Chapter 22: Cardiothoracic Surgery; Short Answer: Thoracic Procedures

What can be used to find the plaque if needed?

A choledochoscope.

What is a pectus excavatum? What implant is used?

A congenital deformity of the chest that is a funnel-shaped, asymmetrical depression due to a posterior displacement of the sternal body. The pectus bar is the implant used.

What complications may require a conversion to an open procedure?

Air embolism injury to the diaphragm and hemorrhage.

When lung is incised, how is the anastomosis checked for leaks?

Anesthesia will inflate the lung in order for the surgeon to check for leaks and hemorrhage from the lung.

What is the primary duty of the ST during the mediastinoscopy procedure?

Assist inserting biopsy forceps into channel of the scope and advancing the forceps. Maintain control of the forceps and prevent contamination.

The Lukens tube is used to obtain bronchial washings. What is the responsibility of the surgical technologist?

Assist the surgeon in taking fluid specimens. When told by the surgeon the ST connects suction tubing to bronchoscope, when disconnected injects 5mL saline into the channel of the scope and quickly reconnects suction to take additional specimen; know correct channel for saline injection.

What is the surgical technologist's responsibility during a flexible bronchoscopy?

Assisting the surgeon inserting a brush or biopsy forceps into the channel of the scope and advancing the forceps. Maintaining control of the forceps and prevent contamination.

What will any procedure that enters the thoracic cavity have placed at the end of the procedure? What is used to secure it?

Chest tubes are sutured to the skin with large diameter nonabsorbable suture.

During a donor lung transplant, what is used to preserve the donor lung? What must the patient do to preserve the lung tissue postoperatively?

Collins solution; The patient will be instructed to perform deep breathing exercises to prevent infection and pneumonia and attempt to walk the first day.

What is the primary purpose of the mediastinoscopy procedure?

Evaluation of nodal involvement or mediastinal masses in patients with lung carcinoma. Typical of the lesions found within the mediastinum are thymomas, lymphomas, and germ cell tumors.

Identify the three methods used for initial diagnosis of lung disease/disorders/conditions.

Initial diagnosis is made by chest x-ray and sputum cytology test, but definitive diagnosis is made with a tissue and cytology biopsy from bronchoscopy. Early detection of bronchial tumors cannot be made with x-rays, only with bronchoscopy.

Compare lobectomy and pneumonectomy; what differences did you find?

Lobectomy: Removal of one lobe of the lung, Pilar nodes are not involved, can be removed without disturbing other portions of the lung. Pneumonectomy: Removal of the entire lung, done for bronchogenic carcinoma, less common.

During any surgery of the thoracic cavity, there is close proximity to major vessels. What should always be readily available on the field?

Long metzenblum scissors and vascular forceps, blunt dissection with the fingers, and kitten sponges.

Is bronchoscopy strictly a diagnostic procedure? Explain your answer.

No, diagnostic or therapeutic. Used for evaluation of hemoptysis, infection, carcinoma of lung, and damage to the lungs due to smoke inhalation. Useful for retrieving foreign objects lodged in airway and laser treatment of tumors. Also useful for post-op evaluation of the transported lung.

What are the signs and symptoms of a pulmonary embolism obstruction?

Often asymptomatic until progressed and heart failure is occurring. Early sign: severe pulmonary hypertension when exercising. Other signs and symptoms: Enlarged pulmonary arteries, septal hypertrophy, tricuspid regurgitation, chronic cough, syncope, palpitations, and hemoptysis.

Describe the classic signs of lung disease.

Patients usually present with a persistent cough, hemoptysis, and shortness of breath. Other signs and symptoms include pleural effusion, pain on inspiration, and/or clubbing of fingers if the cancer has invaded the pleural space.

Name the specific thoracic instruments used during a thoracic procedure.

Potts-Smith forceps, Sarot bronchus clamp, Satinsky vena cava clamp, Davidson scapula retractor, Bailey rib contractor, Alison lung retractor, lovelae lung-grasping forceps, Ryder needle holder, and Bethune rub shears.

What is used to detect a pulmonary embolism?

Pulmonary cardiography is primarily used to detect pulmonary embolism and other blockages of the arterial circulation of the lungs.

What procedures are used for the evaluation of cardiac disease?

Pulmonary cardiography: P.E. or blockages Electrocardiography, echocardiography, and cardiac catheterization: Cardiac disease Bronchoscopy, Mediastinoscopy, and Thoracoscopy: used for diagnosis of suspected lesions

What are the specific diagnostic procedures used for diagnosis of the thoracic cavity?

Pulmonary function, lab tests, and imaging studies that include standard x-rays, CT scanning, MRI and pulmonary angiography.

What procedure will be done to treat the condition? Describe the arteriotomy.

Pulmonary thromboendarterectomy.

When is rigid bronchoscopy preferred? What additional positioning tool is needed for this procedure? During the procedure, why is the head position important?

Rigid scope is equipped with light carrier for illumination of the trachea and primary bronchi and side channels for anesthetic gas and O2 administration. The head is slightly tilted to the left to view right bronchi and to the right to view the left bronchi. Scapular roll, plastic tooth guard is placed over the upper teeth for protection.

Due to the type of surgical procedures and the risk for complications, anesthesia monitoring requires additional devices. What additional monitoring is required for cardiothoracic procedures?

Swan-Ganz catheter for pulmonary wedge pressure and central venous pressure (CVP) readings and arterial catheter for monitoring of arterial blood pressure, and blood gases (ABG's). Electrocardiography, oxygen satuartion, temperature and blood pressure equipment as well.

How are the specimens removed from the biopsy forceps jaw?

The ST takes the brush and rubs it on a microscope slide the circulator is holding. The circulator will then "fix" the specimen to the slide by spraying it with 95% ethanol alcohol. Next, the ST will use the wire cutting scissors to cut the brush off the end of the forceps while holding it over the specimen container the circulator is holding.

Describe what must be done when the bronchial brush is used.

The ST will take the brush and rub it on a microscope slide that the circulator is holding. The circulator will then "fix" the specimen to the slide by spraying it with 95% ethanol alcohol.

Define empyema. What procedure can be done to restore normal lung function?

The collection of pus in the pleural space due to a bacterial infection that is removed by an I&D. A decortication is done to restore normal lung function.

What will be used to prepare the implant for insertion?

The pectus bar introducer and the throacoscope.

Describe the segment of the surgery whereby the thrombus is removed.

Using smooth vascular forceps, Freer elevator, and jemieson dissector; the plaque is raised and excised from the right pulmonary artery. Dissection begins on the posterior wall of the artery and continues in a circumfrential manner.

As an endoscopic procedure in the thoracic cavity, what differences do you note from laparoscopic abdominal surgery?

VATS is indicated when the patient has impaired pulmonary functions and the risk of performing open is outweighed by pathology.

What does VATS stand for? What procedures can be performed?

Video Assisted Thoracic Surgery. Diagnosis and treatment of several thoracic diseases and disorders of the esophagus, lungs, mediastinum, pericardium, and pleura.