II Chapter 22 Short Answer: Thoracic Procedures pp 484

Name the specific thoracic instruments used during a thoracic procedure.

A. Potts-Smith forceps B. Sarot bronchus clamp C. Stainsky vena cava clamp D. Davidson scapula retractor E. Bailey rib contractor F. Alison lung retractor G. Lovelace lung-grasping forceps H. Ryder needle holder I. Bethune rib shears

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

Anesthesia personnel prepare and apply or insert monitoring equipment that may include a Swan-Ganz catheter for pulmonary wedge pressure and central venous pressure (CVP) readings, and arterial catheter for the monitoring of of arterial blood pressure, and blood gases (ABGs). Electrocardiography. oxygen O2 saturation, temperature, and blood pressure equipment are routine as well. For intrathroacic procedures, the anesthesia provider may prefer to use a double-lumen endotracheal tube so that the affected lung can be collapsed during the surgical procedure without interfering with the unaffected lungs ventilation. The use of the double-lumen endotracheal tube requires careful monitoring of ABGs and O2 saturation because of the increased possibility of right-to-left shunt through the non ventilated lung.

Is bronchoscopy strictly a diagnostic procedure? Explain your answer.

Bronchoscopy is an invasive diagnostic and/or therapeutic procedure for the evaluation of hemoptysis, infection, carcinoma of the lung, and damage to the lungs due to smoke inhalation. It is useful for retrieving foreign objects lodged in an airway and for laser treatment of endobronchial tumors. Bronchoscopy is also useful for postoperative evaluation of the transplanted lung.

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 (Euro-Collins) solution is used to preserve the donor lung. The patient will be instructed to perform deep breathing exercises to prevent infection and pneumonia and attempt to walk the first day.

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

Diagnostic procedures and tests that are most frequently used in the diagnosis of thoracic diseases and disorders are made up of pulmonary function, laboratory tests, and imaging studies that include standard x-rays, CT scanning, MRI, and pulmonary angiography. Anteroposterior (AP) and lateral standard x-rays of the chest can determine the size of the heart and great vessel configuration, as well as any valvular or intracoronary calcification. Asymptomatic pericardial cysts and cardiac tumors may also be detected.

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

During the dissection, extra care is taken to avoid injuring the subclavian vessels and phrenic nerve. Long Metzenbaum scissors and vascular forceps, blunt dissection with the fingers, and Kitner sponge.

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

Empyema is the collection of pus in the pleural space due to a bacterial infection that is removed by surgical incision and drainage. The main goal of decortication is to restore the normal lung function. The two other goals include controlling infection, such as in the case of empyema, and prevention of deformity. If not treated, deformity can occur in the chest and the spine of adolescents.

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

Initial diagnosis is made by chest x-rays 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 is removal of one lobe of the lung. In a lobectomy, if a neoplasm is confined to a particular lobe of the lung and hilar nodes are not involved, a lobe of the lung can be removed without disturbing other portions of the lung. An incision is made in 4th intercostal space (fifth or sixth interspace incision is made for the right middle lobe and lower lobe dissections). Pneumonectomy is removal of the entire lung. The chief indication for pneumonectomy is bronchogenic carcinoma. Less common indications include multiple lung abscesses, bronchiectasis, and extensive unilateral tuberculosis. A posterolateral incision is made in the skin and is carried through the subcutaneous and muscle layer with the knife and ESU.

What is the primary purpose of the mediastinoscopy procedure?

Mediastinoscopy is performed for the 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.

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

Patients are often asymptomatic until the disease has progressed and right heart failure is occuring. The earliest sign is severe pulmonary hypertension when exercising: however, the patient may not consider the symptoms abnormal and nor report to the physician. Other signs and symptoms include enlarged pulmonary arteries, septal hypertrophy, tricuspid regurgitation, chronic cough, syncope, palpitations, and hemoptysis (coughing up of blood).

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.

What is a pectus excavatum? What implant is used?

Pectus excavatum is a congenital deformity of the chest that is a funnel-shaped, asymmetrical depression due to a posterior displacement of the sternal body (funnel chest). Pectus excavatum repair by VATS treatment is for aesthetic as well as psychological reasons and restoration of normal respiratory function in extreme cases. It requires pectus bar instruments: Metal bar lock Pectus bar clamp Pectus bar bender Pectus bar introducter Pectus bar plate flipper Pectus bar stabilizer plates x 2 Templates, various lengths 7 - 17 in. The Pectus bar is the implant used and is left in place for at least three years.

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

Procedures that have been performed through VATS include lung wedge resection, lobectomy, lung volume reduction, creation of a pericardial window, pericardiectomy, and thymectomy VATS is also indicated when the patient has impaired pulmonary functions and the risk of performing open surgery is outweighed by pathology.

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

Pulmonary Thromboendarterectomy

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. It is also used to help diagnose narrowing of pulmonary vessels. pulmonary artery aneurysms, and changes to the arteries due to pulmonary hypertension.

What procedures are used for the evaluation of pulmonary disease?

Pulmonary cardiography is primarily used to detect pulmonary embolism and other blockages of the arterial circulation of the lungs. It is also used to help diagnose narrowing of pulmonary vessels. pulmonary artery aneurysms, and changes to the arteries due to pulmonary hypertension. Electrocardiography, echocardiography, and cardiac catheterization are also useful procedures for the evaluation of cardiac disease. The three definitive diagnostic procedures for the diagnosis of suspected lesions are bronchoscopy, mediastinography, and thoracoscopy with the excision of tissue and fluid specimens.

What will be used to prepare the implant for insertion?

The Pectus bar introducer and the thoracoscope.

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

The rigid scope is equipped with a fiber optic light carrier for illumination of the trachea and primary bronchi and side channels for anesthetic gas and oxygen administration. Rigid bronchoscopy is typically performed for the removal of foreign objects in children, although it may be used for biopsy of a large central mass or for evaluating hemoptysis. When positioning the patient for a rigid bronchoscopy, the head is slightly tilted to the left when the surgeon wants to view the right bronchi and slightly tilted to the right to view the left bronchi. If not using a scapular roll, the head of the OR table slightly lowered after the patient has been administered general anesthesia. A plastic tooth guard is placed over the upper teeth for protection.

What can be used to find the plaque if needed?

The surgeon may use a choledochoscope to first identify the location of the plaque if necessary.

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

The surgical technologist may be responsible for assisting the surgeon in inserting the biopsy forceps into the channel of the scope and advancing the forceps. When using flexible forceps, the surgical technologist should assist the surgeon in maintaining control of the forceps and prevent contamination. The surgical technologist should make sure the forceps are in the closed position prior to insertion into the channel.

What is the surgical technologists responsibility during a flexible bronchoscopy?

The surgical technologist may be responsible for assisting the surgeon inserting a brush or biopsy forceps into the channel of the scope and advancing the forceps. The forceps are flexible, therefore, the surgical technologist should assist the surgeon in maintaining control of the forceps and prevent contamination. The surgical technologist should make sure the forceps are in the closed position prior to inserting into the channel.

What complications may require a conversion to an open procedure?

The surgical technologist should be prepared to assist the surgeon with intraoperative complications of VATS, including air embolism, injury to the diaphragm, and hemorrhage; all of which can be reason to convert to an open procedure.

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

The surgical technologist will be responsible for assisting the surgeon in taking fluid specimens. The suction tube with specimen container is positioned for collecting bronchial washings; the specimen container must be held upright and not tipped to prevent the specimen from going through the suction. When the surgeon gives the order, the surgical technologist connects the suction tubing to the bronchoscope. The suction tubing is disconnected and the surgical technologist injects 5 mL of saline solution into the channel of the scope and quickly reconnects the suction to take additional fluid specimen; the surgical technologist must be familiar with the brand/type of bronchoscope being used and know the correct channel in which to inject the saline solution. The surgeon may have the procedure repeated several times.

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

The surgical technologist 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.

How are the specimens removed from the the biopsy forceps jaw?

The surgical technologist 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. Next, the surgical technologist will use the wire cutting scissors to cut the brush off the end of the end of the forceps while holding it over the specimen container the circulator is holding.

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

Upon completion of the dissection, the anesthesia provider will inflate the lung again in order for the surgeon to check for leaks and hemorrhage from the lung.

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 circumferential manner. The surgeon continues removal of the plaque from the segmental and subsegmental arterial branches using a combination of suction and dissection.

What does VATS stand for and what is it? What procedures can it perform?

VATS stands for Video Assisted Thoracic Surgery. VATS is used for the diagnosis and treatment of several thoracic diseases and disorders of the esophagus, lungs, mediastinum, pericardium, and pleura.