placed 5mm away from the mucogingival junction (Fig. 15.20), this allows the unattached muc osa left on the alveolar segment to be reattached at the end of the procedure. Extend the i ncision as far posteriorly as necessary to facilitate tensionless exposure, although unnece ssary lengthening may compromise mucosal vascularity. (cid:142)(cid:3) Deepen the incision through periosteum and raise the entire flap in a subp eriosteal plane, with cautious dissection in the region of the mental or infraobital nerves . (cid:142)(cid:3) Then expose the maxilla or mandible. (cid:142)(cid:3) Close the mucosa wit h a tension-free continuous 3/0 Vicryl resorbable suture. (cid:142)(cid:3) Use an elasticated chin dressing after a mandibular degloving procedure to restrict haematoma and redrape the repositioned mentalis muscles. Complications Immediate (cid:142)(cid:3) Cutaneous paraesthesia due to traction neuropraxia (cid:142)(cid:3) Wound dehiscence Late (cid:142)(cid:3) Gingival recession (cid:142)(cid:3 ) Facial ptosis (cid:142)(cid:3) Nasal alar flaring and shortening of the upper lip after ( cid:142)(cid:3) Maxillary degloving procedure. Acknowledgement We wish to thank Mr Jerry Sharp FRCS, Consultant ENT surgeon, Derbyshire Ro yal Infirmary for his comments on the Thyroidectomy section. This page intentionally left blank Chapter 16 691 Thoracic surgery G. N. Morritt and A. N. Morritt Bronchoscopy 692 Rigid bronchoscopy 694 Flexible bronchosco py 696 Cervical mediastinoscopy 698 Anterior mediastinotomy 700 Chest drain insertion: tube thoracostomy 702 Posterolateral thoracotomy 706 Anterolateral thoracotomy 708 Median stern otomy 710 Lobectomy 712 Right upper lobectomy 714 Right middle lobectomy 716 Right lower lo bectomy 718 Left upper lobectomy 720 Left lower lobectomy 722 Pneumonectomy 724 Right pneum onectomy 726 Left pneumonectomy 728 Right intrapericardial pneumonectomy 730 Left intraperi cardial pneumonectomy 732 Open parietal pleurectomy and bullectomy 734 Open lung wedge biop sy 736 Open excision of pulmonary nodule 738 Excision of mediastinal mass 740 Thoracic neur ogenic tumors 742 Pectus excavatum repair 744 Pectus carinatum repair 746 Rib resection for empyema 748 Decortication for empyema 750 Airway stents 752 Video assisted thoracic surger y (VATS) 754 Vat parietal pleurectomy and bullectomy 756 Vat lung wedge biopsy 758 CHAPTER 16 Thoracic surgery 692 Bronchoscopy This is performed using a rigid bronchoscope or a flexible fibreoptic bronchos cope. The Negus rigid bronchoscope (cid:142)(cid:3) Different sizes e.g. adult, pediatric (cid:14 2)(cid:3) Halogen light source (cid:142)(cid:3) The three most commonly used telescopes are direct vision, 30(cid:13) angled, and 90(cid:13) angled. (cid:142)(cid:3) The telescopes are placed down the rigid barrel of the bronchoscope (cid:1 42)(cid:3) Instruments e.g. graspers, biopsy forceps, and suction devices (cid:142)(cid:3) Telescopes can be attached to a video camera for display on a monitor. The flexible bronchoscope (cid:142)(cid:3) Fibreoptic bronchoscope (cid:142)(cid:3) Outer d iameter \200\2243 \200\2236mm (cid:142)(cid:3) Light transmitted via fibreoptic bundles (ci d:142)(cid:3) Field of vision is usually 80(cid:13) (cid:142)(cid:3) Can be attached to vid eo camera for display on screen. BRONCHOSCOPY1 693 Fig. 16.1 The flexible bronchoscope Fig. 16.2 The flexible bronchoscope. Light is transmitted via fibreoptic bundles CHAPTER 16 Thoracic surgery 694 Rigid bronchoscopy An invasive procedure where a rigid bronchoscope is used to visualize th e oropharynx, larynx, vocal cords, and tracheobronchial tree. It may be combined with flexi ble bronchoscopy for improved distal airway visuali- sation and suctioning. It is preferred to flexible bronchoscopy for unsta- ble patients, centrally located tumors, and cases wher e there is severe airway obstruction and the patient needs to be ventilated. Indications Diagnostic (cid:142)(cid:3) Biopsy (where flexible bronchoscope specimen is ina dequate) (cid:142)(cid:3) Preoperative assessment for lung resection surgery (cid:142)(cid: 3) Massive haemoptysis (cid:142)(cid:3) Airway obstruction (cid:142)(cid:3) Benign strictur e (cid:142)(cid:3) Tracheobronchial toilet. Therapeutic (cid:142)(cid:3) Removal of secreti ons (cid:142)(cid:3) Cauterisation of bleeding points (cid:142)(cid:3) Removal of foreign b odies (cid:142)(cid:3) Relief of airway obstruction (cid:142)(cid:3) Treatment of bronchopl eural fistula (cid:142)(cid:3) Dilation of tracheal or bronchial strictures (cid:142)(cid:3 ) Laser therapy (cid:142)(cid:3) Insertion of airway stents. Contraindications Relative \200\224uncontrolled coagulopathy. Extra care should be taken with patients with active TB, HIV, and hepatitis to avoid the spread of infection. Preprocedure preparation (cid:142)(cid:3) Bleeding time and PTT if a bleeding problem is su spected (cid:142)(cid:3) Atropine 0.6mg IM (to reduce secretions) (cid:142)(cid:3) Patient starved for six hours. Position Supine. Anesthesia (cid:142)(cid:3) General anesthetic (cid:142)(cid:3) Ventilation is provided thr ough a Sanders injector utilizing a Venturi system to inject oxygen under pressure intermittently. Procedure (cid:142)(cid:3) Aspirate pharyngeal secretions. (cid:142)(cid:3) Introduce the b ronchoscope behind the tongue in the midline. (cid:142)(cid:3) Lift the epiglottis up using the beak of the bronchoscope to visualize the vocal cords. RIGID BRONCHOSCOPY1 695 (cid:142)(cid:3) Turn the bronchoscope 90(cid:13) and then pass through the vocal cords int o the trachea (identified by the cartilage rings). (cid:142)(cid:3) Then rotate the bronchoscope back to its original position and note any tracheal narrowing, constriction, deviation or mucosal abnormality. (cid:142)(cid:3) Advance the bronchoscope to the carina. Significant enlargement of the subcarinal nodes will result in widening of the carina. (cid:142)(cid:3) If the pathology is unilateral, then do the examination of the contra- lat eral side first ensuring a) a complete examination, and b) blood and cellular debris will n ot be carried to the other side. (cid:142)(cid:3) Biopsy any abnormal areas. (cid:142)(cid:3) Control bleeding with a cotton pledget on a pledget holder. (cid:142)(cid: 3) If bleeding is uncontrolled pass a Thomson bronchial blocker (or Fogarty catheter) and occlude the lobar or segmental bronchus. If an Nd: YAG laser is a vailable then this can be used to cauterize the bleeding area. (cid:142)(cid:3) If bleeding remains uncontrolled, then turn the patient so the affected side is dependent to maintain the airway to the good side. Provisions should be ma de for immediate thoracotomy. (cid:142)(cid:3) When the preliminary examination is complete, address the indication for the procedure eg extraction of foreign body or biopsy. (cid:142)(cid:3) Collection of specimen and biopsy: (cid:142)(cid:3) Collect aspirated material in a sputum trap and ensure the specimen bottle is labeled clearly before the specimen is sent for culture, sensitivity and cytology. Mark biopsies sent for histopathological examination. (cid:142)(cid:3) If secretions are scanty, a lavage with 50ml of 0.9% saline solution will yield sufficient cells for study. (cid:142)(cid:3) Telescopes may be inserted into the bronchoscope to visualize the distal segments. The side viewing telescopes are used to visualize the upper lobe and segme ntal bronchi. (cid:142)(cid:3) For a more detailed examination a flexible bronchoscope can be used. Complications Are rare. (cid:142)(cid:3) Complications of general anesthesia. (cid:142)(cid :3) Bleeding from biopsy site \200\224control this by applying pressure at the bleeding poi nt with a cotton pledget on a pledget holder soaked in 1:10 000 adrenaline solution. Repeat if necessary. (cid:142)(cid:3) Injury to the upper aero digestive tract e.g. teeth, gums. (cid:142)(cid:3 ) Tracheal or bronchial tears. (cid:142)(cid:3) Pneumothorax or subcutaneous emphysema. (ci d:142)(cid:3) Arrhythmias. (cid:142)(cid:3) Death. CHAPTER 16 Thoracic surgery 696 Flexible bronchoscopy An invasive procedure where a flexible fibreoptic bronchoscope is use d to visualize the nasal passages, pharynx, larynx, vocal cords and tracheo- bronchial tree . Indications Diagnostic (cid:142)(cid:3) Haemoptysis (cid:142)(cid:3) Abnormal finding on CX R e.g. undiagnosed pulmonary infiltrates, mediastinal lymphadenopathy (cid:142)(cid:3) Inhalation injury (cid:142)(cid:3) Bronchiectasis (cid:142)(cid:3) Cough ( cid:142)(cid:3) Foreign body (cid:142)(cid:3) Intubation injury (cid:142)(cid:3) Lung absce ss (cid:142)(cid:3) Sputum cytology suspicious for cancer (cid:142)(cid:3) Stridor or local ized wheezing (cid:142)(cid:3) Thoracic trauma (cid:142)(cid:3) Vocal-cord paralysis. Thera peutic (cid:142)(cid:3) Retained secretions or mucus plugs (bronchial toilet) (cid:142)(cid :3) Laser therapy (cid:142)(cid:3) Difficult endotracheal intubation (cid:142)(cid:3) Forei gn body removal (cid:142)(cid:3) Lung abscess (cid:142)(cid:3) Brachytherapy (cid:142)(cid: 3) Bronchopleural fistula. Contraindications Relative rather than absolute. (cid:142)(cid:3) Bleeding disorders (cid:1 42)(cid:3) Hypoxaemia and hypercapnia (cid:142)(cid:3) Cardiovascular instability \200\224h ypotension, uncontrolled angina, malignant arrhythmia, recent myocardial infarction (cid:142)(cid:3) Severe asthma. Extra care should be taken with patients with active TB, HI V, hepatitis to avoid the spread of infection. Care should also be taken when there is trac heal obstruction, as there is the possibility of losing the airway. Preprocedure preparation (cid:142)(cid:3) Bleeding time and PTT if suspected bleeding probl em (cid:142)(cid:3) Atropine 0.6mg IM (to reduce oropharygeal secretions) (cid:142)(cid:3) Patient starved for 6 hours. Anesthesia (cid:142)(cid:3) Performed under sedation e.g. diazepam IV or midazolam (or unde r general anesthesia if performed as an adjunct to rigid bronchoscopy to visualize segmenta l and lobar bronchi). FLEXIBLE BRONCHOSCOPY1 697 (cid:142)(cid:3) Local anesthetic spray (4% lignocaine). (cid:142)(cid:3) Two milliliters 4 % lignocaine injected into the epiglottis and the entrance of the larynx while the patient takes a deep breath. Position Supine or lying at 45(cid:13) facing the operator. Procedure (cid:142)(cid:3) Pass the tip of the bronchoscope into the widest nostril and gui d into the nasopharynx. (cid:142)(cid:3) From here, the procedure is as for rigid bronchoscopy however, the segmental bronchi can be visualized and biopsied with greater ease. Complications These are rare. (cid:142)(cid:3) Complications of general or local anesthesia (cid:142)(cid:3) Respiratory depression (cid:142)(cid:3) Laryngospasm (cid:142)(cid:3) Bro nchospasm (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Pneumothorax (cid:142)(cid:3) Aspira tion pneumonia (cid:142)(cid:3) Arrhythmias (cid:142)(cid:3) Cardiorespiratory arrest. CHAPTER 16 Thoracic surgery 698 Cervical mediastinoscopy Mediastinoscopy should be carried out in a thoracic operating thea ter with full provision for immediate thoracotomy and appropriate staff available. Indications (cid:142)(cid:3) Preoperative staging of lung carcinoma (cid:142)(cid:3) Diagno stic biopsy of mediastinal masses and lymph nodes e.g. tumors, sarcoidosis, lymphoma. Preprocedure preparation (cid:142)(cid:3) Group & Save (cid:142)(cid:3) Benzodiazepine prem edication. Contraindications Relative \200\224superior vena cava obstruction. Anesthetic General anesthetic with endotracheal intubation. Position (cid:142)(cid:3) Supine with neck fully extended (cid:142)(cid:3) A cushion is pla ced between the scapulae and the head is lowered to drop the patients shoulders and project the trachea forwards. Incision Transverse incision 3cm long, one fingerbreadth above sternal notch. Procedure (cid:142)(cid:3) Divide the strap muscles in the midline. (cid:142)(cid:3) Enter the pretracheal fascia and tracheal rings visualized. (cid:142)(cid:3) Insert a finger ante rior to the trachea and develop the pretracheal space into the mediastinum. (cid:142)(cid:3) Palpate the innominate artery anteriorly. Palpate also for any enlarged lymph nodes. (cid:142)(cid:3) Introduce the mediastinoscope into this space and visualize any abnormal lymph nodes. (cid:142)(cid:3) Perform biopsy of an enlarged lymph node with biopsy forceps after needle aspiration has confirmed that the structure is not vascular. (cid:142)(cid:3) Once biopsy has been performed, haemostasis is secured using diathermy cautery or pressure with gauze swab. (cid:142)(cid:3) Following haemostasis, withdraw the mediastinoscope. (cid:142)(cid:3) Clos e the wound in layers using absorbable sutures. Postoperative management Perform a chest radiograph. CERVICAL MEDIASTINOSCOPY1 699 Complications (cid:142)(cid:3) Control bleeding from biopsy site with a gauze pack. (cid:14 2)(cid:3) Severe bleeding is usually the result of damage to a large blood vessel e.g. supe rior vena cava, azygos vein, innominate artery, and arch of aorta or even right pulmonary a rtery. In this instance, pack the space with a gauze swab and proceed to immediate sternoto my. Identify the bleeding vessel and controlled by clamping and/or suture. (cid:142)(cid:3) Pneumothorax. CHAPTER 16 Thoracic surgery 700 Anterior mediastinotomy Used to sample lymph nodes in the subaortic and periaortic regions that are not easily accessible through cervical mediastinoscopy, and to assess operability of centrally located lung tumors. It is usually performed on the left side. Mediastinotomy should be carried out in a thoracic operating theater with full provision fo r immediate thoracotomy and appropriate staff available. Indications (cid:142)(cid:3) Diagnostic investigation for staging lung cancer (cid:142)(cid :3) To assess operability of upper lobe and hilar lung tumors. Anesthetic General anesthesia with endotracheal intubation. Position of patient Supine. Incision Make a 4 \200\2236cm transverse incision in the left 3rd intercostal space just la teral to the sternal border. Procedure (cid:142)(cid:3) Divide the subcutaneous tissues in the line of the skin incision . (cid:142)(cid:3) Divide the pectoralis major muscle fibers. (cid:142)(cid:3) Divide the i ntercostal muscles taking care to avoid the internal mammary artery. If the artery is seen or is in danger of damage it should be formally ligat ed. (cid:142)(cid:3) Enter the pleural space and carry out preliminary finger palpation of the following structures: (cid:142)(cid:3) Pulmonary hilum. (cid:142)(cid:3) Ascertain rela tionship of the tumor to the left atrium. (cid:142)(cid:3) On the left side, the arch of ao rta and subaortic lymph nodes. (cid:142)(cid:3) Introduce the mediastinoscope and tumor ope rability assessed. (cid:142)(cid:3) Signs of inoperability include: (cid:142)(cid:3) Tumor invasion of the pericardium and left atrium. (cid:142)(cid:3) Tumor invasion of the proximal pulmonary artery. (cid:142)(cid:3) Perform a biopsy of abnormal subaortic lymph nodes or of the tumor. (cid:1 42)(cid:3) Obtain haemostasis using diathermy cautery. (cid:142)(cid:3) Introduce an interc ostal drain (size 24 \200\22328French, Silastic) through a separate stab incision in the left chest wall and connect to a bottle with an underwater seal. (cid:142)(cid:3) Close the wound in layers using absorbable sutures and apply a dressing. Postoperative management Perform a chest radiograph. ANTERIOR MEDIASTINOTOMY1 701 Complications Complications are rare, but potentially life threatening. (cid:142)(cid:3) Co ntrol bleeding using diathermy or local pressure with a gauze swab (for bleeding following biopsy of the subaortic nodes, local pressure is preferred because of the risk of thermal i njury and permanent damage to the recurrent laryngeal nerve from diathermy). If the bleedin g is catastrophic then pack the mediastinum gauze while preparations are made for emergency thoracotomy or median sternotomy. (cid:142)(cid:3) Complications related to general anesthesia. CHAPTER 16 Thoracic surgery 702 Chest drain insertion: tube thoracostomy Indications (cid:142)(cid:3) Pneumothorax (cid:142 )(cid:3) Spontaneous (cid:142)(cid:3) Tension (cid:142)(cid:3) Haemothorax (cid:142)(cid:3) Pleural effusion (cid:142)(cid:3) Empyema. Contraindications (cid:142)(cid:3) Relative (cid:142)(cid:3) Coagulopathy (cid:142)(cid:3) Pleural adhesions. Equipment (cid:142)(cid:3) Sterile instrument pack (cid:142)(cid:3) Non-absorbable sutures (cid:142)(cid:3) Local anesthetic e.g. lignocaine or bupivicaine (cid:142)(cid:3) Chest dra in (cid:142)(cid:3) Bottle with underwater seal (cid:142)(cid:3) Dressing. Chest drain tube (cid:142)(cid:3) Straight or right angled (cid:142)(cid:3) Silicone or pla stic (cid:142)(cid:3) Most commonly use size 24 to 28Fr. gauge (a Bonnano suprapubic catheter can be used if the effusion is not viscous) (cid:142)(cid:3) Multiple drainage holes (cid:142)(cid:3) Radio opaque line for radiographi c localization. Preprocedure preparation Premed e.g. benzodiazepine (if the patient is anxious). Position Patient sitting in a comfortable position on the edge of the bed resting on a pill ow placed on the bedside table. Procedure (cid:142)(cid:3) Chose the site depending on the location of collection. Usually 4th or 5th intercostal space in the anterior axillary line. (cid:142)(cid:3) Clean the skin with Betadine. (cid:142)(cid:3) Infiltrate local anesthetic into the skin, subcutaneous tissues, muscle, and pleura at the chosen site. (cid:142)(cid:3) After 5 \200\22310 minutes, make a small incision (approximately 1.5cm) in the intercostal space. (cid:142)(cid:3) Deepen the incision using scissors or artery forceps to enter the pleura. (cid:142)(cid:3) Introduce a finger into the pleural cavity to ensure that the lung is free . CHEST DRAIN INSERTION: TUBE THORACOSTOMY1 703 (cid:142)(cid:3) Place a heavy non-absorbable suture on one side of the incision to secure the drain after insertion. (cid:142)(cid:3) Insert a second heavy non-absorbable vertical mattress suture in the cente r of the wound in preparation for closure of the wound when then drain is removed. This met hod is preferable to a purse-string suture, which is commonly advocated, as the purse-strin g suture tends to convert the linear incision into a circle when it is tied. This may lead to the incision being held open resulting in poor wound healing. (cid:142)(cid:3) Introduce the drain through the opening, ensuring that all the drainage holes are within the pleural space. (cid:142)(cid:3) In the treatment of pneumothorax, direct the drain towards the apex of the chest whereas for the treatment of a pleural effusion the drain is directed basally. (cid:142)(cid:3) Secure the drain with the previously inserted suture. (cid:142)(cid:3) Con nect the drain to a bottle with the underwater seal. (cid:142)(cid:3) Suction may or may no t be applied depending on the surgeon \200\231s preference. (cid:142)(cid:3) In the event that the incision is too large for the tube, additional sutures are inserted. (cid:142)(cid:3) Apply a dressing. Postprocedure management (cid:142)(cid:3) Perform a chest radiograph to confirm correct dra in position and lung re-expansion (cid:142)(cid:3) Analgesia. Complications This is a potentially dangerous procedure. (cid:142)(cid:3) Bleeding \200\224 sometimes can be catastrophic e.g. from cannulation of large intrathoracic vessels (or even the heart). If recognized, the tube should be clamped and the patient resuscitated and transferred to theater for emergency thoracotomy and contr ol of bleeding. (cid:142)(cid:3) Pain from intercostal nerve damage. (cid:142)(cid:3) Pulmonary laceration. (cid:142)(cid:3) Air leak. Chest drain management Chest tube patency Observe the underwater seal bottle for fluctuatio ns of the fluid column with respiration (about 6cm). If no fluctuation occurs, then the tub e is probably blocked and should be removed or replaced. Air leak (cid:142)(cid:3) Bubbling in the underwater seal bottle generally indicates an ong oing air leak, which can be from the lung or a leak in the chest drain system. Place a Vaseline impregnated gauze around the tube at the skin exit site to prevent air from leaking into th e chest through the tube tract when suction is being applied to the underwater sealed bottl e. (cid:142)(cid:3) Repeat chest radiographs daily until the air leak stops. This may take several days. CHAPTER 16 Thoracic surgery 704 (cid:142)(cid:3) In the event that the air leak almost stops on normal respiration but some bubbles still appear when the patient is asked to cough, clamp the intercostal drain tube and take a chest radiograph after one hour. If there is no or minimal pneumothorax visible on the chest radiograph then the drain may be safely removed. If the patient experiences di scomfort or the chest radiograph shows a significant pneumothorax release the clamp with a further period of suction instituted. Fluid drainage Note the quantity and character of the tube drainage regularly. Chest tube removal (cid:142)(cid:3) Indications (cid:142)(cid:3) When the drain has stopped draining air or fluid (cid:142)(cid:3) The lung is fully expanded on chest radiograph (cid:142)(cid:3) Remove on breath holding (usually f orced inspiration) (cid:142)(cid:3) Drain should be pulled out rapidly and the suture tied before allowing the patient to breathe. This page intentionally left blank CHAPTER 16 Thoracic surgery 706 Posterolateral thoracotomy Allows good access to all areas of the thoracic cavity. Indications (cid:142)(cid:3) Unilateral lung resection (cid:142)(cid:3) Resection of chest wall neoplasms (cid:142)(cid:3) Unilateral lung volume reduction surgery (cid:142)(cid:3) B ullectomy (cid:142)(cid:3) Tumors of the posterior mediastinum (cid:142)(cid:3) Oesophageal surgery. Contraindications Inability to tolerate major surgery. Anesthetic General anesthesia with double lumen endobronchial intubation. Position (cid:142)(cid:3) Left or right strict lateral position with break of table in the patient \200\231s chest area. Alternatively a pillow can be placed between the chest and operating table to e levate the chest and splay open the upper ribs to facilitate the incision. (cid:142)(cid:3) The upper arm is placed on an armrest elevating the scapula as far as possible to facilitate the incision. Incision Posterolateral incision in the line of the ribs 1 \200\2232cm below the angle of t he scapula (5th or 6th intercostal space). Procedure (cid:142)(cid:3) Divide the skin, subcutaneous fat, and latissimus dorsi muscle i n line of the incision. (cid:142)(cid:3) Secure haemostasis using diathermy cautery or ligature. (cid:142)(cid:3) R etract the serratus anterior muscle anteriorly. (cid:142)(cid:3) Incise the fascia in the t riangle of auscultation, just behind the angle of the scapula to expose the ribs and intercostal muscles. (cid:142)(cid:3) Divide the trapezius muscle (situated posteriorly) for approximately 2cm in the line of the incision. (cid:142)(cid:3) Retract the scapula superiorly using a scapula retractor. (cid:142)(cid:3) Then introduce your hand under the scapula and count the ribs from the top starting with t he highest rib that can be felt, usually the 2nd rib. Mark the 5th or 6th rib with diatherm y. (cid:142)(cid:3) Score the periosteum of the superior surface of the rib where entry into t he chest is required with the diathermy cautery throughout its length. (cid:142)(cid:3) Elevate the periosteum along the length of the rib using a periosteal elevator. (cid:142)(cid:3) Divide the costo-transverse ligament posteriorly to facilitate movement of the rib. POSTEROLATERAL THORACOTOMY1 707 (cid:142)(cid:3) Cover the ribs with skin towels. Then introduce the rib spreader between t he ribs and gradually open it to spread the ribs to gain adequate exposure. (cid:142)(cid:3) Deflate the lung. Closure (cid:142)(cid:3) Insert two chest drains (24 \200\22328Fr., Silastic) through separ ate stab incisions one anterior and one posterior. Direct the anterior drain to the apex and the pos terior drain to the base of the pleural space. (cid:142)(cid:3) Secure the drains to the sk in with heavy non-absorbable sutures. (cid:142)(cid:3) Place three pericostal \200\230figu re of eight \200\231 Vicryl sutures around the ribs on either side of the incision. (cid:142)(cid:3) Approximate the ribs with a rib approximator. (cid:142)(cid:3) Tie the per icostal sutures. Alternatively, suture the intercostal muscles in layers with a continuous absorbable suture (e.g. Vicryl). (cid:142)(cid:3) Suture the divided muscles individually in layers using absorbable continuous sutures e.g. Vicryl. (cid:142)(cid:3) Suture the subcutaneous fat in a similar way. (cid:142)(cid:3) Close the s kin with an absorbable continuous subcuticular suture e.g. Monocryl. (cid:142)(cid:3) Apply a dry protective dressing. (cid:142)(cid:3) Connect the drains to bo ttles with underwater seals. Postoperative management (cid:142)(cid:3) Transfer the patient to the HDU (cid:142)(cid:3) Connect the drains to suction (5KPa) (cid:142)(cid:3) Perform a baseline chest radiograph ( cid:142)(cid:3) Provide analgesia with PCA, epidural or paravertebral block (cid:142)(cid:3 ) Monitor continuous ECG, O2 saturations, and urine output. Complications (cid:142)(cid:3) Complications of general anesthesia (cid:142)(cid:3) Hemorrh age (cid:142)(cid:3) Pneumothorax (cid:142)(cid:3) Bronchopleural fistula (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Post thoracotomy pain \200\224due to damage to the interco stal nerve. 5% of patients have troublesome pain. CHAPTER 16 Thoracic surgery 708 Anterolateral thoracotomy Indications (cid:142)(cid:3) Open lung biopsy (cid:142)(cid:3) Cl osed mitral valvotomy (cid:142)(cid:3) Some anterior mediastinal masses (cid:142)(cid:3) An terior mediastinal cysts (cid:142)(cid:3) Pericardial window for pericardial effusion that is resistant to drainage with a needle. Anesthetic General anesthesia with double lumen endobronchial intubation. Position Supine with the side to be operated upon tilted at 30(cid:13), by placing a pillow under the patients shoulder. Incision Anterior 5th intercostal space, from the midline to the angle of the scapula. Procedure (cid:142)(cid:3) Incise the skin and the subcutaneous tissues in line of the inci sion. (cid:142)(cid:3) Divide the latissimus dorsi muscles in the line of the incision. (ci d:142)(cid:3) Count the ribs downward on the surface of the chest from the angle of Louis ( the level of the 2nd rib) and the 5th rib is scored with the diathermy. (cid:142)(cid:3) Enter the 5th intercostal space. (cid:142)(cid:3) Strip the periosteum fro m the inferior surface of the rib. (cid:142)(cid:3) Divide the pleura and enter the chest. (cid:142)(cid:3) Elevate the periosteum posteriorly to allow free movement of the rib. (cid :142)(cid:3) Cover with the skin towels. Introduce the rib spreader between the ribs and gradually open it to spread the ribs to gain adequate exposure. (cid:142)(cid:3) Deflate the lung. Closure (cid:142)(cid:3) Insert two chest drains (24 \200\22328Fr. gauge, silastic) through separate stab incisions one anterior and one posterior. Direct the anterior drain to the a pex and the posterior drain to the base of the pleural space. (cid:142)(cid:3) Secure the d rains to the skin with heavy non-absorbable sutures. (cid:142)(cid:3) Place three pericosta l \200\230figure of eight \200\231 Vicryl sutures around the ribs on either side of the incision. (cid:142)(cid:3) Approximate the ribs with a rib approximator. (cid:142)(cid:3) Tie the per icostal sutures. Alternatively, suture the intercostal muscles in layers with a continuous absorbable suture (e.g. Vicryl). (cid:142)(cid:3) Individually suture the divided muscles in layers using absorbable continuous sutures e.g. Vicryl. (cid:142)(cid:3) Suture the subcutaneous fat in a similar way. (cid:142)(cid:3) Close the s kin with an absorbable continuous subcuticular suture e.g. Monocryl. ANTEROLATERAL THORACOTOMY1 709 (cid:142)(cid:3) Apply a dry protective dressing. (cid:142)(cid:3) Connect the drains to bo ttles with underwater seals. Postoperative management (cid:142)(cid:3) Transfer the patient to the HDU (cid:142)(cid:3) Connect the drains to suction (5KPa) (cid:142)(cid:3) Perform a baseline chest radiograph ( cid:142)(cid:3) Provide analgesia with PCA, epidural, or paravertebral (cid:142)(cid:3) Mon itor continuous ECG, O2 saturations, and urine output. Complications (cid:142)(cid:3) Complications of general anesthesia (cid:142)(cid:3) Hemorrh age (cid:142)(cid:3) Pneumothorax (cid:142)(cid:3) Bronchopleural fistula (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Post thoracotomy pain \200\224due to damage to the interco stal nerve. 5% of patients have troublesome pain. CHAPTER 16 Thoracic surgery 710 Median sternotomy The most frequently used approach for operations on the heart and mediast inum. In contrast to thoracotomy no muscles are divided so there is reduced postoperative p ain. Indications (cid:142)(cid:3) Mediastinal tumor resection (e.g. thymoma) (cid:142)(cid:3) Bi lateral lung volume reduction surgery/bullectomy (cid:142)(cid:3) Transpericardial access t o trachea/bronchus e.g. carinal tumors (cid:142)(cid:3) Resection of multiple pulmonary les ions e.g. metastectomy (cid:142)(cid:3) Trauma. Position Supine. Anesthetic General anesthesia with endotracheal intubation. Incision Vertical midline from the sternal notch to the xiphisternum. Procedure (cid:142)(cid:3) Divide the skin and subcutaneous tissues in the line of the inci sion. (cid:142)(cid:3) Locate the middle of the sternum and score with diathermy cautery from top to bottom. (cid:142)(cid:3) Perform sternotomy using an oscillating electric sternotomy saw. (cid:142) (cid:3) Control bleeding from the periosteum with diathermy. (cid:142)(cid:3) Insert the sk in towels on either side of the wound. Then insert the sternal spreader and open it to sepa rate the two halves of the sternum. Avoid over distraction to prevent distraction injury to the lower cords of the brachial plexus. Closure (cid:142)(cid:3) Insert two chest drains (24 \200\22328Fr., Silastic) into the medi astinum through separate stab incisions below the sternotomy. (cid:142)(cid:3) If the pleural space has been entered direct one of the mediastinal drains into the pleural space or use a third drain. (cid:142)(cid:3) Suture the drains in place with heavy non-absorbable sutures. Insert a closing stitch. (cid:142)(cid:3) Appose the sternal halves using six stainless steel wires, taking care to ensure that there is no bony step. (cid:142)(cid:3) Inspect the under surface of the sternum for bleeding at the wire entry and exit sites. Control this using diathermy or sutures. (cid:142)(cid:3) Twist the wires until the sternal edges are firmly approximated. Cut the w ires using wire cutter and bend them 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. MEDIAN STERNOTOMY1 711 Postoperative management (cid:142)(cid:3) Transfer the patient to HDU (ICU in the event of cardiac surgery) (cid:142)(cid:3) Connect the drains to suction (5KPa) (cid:142)(cid:3) Per form a baseline chest radiograph (cid:142)(cid:3) Provide pain control with PCA, epidural, or paravertebral block (cid:142)(cid:3) Monitor continuous ECG, O2 saturations, and urine o utput. 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 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.