Module 18 Thoracic Surgery RPN2023 PDF

Module 21: Thoracic Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 23 Tighe (2015) Instrumentation of the Operating Room Chapter 88, 89 ORNAC Sta...

Module 21: Thoracic Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 23 Tighe (2015) Instrumentation of the Operating Room Chapter 88, 89 ORNAC Standards 2023 Learning Outcomes Describe the anatomy of the thoracic cavity including the lungs. Explain basic procedural considerations for thoracic surgery. Describe the use and indications for double-lumen endotracheal tubes in specific thoracic surgeries. Thoracic Anatomy Thoracic Cavity The thoracic cavity is the chamber that is protected by the thoracic wall or the ribcage. The thoracic cavity may also be referred to as the thorax, chest, or chest cavity, which encompasses this space between the neck and diaphragm. Anteriorly, the thoracic cavity is formed by the sternum and costal cartilages. Laterally, 12 pairs of ribs outline the thoracic cage. Posteriorly, there are 12 thoracic vertebrae that form the thoracic cavity. Some of the muscles that form the thoracic cage include external and intercostal muscles, serratus muscle, and latissmus dorsi. The thoracic cavity consists of structures that make up the Module 18: Thoracic cardiovascular, digestive, respiratory, and endocrine systems. The chest cavity, which extends from the neck down to the diaphragm, is further subdivided into right pleural cavity, left pleural cavity, mediastinum, and pericardial cavity. There are organs within each cavity, which will be discussed in more detail in the next section. The mediastinum is the center of the chest. It lays medially between the right and left pleural cavities. The mediastinum contains all the thoracic viscerae, except the lungs. The mediastinum contains the pericardial cavity, thymus, esophagus, trachea, thoracic duct, lymph nodes, azygous vein, sympathetic chain, vagus nerve, splanchic nerves, and phrenic nerve. Blood Supply The arteries of the thoracic cage bifurcate anteriorly from internal thoracic artery and posteriorly from the aorta. The veins of the thoracic cage bifurcate anteriorly from the mammary veins and posteriorly from the azygous and hemiazygous veins. Intercostal nerves are distributed throughout the thoracic cage. Surgeons are careful to prevent injury to these nerves intraoperatively. If the nerves are disturbed during surgery, an anaesthetic agent, such as Marcaine, may be injected to prevent postoperative pain. Lung Anatomy Each lung occupies a single pleural cavity. Each pleural cavity has parietal and visceral pleura. The parietal pleura is the outer layer serous membrane that lines the surface of the chest wall (hemithorax). The visceral pleura is the inner membrane that lines the lung parynchema. The pleural space holds about 50ml of pleural fluid. There is a negative intrapleural pressure that facilitates pulmonary ventilation. The right lung is covered by the right pleural cavity. The right lung contains upper, middle, and lower lobes, which are perfused by the right pulmonary artery. Oxygenated blood is transported to the heart via the right pulmonary vein. The left lung is protected by the left pleural cavity. The left lung contains upper and lower lobes, which are perfused by the left pulmonary artery. Oxygenated blood is transported to the heart via the left pulmonary vein. Each lung has a corresponding bronchus (right or left bronchus), which serve as the entry point for oxygen and escape route for carbon dioxide. There are lymph nodes stations distributed throughout the thorax, which may be referred to as mediastinal lymph nodes. These can be resected during surgeries, such as mediastinoscopy or lung wedge resection, for diagnosis of primary lung cancer or metastatic malignancies, such as esophageal or breast cancers. The lymph nodes to be sampled may vary depending on the location of the lesion and the type and stage of cancer. Module 18: Thoracic  Perioperative Nursing Considerations Nursing Assessment The risk for injury or failure to achieve the expected outcome are equally present in Thoracic surgery as in any surgical or invasive procedure. No procedure is routine and unexpected outcomes can occur even when planning and preventive measures have been employed under the most optimal circumstances. Blood Replacement - Some patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, surgicel, etc to anticipate any critical surgical needs. If autologous transfusion is required, ensure that the blood collection and reinfusion systems are in place and the institutional policies and procedures are followed. Patient Positioning The surgical procedure determines the patient’s intraoperative position. Patient who are undergoing bronchoscopy are placed in a supine position. Patients undergoing a thoracotomy may be positioned in one of the three positions: (1) lateral for posterolateral approach, (2) supine for median sternotomy, or (3) supine or semilateral for anterolateral approach. Care is taken to ensure that the patient is positioned safely to prevent injuries. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Other positioning devices, such as bean bags and bolsters, may be used for lateral decubitus position. The patient position and the associated positioning devices may vary depending on the surgeon’s preferences and available institutional resources and policies. It is recommended that the perioperative nurse collaborates with the surgical team to ensure that the patient is positioned safely before, during, and after surgery. Instrumentation and Counting Thoracic surgery includes open or endoscopic approaches (Video-assisted thoracoscopic surgery [VATS]). Rigid and flexible bronchoscopy require a bronchoscope to visualize the larynx, trachea, and bronchi. Common thoracic specialty instruments for an open approach: - Allison lung retractor - Finochetto retractor - Doyens - Rib-approximator, - Duval lung clamps. Module 18: Thoracic  Initial Count (major) → Closing Count (major) → Final Count (minor) Common instruments for an endoscopic approach: - Telescope - Camera - Light Cord - Endoscopic instruments (e.g. graspers, dissectors, suction, monopolar) Initial Count (major) → Closing Count (minor) → Final Count (minor) *If the case is converted to open or the incisions are extended to greater than 10mm, a major count will be required for Closing count. Equipment Forced-Air Warming Blankets - The large amount of skin exposure required for either a laparotomy or a laparoscopic approach presents a risk for hypothermia. Fiberoptic light sources, headlights, video monitors – for VATS procedures Intermittent pneumatic compression devices – long surgical cases, improves blood return and circulation Chest Drainage Systems In a normal pleural cavity, there is a negative intrapleural pressure. After thoracic surgery, the patient’s intrapleural pressure may be disturbed. Collapse of the normal lung follows any condition that reduces the negative intrapleural pressure or increases positive intrapleural pressure. One or more chest catheters (or tubes) may be inserted intraoperatively to serve as a conduit for draining air, blood, or other fluids from the intrapleural space, thus re-establishing the negative intrapleural pressure. The chest tubes are connected to water-seal or gravity drainage systems. Water-seal suction may be required if there is persistent air leak that cannot be controlled by gravity drainage alone. Double-lumen Endotracheal Tube Anaesthetists may insert a double-lumen (ETT) for surgeries requiring single-lung ventilation, such as right or left lung lobectomy. A double-lumen ETT has two lumens (bronchial and tracheal lumens). The bronchial lumen (coloured blue) is inserted into the non-operative bronchus to ventilate the non-operative lung while deflating the operative lung during surgery. The tracheal lumen (coloured white) sits above the carina, which is clamped intraoperatively to deflate the operative lung. A flexible bronchoscope is required post-induction for confirmation of the bronchial lumen placement. Module 18: Thoracic  Surgical Interventions Rigid Bronchoscopy- Insertion of a rigid bronchoscope through the mouth and into the trachea, right bronchus, and left bronchus Procedural Considerations: - Some patients may experience anxiety and discomfort, especially if only local anaesthetic or light sedation is used during the procedure. - Since the patient’s oral airway will be entered and manipulated, the perioperative nurse inspects the teeth and lips for integrity pre- and postoperatively. - Some surgeons may ask the patient to gargle and rinse their mouth with topical anaesthetic agents, such as lidocaine. Mediastinoscopy - A small incision is made above the sternal notch. A mediastinoscope is placed through the incision to examine mediastinum, which is a space in the chest between the lungs. Procedural Considerations: - Depending on the institution, there may be a thoracotomy set available in the room on standby if uncontrolled bleeding occurs after biopsy. - The perioperative nurse must be aware of potential complications, such as bracheocephalic artery injury, associated with mediastinoscopy. *Thoracotomy – A large opening into the chest wall using one of three surgical approaches to operate on the lung. Procedural Considerations: - The surgeon will decide to use one of the three thoracotomy approaches to perform lung surgery, such as lung wedge resection, segmentectomy, lung lobectomy, pneumonectomy, lung volume reduction surgery. - The perioperative nurse must confirm one of the three thoracotomy approaches with the surgeon, preoperatively. The approach will determine the patient position. Pneumonectomy - Removal of an entire lung Procedural Considerations: - Mediastinal lymph nodes, parietal pleura, diaphragm, or chest wall may be resected intraoperatively. - Prepare chest tubes on sterile table. *Video- Assisted Thoracoscopic Surgery (VATS) – A minimally invasive surgical technique that uses an endoscopic approach to visualize the thoracic cavity for diagnostic and/or therapeutic purposes Anaesthesia considerations: GA; double-lumen ETT may be required for single-lung ventilation; intercostal nerve blocks intraoperatively unless contraindicated Module 18: Thoracic Patient Position: Lateral for posterolateral approach; Supine or semilateral for anterolateral approach Procedural Considerations: - The following procedures may be performed via VATS approach: lung wedge resection, segmentectomy, lung lobectomy, lung volume reduction surgery, and pleurodesis. These surgeries may also be performed through a thoracotomy incision. - Ensure that thoracic instrument trays are available in case of conversion to a thoracotomy. - Insufflation may or may not be used. Check with your surgeon’s preferences. Wedge Resection of Lung via VATS - Removal of a wedge-shaped section of the lung with lesion, tumor, or some other type of tissue, such as bulla Procedural Considerations (in addition to VATS): - Frozen sections may be sent to pathology for confirmation of tumour-free margins. - Chest tubes are placed inside chest before chest closure. Lung Lobectomy via VATS – Removal of one or more lobes of the lung Procedural Considerations: Same as above. Lung Volume Reduction Surgery (LVRS) via VATS – Removal/Resection of hyperinflated lung tissue Procedural Considerations (in addition to VATS): - Stapling devices lined with bovine pericardium are used to staple and cut hyperinflated lung tissue. Esophagectomy - The removal and reconstruction of the esophagus Surgical Approach: Consider the surgical approach, which will determine the patient position, retractors, and other equipment needed e.g. Transthoracic approach to esophagectomy will require finochetto chest retractor Procedural Considerations: - There are three types of conduits, which include stomach, jejunum, and colon, that may be used during the reconstruction of the esophagus. - Intraoperative pathologist may be needed for confirmation of tumour-free margins before reanastamosis of esophagus and stomach/jejunum/colon. Module 18: Thoracic  Transhiatal Transthoracic En Bloc (Tri- Esophagectomy Esophagectomy incisional Esophagectomy) Surgical Two-incision One-Stage Technique Three-incision Approach Approach 1. Thoracoabdominal Approach and Patient 1. Laparotomy Incision (Right/Left) – Lateral 1. Right Positioning with Upper Thoracotomy – Midline OR Left Lateral Abdominal 2. Laparotomy Incision – Two-Stage Technique with Upper Supine 1. Laparotomy with Midline 2. Left Neck Upper Midline abdominal Incision – abdominal Incision Incision – Supine (Supine) – Supine Supine 2. Thoracotomy 3. Left Neck (Right/Left) – Lateral Incision – Supine Type of Cervical anastamosis Intrathoracic anastamosis Cervical anastamosis Anastamosis Advantages - Avoidance of -Permits direct visualization-Three-incision thoracic incision, thus and exposure of approach reduces the minimizing the upper/thoracic esophagus in complications associated pulmonary comparison to transhiatal associated with complications such as esophagectomy. This allows intrathoracic intrathoracic for a more thorough esophagogastric anastamotic leak and oncological operation as a anastamosis mediastinitis result. -More extensive/radial -Shorter duration of thoracic, mediastinal, hospital stay and upper abdominal -Avoidance of lymph node dissection thoracotomy -Permits wider margins minimizes pain around tumour-bearing esophagus Disadvantage -Poor visualization of -Combined abdominal and -Combined abdominal upper and middle thoracic incisions may and thoracic incisions esophageal tumours, compromise cardiorespiratory may compromise thus potentially function cardiorespiratory compromising the -There is higher risk for function oncological integrity of intrathoracic anastamotic leak, -Greater pain the surgery which can lead to mediastinitis, -Longer duration of -Higher anastamotic leak sepsis, and death. hospital stay rate -Greater pain associated -Higher risk of recurrent with thoracotomy laryngeal nerve injury incision Module 18: Thoracic Module 18: Thoracic