Thoracic Surgery PPT (George Brown College) PDF

Thoracic Surgery S425: RPN PERIOPERATIVE PROGRAM  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 specif...

Thoracic Surgery S425: RPN PERIOPERATIVE PROGRAM  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.  Surgical Anatomy Thoracic Cavity  Anatomy – Blood Supply ▪ Bronchial arteries, arising from the aorta supply nourishment to the lungs ▪ Pulmonary arteries carry to the blood to the pulmonary parenchyma ▪ Pulmonary veins transport oxygenated blood to the left atrium ▪ Intercostal nerves are distributed throughout the thoracic cage  Anatomy – Pleural Cavity - Lungs ▪ Right and Left pleural cavities ▪ Contains lungs separated by mediastinum  Pleural Cavity ▪ Parietal pleura - membranes that line the inner surface (walls) of each pleural cavity ▪ Visceral pleura – serous membrane on the outer surface of each lung Lungs (Pleural Cavity) Trachea → Primary bronchi → Secondary bronchi → Bronchioles → Alveolar Ducts → Alveoli Right Lung Left Lung Visceral and parietal Pleura Diaphragm Ribcage Muscle Fat Skin  Mediastinal Lymph Nodes ▪ Distributed throughout thorax ▪ May be resected for diagnosis of primary of metastatic lung malignancies  Perioperative Nursing Considerations ▪ Anesthesia ▪ Positioning ▪ Count ▪ Instrumentation ▪ Double Endotracheal Tube (ETT) ▪ Chest Drainage System  Positioning Patient Position Surgical Procedure Lateral Thoracotomy VATS Single-Lung Transplant Transthoracic Esophagectomy Single Lung Volume Reduction Surgery Supine Rigid/Flexible Bronchoscopy Mediastinoscopy Sternotomy Single/Double Lung Transplant Single/Double Lung Volume Reduction Surgery Transhiatal Esophagectomy  Instrumentation ▪ Open Instrumentation (ie. Thoracotomy) – Major laparotomy tray (short and long instruments) – Thoracic Specialty instrumentation – (ie. Allison lung retractor, Finochetto retractor, CV clamps, Duval forceps, Doyen Rib cutter) ▪ MIS Instrumentation (ie. VATS) ▪ Bronchoscopic Instrumentation - Rigid or flexible – Designed to inspect and observe the larynx, trachea, bronchi, or mediastinum – Remove secretions, obtain washing or tissue for bacterial or cytologic studies – Remove tissue and/or foreign bodies Instrumentation - Open VATS Instrumentation  Double Lumen ETT ▪ Endotracheal tube with 2 lumens – Tracheal lumen (collapses operative lung) – Bronchial lumen (ventilates non-operative lung) ▪ Used for surgical procedures requiring single lung ventilation ▪ Right or left double-lumen – Bronchial lumen = ____________________ – Tracheal lumen = _____________________ Placement of bronchial lumen confirmed with flexible bronchoscopy Double Lumen ETT  Chest Drainage System ▪ Provides a conduit for drainage of air, blood, or fluid from intrapleural or mediastinal space ▪ Inserted post operatively to restore negative pressure – Pneumothorax ▪ Ensure correct size (20, 28, 32 fr) and number of chest tubes ▪ Ensure correct pressure setting and correct system (Pleurovac vs Thopaz) – Water-seal or gravity drainage systems  Surgical Interventions Endoscopic Open Bronchoscopy – Rigid and Thoracotomy Flexible Esophagectomy Mediastinoscopy Thorascopy – Video- Assisted Thorascopic Surgery (VATS)  Bronchoscopy Rigid Bronchoscope ▪ Insertion of a rigid bronchoscope through the mouth and into the trachea, right bronchus, and left bronchus ▪ Can be combined with flexible bronchoscopy to maximize visualization and examination Rigid Bronchoscopy Flexible Bronchoscopy  Mediastinoscopy ▪ A small incision is made above the sternal notch ▪ Mediastinoscope is placed through the incision to examine mediastinum (space between in the chest between the lungs) ▪ Direct visualization and possible biopsy of lymph nodes ▪ May precede exploratory thoracotomy Mediastinoscopy  Video-Assisted Thorascopic Surgery (VATS) ▪ Minimally invasive technique using endoscope to visualize the thoracic cavity for diagnostic or therapeutic purposes ▪ Potential conversion to “open” approach thoracotomy VATS Set-Up  Lung Resections with VATS Using VATS approach: ▪ Wedge resection ▪ Segmentectomy ▪ Lobectomy ▪ Pneumonectomy ▪ Lung Volume Reduction Surgery  Wedge Resection VATS Approach ▪ Removal of a wedge-shaped section of the lung with lesion, tumor, or some other type of tissue, such as bulla ▪ A small portion of normal lung tissue around the lesion/tumour is resected for adequate margins ▪ Diagnostic or therapeutic ▪ Chest drainage system required Wedge Resection  Lung Lobectomy VATS Approach ▪ Removal of one or more lobes of the lung ▪ The corresponding pulmonary artery (PA), pulmonary vein (PV), and bronchus of the lobe are mobilized using fine and blunt dissection ▪ PA, PV, bronchus, oblique and/or horizontal fissures are ligated using suturing or stapling devices (ie. GIA) ▪ Chest drainage system required Lung Lobectomy  Pneumonectomy VATS Approach ▪ Removal of an entire lung ▪ Indications: Invasive lung tumour, aneurysm, intrathoracic bleeding ▪ PA, PV, and bronchus of the left/right lung are mobilized and ligated using stapling device (ie. TA)  Lung Volume Reduction Surgery - VATS ▪ Removal/ resection of hyperinflated lung tissue ▪ Indications: Chronic Pulmonary Emphysema ▪ Small wedges of damaged/hyperinflated lung tissue are removed ▪ Lung tissue is stapled off and the stapling line is lined with bovine pericardium to prevent leaks ▪ Chest drainage system required – drained by gravity Lung Volume Reduction Stapling Devices  Open Thoracic Surgeries Thoracotomy ▪ A large opening into the chest wall through a median sternotomy, anterolateral, or posterolateral incision ▪ “Open” approach into the chest ▪ Most common incision is posterolateral thoracotomy ▪ Common procedures using thoracotomy approach – Wedge resection – Segmentectomy – Lung lobectomy – Pneumonectomy – Lung Volume Reduction surgery Thoracotomy Approach  References ▪ Rothwell, J. (2022). Alexander’s care of the Patient I Surgery (17th ed.) Mosby Elsevier. ▪ Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.) Mosby. ▪ ORNAC Standards 2023