines will g ape widely and when healing is subject to tension that may cause the scar to gape or even d evelop a hypertrophic scar. Wrinkle lines may be caused by either the pull of underlying muscles (around the eyes or mo uth) or from movements around a joint (neck or wrist). In general these are similar to the RSTL, though may be different such as in the glabellar or the lateral palpebral fissure (cr ow \200\231s feet). The RSTL can be found easily by pinching the skin between the thumb and index finger. A ser ies of ridges and furrows develops which are made with greater ease and are more extensive when they are parallel to the RSTL. ANATOMY OF THE INTEGUMENT1 763 Epidermis p a l f p a l f Dermis n r e t t a p m o d n a R s u o e n a t u c o c s a F p a l f Axial vessels s u o e n a t u c o u c s u M Musculocutaneous perforator i Fascial vessel Segmental artery l Muscle Fascia Fig. 17.1 Blood supply to the integument CHAPTER 17 Principles of plastic surgery 764 Normal wound healing There are 4 distinct but overlapping phases in wound healing (Fig. 17. 2): Haemostasis (cid:142)(cid:3) Occurs immediately after an injury (cid:142)(cid:3) Following vasoconstriction, platelets adhere to the vessels of the microcirculation leading to the release of cytokines (cid:142)(cid:3) The clotting cascade is initiated which leads to the deposition of a fibrin network. Inflammation (cid:142)(cid:3) Polymorphs enter the wound, cleaning it of debris (cid:142)(c id:3) Monocytes follow which orchestrate the ingrowth of blood vessels and fibroblasts. Proliferation Four main events happen in this phase (cid:142)(cid:3) Fibroplasia (cid:142)( cid:3) Matrix deposition (cid:142)(cid:3) Angiogenesis (cid:142)(cid:3) Epithelialisation. Remodeling (cid:142)(cid:3) Collagen is degraded and deposited in a more ordered fashion (c id:142)(cid:3) Myofibroblasts cause wound contraction (cid:142)(cid:3) Maximal tensile stre ngth occurs by 12 weeks (cid:142)(cid:3) Ultimately the scar only has 80% of normal skin st rength. N O R M A L Proliferation Remodeling Inflammation Macrophage Myofibroblast Fibroblast W O U N D r e b m u n Polymorpho- nuclear leucocyte l l e c Endotheliocyte Fibrocyte H E A L N G e v i t a l e R I 100 20 Time (days) Fig. 17.2 Diagram showing relative timings of the stages of wound healing 3 1 7 6 5 CHAPTER 17 Principles of plastic surgery 766 Abnormal wound healing Delayed wound healing develops when there is interference of one of the steps of wound healing. Factors that may be responsible are: Local factors (cid:142)(cid:3) Foreign bodies (cid:142)(cid:3) Infection (cid:142)(cid:3) I schaemia (cid:142)(cid:3) Arterial or venous insufficiency (cid:142)(cid:3) Smoking (cid:14 2)(cid:3) Neoplasia. Systemic factors (cid:142)(cid:3) Nutritional deficiency (cid:142)(cid:3) Diabetes (cid:142 )(cid:3) Ageing (cid:142)(cid:3) Liver disease (cid:142)(cid:3) Alcoholism (cid:142)(cid:3) Medications, particularly steroids and immunosuppessoats (cid:142)(cid:3) Immobility (cid: 142)(cid:3) Cancer (cid:142)(cid:3) Anticancer therapy (X-rays). Techniques to assess wounds (cid:142)(cid:3) Inspection (cid:142)(cid:3) Bacteriology swab (cid:142)(cid:3) Histological biopsy (cid:142)(cid:3) Radiological imaging (cid:142)(cid:3) Biopsy. Types of abnormal healing (cid:142)(cid:3) Delayed (cid:142)(cid:3) Dehiscence (cid:142)(ci d:3) Stretched scar (cid:142)(cid:3) Keloid (cid:142)(cid:3) Hypertrophic scar. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 768 Keloids and hypertrophic scars (cid:142)(cid:3) Keloids and hypertrophic scars are characte rized by excessive accumulation of collagen within the wound. There are abnormalities of cell migration and pr oliferation, inflammation, and the synthesis and secretion of matrix proteins and cytokines . (cid:142)(cid:3) Keloids grow beyond the borders of the original wound, can form some time after a tissue injury and generally do not resolve spontaneously. Hypertrophic sc ars stay within the limit of the original wound, usually develop soon after the tissue inju ry and tend to regress spontaneously. (cid:142)(cid:3) Histologically they differ from normal skin by having a rich blood supply, high cell density and a thick epidermal layer. Hypertrophic scars have collagen fib ers arranged in a loose, wavy pattern. Keloids have irregularly shaped collagen fibers in a disorganized pattern. Predisposing factors That certain patients and conditions may predispose to hypertrophic sc ar formation is well known. Both hypertrophic scars and keloids occur more commonly in dark -skinned individuals. Wounds that cross skin tension lines or wounds that are located on th e ear lobes or presternal and deltoid areas are common sites for these forms of abnormal he aling. Conservative management includes pharmacologic therapy, pressure, laser, and radioth erapy. Each method has varying degrees of reported success. (cid:142)(cid:3) Black, Asian, and Celtic (red hair and freckles) skin. (cid:142)(cid:3) Wounds on the anterior chest, sho ulders and anterior neck as well as wounds that cross skin tension lines. (cid:142)(cid:3) A wound that has healed by secondary intention, especially if the healing time is greater than 3 weeks. (cid:142)(cid:3) Wounds with prolonged inflammation (foreign body, infection, burn). Treatm ent No single, universally successful treatment for hypertrophic scars and keloids exists a nd the recurrence rate is high. Surgical treatment is reserved for cases that are unrespons ive to conservative management. (cid:142)(cid:3) Compression dressings are custom-made for the patient and should be worn 24 hours a day. (cid:142)(cid:3) Corticosteroids injected directly into the lesion act by diminishing colla gen synthesis and decreasing mucinous ground substance. (cid:142)(cid:3) Excision is most e ffective when combined with external radiation, steroid injection, (cid:140) pressure therapy. There is a high risk of recurrence. (cid:142 )(cid:3) Radiation is most effective when used in the immediate postoperative period. (cid:142)(cid:3) Cryosurgery with liquid nitrogen is used to cause cell damage and to affect the microvasculature. (cid:142)(cid:3) Laser therapy. (cid:142)(cid:3) Silicone sheets sometimes in combination w ith compression applied over a scar are reported to reduce the bulk. (cid:142)(cid:3) Massage with aqueous cream ma y be effective. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 770 Reconstructive ladder When a plastic surgeon assesses a wound, or a situation in which a wo und will result from resection, a basic set of rules guides the formula- tion of a treatmen t plan. The least complex methods, such as direct closure, are on the lower rungs whilst th ere is an increase in complexity to the top. The size and nature of the injury as well as factors such as the patient \200\231s general condition will determine which treatment method is used. In general the least complex metho d of achieving the desired result is used. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 772 Primary and secondary intention healing Primary intention (primary closure) This is where t he edges of the wound are in direct contact. This is most appropriate for small and uninfec ted wounds. Methods of skin closure may be: (cid:142)(cid:3) Sutures (cid:142)(cid:3) Stapl es (cid:142)(cid:3) Glue (cyanoacrylate) (cid:142)(cid:3) Adhesive strips. Secondary intention This is where the wound edges are not in contact. Healing takes place b y a combination of wound contracture and granulation/epithelisation. Whilst this generally leads to a wider and less attractive scar it may be appropriate in situations such as: (cid :142)(cid:3) Infection (cid:142)(cid:3) Wound breakdown (cid:142)(cid:3) Poorly vascularise d areas (cid:142)(cid:3) Patient not fit for surgery. Delayed primary and secondary closure Can be used when an open wound is clean and free of i nfection or other underlying pathology. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 774 Skin grafts If a wound is too large for suturing, and healing by secondary intention or sec ondary closure is inappropriate, a skin graft may be suitable. A skin graft consists of the epidermis and a variable amount of the dermis. This is placed on the recipient site where it attains a new blood supply and integrates itself into the recipient site. The bed must b e suitable for grafting and: (cid:142)(cid:3) Be free of friction. (cid:142)(cid:3) Have no contamination. (cid:142)(cid:3) Have no infection. Pseudomonas aeruginosa and group A (cid :168) haemolytic streptococci are both particularly problematic. (cid:142)(cid:3) Have an adequate blood supply. Bare tendon or bone for example are not suitable. Anatomy (Fig. 17.3) In all skin grafts the epidermis is taken but the amount of dermis vari es. If only part of the dermis is taken it is a split thickness skin graft; whereas in a fu ll thickness skin graft the whole of the dermis is taken. SKIN GRAFTS1 775 Hair follicle Sebaceous gland Hair Epidermis Thin Medium Split thickness skin graft Dermis Thick Full thickness skin graft Subcutaneous fat Duct of sweat gland Sweat gland Fig. 17.3 Depth of skin grafts CHAPTER 17 Principles of plastic surgery 776 Split thickness skin graft This includes the epidermis and only part of the dermis. Advantages (cid:142)(cid:3) Donor site heals by epithelisation from remaining dermal elemen ts such as sweat glands and hair follicles (cid:142)(cid:3) Can be re-harvested (cid:142)(cid:3) Larger amounts can be harvested (cid: 142)(cid:3) Can conform to defects as it is thin. Disadvantages (cid:142)(cid:3) Less resilient to trauma (cid:142)(cid:3) Less esthetically acceptable (cid:142)(cid:3) Can contract leading to secondary deformities. Donor site Virtually any part of the body can be used as a donor, including the scalp. Whil st the area does heal it leaves a scar and so a relatively hidden area is preferable. A var iety of dressings have been used (alginate, semi- occlusive or occlusive) but they all aim to protect the healing donor site. It is not necessary to keep checking these sites unless specifically indi- cated such as the suspicion of infection. Healing takes from seven days to several weeks depending on the thickness.