Fuller: Chapter 33:Thoracic and Pulmonary Surgery

Arterial blood gases

A blood test that determines carbon dioxide and oxygen saturation, pH, and other important parameters of respiration and oxygen perfusion. Blebs: Areas of overdistention in lung tissue.

Empyema

A pus-filled area of the lung.

Closed chest drainage

A system of removing air or fluid from the thoracic cavity and restoring negative pressure so that the lungs can expand properly after thoracic surgery or penetrating trauma to the chest wall.

Pneumothorax

Air in the chest cavity, which prevents the lungs from expanding and may displace the mediastinal structures.

Blebs

Areas of overdistention in lung tissue.

Hemoptysis

Bloody sputum or bleeding arising from the respiratory tract.

Explain the difference between bronchial washings, cytology brushing, and tissue biopsy?

Bronchial Washings- If sputum or fluid samples are to be taken, suction tubing adapted with a Lukens trap is attached to the tubing. Cells are washed free from the bronchus and retrieved with the suction cannula attached to a Lukens trap. This small vial collects solutions as they are suctioned. The trap must be held upright to avoid losing the specimen. The surgeon performs bronchial lavage by injecting saline into the side channel. (Rigid) Cytology brushing- The surgeon obtains cytology samples by inserting a small brush through the operating channel. The technologist must make sure the instrument is long enough to extend outside the tip of the scope. After the brush is removed, the scrub dips it in a specimen container holding a small amount of saline. This process may be repeated several times. In some cases the tip of the cytology brush may be cut from the wire and placed in the fixative container. (Flexible) Tissue biopsy- Biopsy forceps may be used to obtain small tissue samples. These forceps must be handled carefully, because they are very small and easily lost. After the forceps is withdrawn from the scope, the sample should be placed immediately in a specimen container or on a Telfa pad. A hypodermic needle is helpful for removing bits of tissue from the biopsy forceps. (Flexible) Tissue biopsy- Biopsy tissue is removed with cup forceps. The scrub is responsible for removing the tissue from the forceps. The sample is placed on a moistened Telfa pad to prevent its loss. The tissue must be handled gently when removed from the forceps so that it is not crushed, because this may distort the pathology. (Rigid)

List the diagnostic procedures associated with thoracic and pulmonary surgery.

Bronchoscopy (rigid and flexible) Mediastinoscopy Video-assisted thoracoscopic surgery (VATS). Thoracoscopy Lung volume reduction surgery Scalene biopsy Thoracotomy Lobectomy Pneumonectomy Rib resection for thoracic outlet syndrome Decortication of the lung Lung transplantation

b. Bronchoscopy

Bronchoscopy is endoscopic examination trachea and bronchi. The surgical goal is to assess the respiratory structures, remove specimens for biopsy, or perform a minor surgical procedure.

n. Decortication of the lung

Decortication of the lung is the surgical removal of a portion of the parietal pleura.

dyspnea

Difficulty breathing

Explain the pleural cavity. Include in your explanation the pleural sac, pleural space, and negative pressure.

Each lung is enclosed in a pleural cavity and covered by a double membrane, the pleural sac. The outer membrane forms the parietal pleura, which lines the thoracic cavity and outer mediastinal walls. The inner, or visceral, pleura covers the lungs. A small amount of pleural fluid is secreted into the pleural space between the two membranes. Pleuritis is inflammation of the pleural membranes. An increase in fluid (e.g., serous fluid, pus, or blood) is called a pleural effusion. The pleural space is called a potential space because during respiration, the space increases or decreases as the lungs fill with air. In pleural effusion, the lungs cannot expand fully. The pleural space normally maintains negative pressure in relation to atmospheric air and the alveoli. If the chest wall and pleural space are opened, such as during trauma or surgery, air rushes in and collapses the lungs in the same way vacuum-packed wrappers fill with air when punctured. Figure 33-2 illustrates the lungs and bronchial tree.

Decortication of the lung

Emphysema

Lung volume reduction

Emphysema

Lung transplantation

Emphysema, obstructive pulmonary disease

d. Flexible bronchoscopy

Flexible bronchoscopy utilizes a slender fiberoptic endoscope capable of entering the primary and peripheral bronchi. The modern flexible scope may also be used for interventional procedures such as cryosurgery and laser surgery

k. Lobectomy

In a lobectomy, a lobe of the lung is removed to prevent the spread of cancer or to treat a benign tumor. Lobectomy may be performed as a VATS procedure or as an open procedure. The principles and anatomical divisions are the same for open and closed procedures. If thoracoscopy is planned, instruments for converting to an open procedure must be available.

h. Lung volume reduction surgery

In lung volume reduction surgery, portions of the lung severely affected by chronic pulmonary emphysema are removed to improve pulmonary function. Segmental resection is performed by means of a VATS technique using surgical staples.

g. Thoracoscopy: lung biopsy

In thoracoscopic lung biopsy, a small portion of lung tissue is removed for pathological assessment.

Bronchoscopy

Infectious disease

Hypoxia

Lower than normal oxygen perfusion.

e. Mediastinoscopy

Mediastinoscopy is endoscopic examination of the mediastinum through an incision. Thymus and lymph node biopsy are performed to establish a diagnosis.

l. Pneumonectomy

Pneumonectomy is the removal of the entire lung.

What is the difference pneumonectomy, segmental resection, and wedge resection?

Pneumonectomy is the removal of the entire lung. In lung volume reduction surgery, portions of the lung severely affected by chronic pulmonary emphysema are removed to improve pulmonary function. Segmental resection is performed by means of a VATS technique using surgical staples. A wedge resection is a large tissue biopsy or the removal of a small peripheral lesion. These are commonly removed with the linear surgical stapler during thoracoscopy.

What diagnostic tests would be done on a patient who will undergo lung and respiratory surgical procedures?

Pulmonary function tests (PFTs) are a specific group of procedures that measure lung function. These noninvasive tests are performed with a complex breathing machine, which measures the parameters digitally. The following tests are included in this group: •Tidal volume: The amount of air exhaled during normal respiration. •Minute volume: The amount of air exhaled per minute. •Vital capacity: The total volume of air exhaled after maximum inspiration. •Functional residual capacity: The volume of air remaining in the lungs after exhalation.•Total lung capacity: The total amount of air in the lungs when fully inflated. •Forced vital capacity: The amount of air expelled in the first, second, and third seconds after exhalation. •Peak expiratory flow rate: The maximum amount of air expelled in forced expiration. A complete blood count (CBC), including white blood cell differential, is performed as a basic screening tool for surgical patients. Among the most important blood tests for pulmonary function is determination of arterial blood gas values, commonly called arterial blood gases (ABGs). Imaging studies of the pulmonary and thoracic structures include radiographs, magnetic resonance imaging (MRI), ultrasound scans, and computed tomography (CT).

What procedure is performed to relieve thoracic outlet syndrome?

RIB RESECTION FOR THORACIC OUTLET SYNDROME

c. Rigid bronchoscopy

Rigid bronchoscopy is used for interventional procedures, which require a large-bore endoscope and rigid instruments, such as removal of a tissue mass or a foreign body. This is because the lumen of the rigid scope is larger than that of the flexible bronchoscope.

i. Scalene node biopsy

Scalene node biopsy is performed on patients with palpable nodes in the area of the scalene fat pads. Biopsy is performed to establish cancer staging or to confirm a diagnosis.

What type of pathology is involved in thoracic outlet syndrome?

Subclavian vein and brachial plexus compression The opening of the thoracic outlet is formed by the first ribs, the spine, and the sternum. TOS occurs when the brachial plexus and the subclavian vein or artery are compressed as they pass from the neck into the upper extremity (in the region between the thoracic outlet and the insertion of the pectoralis minor muscle). The obstructing structures may include the first rib, clavicle, or pectoralis tendon. The causes of TOS include trauma, structural anomaly, repetitive motion, and poor posture.

Pulmonary function tests (PFTs)

Tests performed to measure the function and strength of the pulmonary system.

Expiration

The act of breathing out (exhalation).

Inspiration

The act of taking a breath (inhalation).

Perfusion (oxygen)

The distribution of oxygen to tissues.

Diffusion (oxygen)

The molecular passage of oxygen across the alveoli and into the bloodstream.

Hemothorax

The presence of blood in the thoracic cavity or between the pleural sac and lungs, usually caused by trauma.

Ventilation

The process

What organs and structures are located in the mediastinal space?

This space contains the heart, large vessels, bronchi, trachea, esophagus, and thymus gland which produces hormones necessary for immune function. The thymus gland, which is located in the mediastinal space in children, regresses in adulthood. regional lymph nodes within the mediastinal space is performed to determine or rule out a cancer diagnosis.

Rib resection

Thoracic outlet syndrome

m. Rib resection for thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a rare condition in which the subclavian vessels and the brachial plexus are compressed at the apex of the thorax. The surgical goal is to release the compression of the neurovascular tissue and restore function to the affected upper extremity, neck, or shoulder.

j. Thoracotomy

Thoracotomy is the general term for open surgery of the thoracic cavity. The procedure for opening and closing the chest generally is the same for any thoracotomy. Thoracic emergencies involving open or penetrating wounds with severe hemorrhage, may require the thoracotomy to be performed in the emergency department. In these cases, the patient is rushed to the operating room as soon as hemostasis is controlled. Refer to Chapter 37 for a more detailed description of emergency thoracotomy.

Define the following surgical procedures associated with thoracic and pulmonary surgery. a. Insertion of chest tube

To provide closed chest drainage, chest tubes must be surgically inserted. In the case of a surgical procedure involving thoracotomy, the tubes are inserted just before the chest is closed to establish negative pressure as soon as possible following endotracheal extubation. After a spontaneous or traumatic air leak or a surgical procedure in which the right or left pleural cavity is opened, negative pressure must be restored to allow the lungs to expand. The surgeon achieves this by making an opening into the affected pleural cavity through a small thoracic incision. One or more chest tubes are inserted and connected to a water-seal chest drainage system to remove air, blood, and other fluids from the thoracic or pericardial cavity. Suction is applied. Chest tubes are made of heavy Silastic or polyvinyl chloride tubing that has numerous perforations at the proximal end. After surgery, the chest tube is inserted through a stab incision away from the surgical incision. Chest tubes may be placed in one or more locations. They are sutured to the chest wall with heavy, nonabsorbable sutures and dressed with petroleum gauze, fluffed, and flat gauze.

o. Lung transplantation

Transplantation of one or both lungs is performed to remove a diseased lung and replace it with a donor lung. Single-lung transplantation increasingly is used as a way to maximize the allocation of donor lungs. If both lungs are diseased, bilateral transplantation is indicated. Living donor transplantation involves removal of the donor's lower lobes only.

f. VATS

Video-assisted thoracoscopic surgery (VATS) is minimally invasive surgery of the thoracic cavity. This technique is similar to other types of minimally invasive procedures in which cannulas are inserted through the body wall and used to receive a rigid scope and telescope instruments. This technique is different from endoscopic (bronchoscopic) surgery in which a flexible or rigid scope is inserted through the airway via the trachea. The term video-assisted thoracoscopy or VATS was coined at a time when minimally invasive endoscopic surgery was in its early development. At that time, video display from the endoscope to a monitor was a relatively new technology. Thoracoscopy has now been developed to the extent that it has taken the place of most open procedures of the thorax.