Open Chest Surgery

1. Open Chest Surgery

2. Outline • A & P of descending aorta • Pathology • Diagnosis • Anesthesia • Medications • Patient preparation (positioning, prep, draping) • Equipment, Instrumentation, Supplies • Thoracotomy for descending thoracic aneurysm (groin incision for femoral bypass) • Other Aortic Aneurysm Types (I, II, III) • PTCA • CPB • Cell Salvage

3. Anatomy & Physiology of the Thoracic Cavity Refer to Thoracic I Lecture Notes

4. Pathology • Lungs • Carcinoma=a new growth or malignant tumor • Lung cancer #1 cause of death r/t cancer • Tumors Divided into 4 Groups: • Small Cell Carcinoma or Oat Cell (malignant) • Large Cell Carcinoma (malignant) • Adenocarcinoma (malignant) of bronchi = primarily smokers of bronchioles = 50%smokers & 50%nonsmokers • Squamous Cell Carcinoma (benign) formed from epithelial or squamous cells which line mucous membranes) • 90% malignant lung cancers r/t smoking

5. Pathology • All tumor types with the exception of small cell (oat cell), have a good prognosis with medical and or surgical intervention • Surgical Interventions include: • Wedge/Tumor Resection with margins • Lobectomy • Pneumonectomy • Medical Interventions include: • Chemotherapy • Radiation

6. Initial Diagnosis • Cytology of sputum sample • Will determine the type of cells that are present in the respiratory system • Will show presence of cancer cells but not where they actually came from in the lungs • Most preliminary of all tests • Chest X-ray must follow to narrow down location of tumor or mass

7. Initial Diagnosis • Chest X-ray • may be found on routine exam (asymptomatic) • may be ordered after presents with symptoms: Cough Bloody sputum (hemoptysis) Dyspnea

8. Diagnosis • Cell type determines the course of treatment • Tumors are looked at in terms of “staging” • Staging means,” how developed is the tumor”? • Is it in the lymph nodes, has it metastasized to another area, or is it localized • Staging is accomplished by sending a tissue sample to pathology and having it analyzed for type • Tissue samples are obtained by biopsy • Tissue samples can be of lymph nodes or lung tumor, done with a biopsy needle or actual wedge resections of the lung • Biopsy can be done by bronchoscopy or mediastinoscopy

9. Specimens • Specimens must be handled appropriately • Mishandling could damage a sample causing it to not be analyzable • There are two types of tissue samples in the OR related to node or tissue: Fresh frozen Permanent

10. Specimens • Fresh Frozen • Identifies type of tumor • Determines margins • Will entail waiting on path report • Depending on path report may be done and close or have to reopen or proceed • Sent when tumor has not been previously identified by mediastinoscopy, bronchoscopy, or needle biopsy

11. Permanent • Must ID the type of tumor before it can be stained to determine staging • There are different stains required for different types of tumors • Would send a wedge or lobe for permanent if the tumor type had already been Identified by a previous biopsy (from mediastinoscopy, bronchoscopy, or needle biopsy)

12. Specimens • Sometimes may hear “send this for Fresh” and the doctor will want cytology run • Cytology identifies an infectious process: • Fungal • Bacterial • AFB (acid fast bacillus) checks for TB

13. Other Diagnostic Tests for Review • CT scan or MRI • Shows location of tumor so that if a thoracotomy is done, the surgeon knows where to operate to excise the lesion

14. Preoperative Patient Preparation • Chest X-ray, MRI, AND or CT Scans should be in the OR before the patient arrives. They May accompany the patient. They should be displayed in the x-ray box for the surgeon. • Type & cross should be done in the event that the patient experiences extreme blood loss and needs blood replacement during surgery • These procedures are risky (large vessels are present in the thorax & mediastinum, and could be accidentally injured

15. Anesthesia • CVP (anesthesia preference) • Arterial line • Epidural • Blood available

16. NS Sterile Water Antibiotic in the Irrigant Local: Lidocaine Marcaine With or without Epi Bone Wax Surgicel Avitene Thrombin and Gelfoam Focal-Seal Other Fibrin Sealants: Bio-Glue Hema-Myst Medications

17. Thoracic Incisions • Posterolateral Thoracotomy • Anterolateral Thoracotomy • Thoracoabdominal Incision • Median Sternotomy • Alternative: Transaxillary, supraclavicular, cervical mediastinotomy, anterior approach

18. Thoracotomy • Surgical incision into the thorax or chest wall: • Two Types: • Posterolateral Thoracotomy • Anterolateral Thoracotomy

19. Posterolateral Thoracotomy • Lateral chest position for patient • Maximum exposure to lung, esophagus, diaphragm, and descending aorta • Anterior submammary fold about nipple level to scapular tip • May be as high as spine of scapula • For pulmonary resections (lobectomy, pneumonectomy, wedge resection), hiatal hernia repair, and thoracic esophagus

20. Anterolateral Thoracotomy • Supine position • Support under affected side to shoulder 20 to 45° for posterior incision extension • Hips may be rotated by buttock padding • Submammary incision just below breast from anterior midline to mid or posterior axillary line • Access at fourth intercostal space • For pulmonary cyst or localized lesion resection or open lung biopsy

21. Thoracoabdominal Incision • Lateral position • Incision from posterior axillary line to abdominal midline • 7th or 8th intercostal space • Exposure to upper abdomen, retroperitoneal area, and lower chest • Repair of hiatal hernia, esophagectomy, espophagogastrectomy, retroperitoneal tumors, and thoracic aneurysm resection

22. Factors Influencing Thoracic Incision Location • Exposure • Physiologic intrapleural pressure changes • Chest movement • Maintenance of chest wall integrity and diaphragm • Lung and underlying pleura condition • Minimizing invasiveness of procedure

23. Patient Positioning • Posterolateral • Operative side up • Beanbag (surgeon preference) under drawsheet • Pillow under head • Upper arm on padded mayo • Lower arm on padded armboard • Axillary roll (protect brachial plexus) • Padding under bottom leg • Pillows between legs (peroneal nerve) and feet • Safety strap and tape across mid pelvic area • Lower body Bair hugger sheet, cover with blanket

24. Prep • Towel drape over epidural catheter • Base of neck to hips and side to side to bed • Begin at incision site work around in circle, prepping axilla last • Usually betadine soap followed by betadine paint

25. Draping • Towels x 4 or five • Drying towels • Ioban • Universal sheet or laparotomy sheet

26. Equipment • ECU • Suction x 2 (1 for surgery & 1 for beanbag) • Bair Hugger • Bronchoscopy Cart • Stapler Cart

27. Instrumentation • CV or Major Tray • Chest Tray • Chest Retractor of Surgeon Choice (Finochettio, Tuffier, Burford) • Extra long instrument tray • Doctor specials • Long medium and large clip appliers

28. Chest Tray Instruments • Bronchus clamps • Duval Lung clamps • Allison lung retractor (whisk) • Davidson scapular retractor • Doyan raspatories (pigtails) right & left • Elevators (Cameron, Alexander, periostial, other) • Box cutter, Bethune rib shears, Guillotine • Bailey rib approximator

29. Supplies • Basic or Cardiovascular pack • Minor or Major basin set • Transverse Laparotomy or Universal drape pack • Gowns, Gloves, Towels • Chest tubes (various are surgeon preference) • Clip cartridges • Suture (prolene, silk, heavy fascia/muscle layer suture, vicryl, other nonabsorbable, skin suture) • For chest tubes, cutting needles with heavy silk ties • Magnetic pad/drape • Bovie with extension • Suction tubing, yankaur tip, cell saver (optional)

30. Supplies Continued • Kittners • Raytex for sponge sticks • Laparotomy sponges • Long umbilical tapes

31. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Incision made with #10 or #20 blade on #3 knife handle (made at 4th intercostal space for UL/5th or 6th for ML or LL) • Cautery used to bovie bleeders and open the fascia and muscle layer • Surgeon will used his hand to loosen fascia • Surgeon assistant will hold a scapular retractor so surgeon can free up entire area • May want forceps (debakeys) and cautery or metz to open muscle layer • If removing a rib will use periosteal elevator such as a cameron or alexanders to scrape away fascia and cartilage from rib • Will use doyan pigtail to completely free rib • Will cut rib at either end to remove it with a guillotine or rib shear

32. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Self-retaining retractor of choice is placed after rib removal • If does not remove a rib will place self-retaining retractor of choice • May use a burford (short or long blades or one of each) or tuffier or finochettio • Once retractor is in, will change bovie tip to long extention tip and give the surgeon and his assistant long debakeys (may want extra long debakeys/have extra long instrument set available) • Will begin dissection of lobe to be removed or entire lung

33. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Will use right angle and 0 silk ties to tie off vein and arteriole branches, as well as long medium and large clips • May also request silk or prolene suture on a 3-0 or 4-0 taper needle • Will dissect with long metz alternating with the cautery, debakeys and a long kittner on a long kelly • May request lung retractor (whisk or egg-beater) and or a sponge on a stick to the assistant for exposure • Will request one or two lovelace lung clamps when ready to staple bronchi or lobe tissue

34. Staplers used for Lobectomies and Pneumonectomies • Linear staplers (old name GIA) • Come in 55mm and 75mm • May want bovine pericardial or synthetic peri-strips applied to stapler (used to reinforce suture line made by the stapler) • Thoracotomy staplers (are U-shaped) • Come in 35mm, 60mm, and 90mm staple line length • 35mm and 60mm may be 3.5mm (blue) or 4.8mm (green) staple width and have reloads in those sizes • White staple reloads are thicker than the blue or green • 35mm also come in a vascular style (red) for bronchi • Manufacturers recommend a new stapler be used after reloading three times (This is often not done for cost saving reasons)

35. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Once a stapler is fired a 15 blade on a long #3 knife handle will be used to free the tissue from the staple line • Several stapler applications may be needed • Once the wedge, lobe or lung is removed the chest cavity will be irrigated with warm NS or Water using an asepto or cytal pitcher and suction • Irrigant will be left in momentarily to determine air leaks in the suture line (there will be bubbling) • Repair suture may be needed (silk or prolene) • Hemostatic or synthetic sealant agents may be used

36. Irrigation • NS is used when there is no cancer • Water is used if there is cancer present • Water causes lyses of cancer cells, which can allow those cells to be suctioned out of thorax • NS could lead to metastasis or spreading of the cancer cells to other areas if those cells that are present are not lysed and suctioned out • These patients often will receive radiation or chemotherapy post-hospitalization

37. Specimen • If a lobe or wedge is removed, it will be sent for frozen with margins • Clarify specimen type and what the specimen is with the surgeon • NEVER pass off lung tissue or lymph nodes to go in formaldehyde (permanent specimen) unless CERTAIN that is what surgeon wants! • Ask before you pass it off • Waiting will be involved to determine if margins are clear • If margins are not clear, you will go back and remove more lung tissue

38. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Once the irrigant is suctioned out, chest tubes of the surgeon’s choice will be placed using a 10 blade on a #3 knife handle (incisions are made below the thoracotomy incision), cautery may be used, a tonsil or kelly will be used to pass the chest tube through the chest wall for placement in the thoracic cavity • These will be sewn in using a large cutting eyed-needle with a #1 silk tie for each chest tube inserted • These should be cut for approximately 5 inches of length, a Y connector inserted for two, and hooked up to the pleurevac • Pleurevac should be filled with NS to appropriate level • Chest tubes must be secured with tape or plastic tie bands

39. Pleurevacs • Pleurevacs (water seal drainage with suction) • Pneumovac or pneumonectomy pleurevac (pressure control chambers/NO suction) • Pneumonectomy pleurevacs are used only for pneumonectomies • May not use any chest tubes with a pneumonectomy • Regular pleurevacs are used for chest drainage for all other chest procedures

40. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Pericostal closure of the thoracotomy incision will begin with one or two bailey rib approximators for rib reapproximation • Heavy (#1) absorbable suture (vicryl, dexon, or PDS) on a CTX or TP-1 taper needle for intercostal muscle closure • These are usually interrupted sutures (have mayo scissors ready to cut and hemostats) • They are usually placed, needle cut, and tagged with a hemostat • They are tied after they are all placed

41. Thoracotomy with Lobectomy or Pneumonectomy (Procedure) • Remaining muscle/fascia will be closed with a running #1 PDS or Vicryl on a CTX taper needle • Subcutaneous tissue will be closed with a 2-0 or 0 Vicryl on a CT-1 or CTX tapered needle • Subcuticular layer will be with 4-0 Vicryl or Monocryl on a PS-1 cutting needle • Skin staples may be used in some institutions • Dressing is drain sponges or 4x4s for the chest tubes, telfa, 4x4s, and Primapore • Other dressing choices may be used • Watch when patient is being moved to make certain that chest tubes are clear and not pulled out!

42. Descending Thoracic Aneurysm • Anatomy and Physiology of Thoracic Aorta • Thoracic aorta extends to the diaphragm • Thoracic aorta supplies chest wall, diaphragm, esophagus, bronchus, and the spinal cord

43. Aneurysm • Localized abnormal dilation of an artery resulting in pressure of the blood on the vessel wall that has been weakened

44. Pathology of Aneurysms • Develop at sites of arterial weakness • Causes: 1. Atherosclerosis 1° cause 2. Congenital weakness Marfan’s syndrome Ehlers Danlos syndrome (both are hereditary disorders that affect the elastic connective tissues which lead to weakening or thinning of the aorta) 3. Acquired Trauma

45. Aneurysms • Three types: • True-arterial wall weakness aneurysmal sac involves one or all layers of the arterial wall • False-results from trauma, causes leakage into a layer of the arterial wall creating a blood clot or hematoma • Dissecting-as intima of artery tears, blood escapes which can lead to hemorrhage and sudden death

46. Thoracic Aneurysm • Origin point at or below the left subclavian artery • Depending on extensiveness of aneurysm, can be operative or inoperable • Most frequent complication is paralysis

47. Diagnosis • Majority are Asymptomatic until they become enlarged • Discovered on routine chest x-rays • Routine physicals when an abdominal bruit is auscultated or a pulsatile mass is palpable • Symptoms include neck, chest, lower back, abdominal, or flank pain that extends to the groin • Depending on aneurysm involvement can cause symptoms associated with structures supplied with blood at that section of the aorta

48. Diagnostics/Preoperative Testing • Confirmed with: • Ultrasound • CT • MRI • Aortograms

49. Anesthesia • Arterial line • Swan ganz catheter • NG tube • TEE to check placement of bypass cannuli (some places may use C-Arm) • Epidural Catheter • BLOOD available (may want in room)

50. Medications • NS irrigation with antibiotic of choice • Topical hemostatic agents of choice