Anatomy of the Thoracic Cavity

Anatomy of the Thoracic Cavity

• The thoracic cavity houses the right and left pleural cavities, containing the lungs separated by the mediastinum.
• Blood supply includes bronchial arteries (from the aorta), pulmonary arteries (to the lungs), and pulmonary veins (carry oxygenated blood to the left atrium).
• Intercostal nerves are distributed throughout the thoracic cage, providing sensory and motor functions.

Pleural Cavity

• Parietal pleura lines the inner surface of the pleural cavity while visceral pleura covers the outer surface of the lungs.
• The trachea branches into primary bronchi, which further divide into secondary bronchi, bronchioles, and alveoli.

Mediastinal Lymph Nodes

• Located throughout the thorax, mediastinal lymph nodes are crucial for diagnosing lung malignancies; they can be resected for examination.

Perioperative Nursing Considerations

• Critical elements include anesthesia management, proper positioning, surgical counts, instrumentation readiness, and the use of double-lumen endotracheal tubes for ventilation control.
• Chest drainage systems are vital for post-operative care to restore negative pressure in the thoracic cavity.

Positioning for Surgical Procedures

• Lateral Position: Utilized for thoracotomy, VATS, single-lung transplant, and transthoracic esophagectomy.
• Supine Position: Used for bronchoscopy, mediastinoscopy, sternotomy, and lung transplantation.

Instrumentation

• Open Instrumentation: Includes major laparotomy trays and thoracic specialty instruments like Allison lung retractors and Doyen rib cutters.
• VATS Instrumentation: Specifically designed for minimally invasive surgeries.
• Bronchoscopic Instrumentation: Can be rigid or flexible for inspecting and treating airway issues.

Double Lumen Endotracheal Tubes (ETT)

• Designed with two lumens: one to collapse the operative lung and the other to ventilate the non-operative lung, crucial for procedures requiring single-lung ventilation.
• Placement confirmation is done via flexible bronchoscopy.

Chest Drainage System

• Facilitates the drainage of air, blood, or fluid from the pleural or mediastinal space, essential for conditions like pneumothorax.
• Needs correct sizing and setup (Pleurovac vs Thopaz) for optimal functioning.

Surgical Interventions

• Endoscopic options include rigid/flexible bronchoscopy, mediastinoscopy, and VATS.
• Open approaches involve thoracotomy and esophagectomy for more extensive access.

Bronchoscopy

• Rigid bronchoscopy allows for direct visualization and potential biopsy of the respiratory tract, often combined with flexible methods for enhanced examination.

Mediastinoscopy

• Involves a small incision above the sternal notch for direct visualization of the mediastinum and potential lymph node biopsy.

Video-Assisted Thoracoscopic Surgery (VATS)

• A minimally invasive technique using an endoscope for diagnosis and treatment, with the potential to convert to an open thoracotomy if needed.

Lung Resections with VATS

• Includes wedge resection, segmentectomy, lobectomy, pneumonectomy, and lung volume reduction surgery, all requiring a chest drainage system post-operatively.

Wedge Resection

• Removes a small, wedge-shaped section of lung tissue along with surrounding healthy tissue for adequate margins.

Lung Lobectomy

• Involves the removal of one or more lung lobes, mobilizing associated pulmonary arteries, veins, and bronchi, with ligation of fissures.

Pneumonectomy

• Entire lung removal indicated for invasive tumors or intrathoracic bleeding, with surgical ligation of the respective vasculature.

Lung Volume Reduction Surgery

• Targets chronic pulmonary emphysema by resecting hyperinflated lung tissues; the stapling line is reinforced to prevent leaks.

Open Thoracic Surgeries

• Thoracotomy is the primary approach involving a large chest wall opening; the common incision is posterolateral.
• Procedures include wedge resections, lobectomies, and pneumonectomies.