1 / 61

THORACIC INCISIONS

THORACIC INCISIONS. PRESENTER: DR ANEFU, N. E MODERATOR:DR S. EDAIGBINI AHMADU BELLO UNIVERSITY TEACHING HOSPITAL,ZARIA,NIGERIA . OUTLINE. INTRODUCTION HISTORICAL PERSPECTIVES ANATOMY OF THE CHEST BASIS GENERAL PRINCIPLE TYPES OF THORACIC INCISIONS CURRENT TREND FUTURE TREND

tansy
Download Presentation

THORACIC INCISIONS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. THORACIC INCISIONS PRESENTER: DR ANEFU, N. E MODERATOR:DR S. EDAIGBINI AHMADU BELLO UNIVERSITY TEACHING HOSPITAL,ZARIA,NIGERIA

  2. OUTLINE • INTRODUCTION • HISTORICAL PERSPECTIVES • ANATOMY OF THE CHEST • BASIS • GENERAL PRINCIPLE • TYPES OF THORACIC INCISIONS • CURRENT TREND • FUTURE TREND • CONCLUTION

  3. INTRODUCTION • Incision;- Is a surgical wound made by a surgeon on the skin, with intension of gaining access to a lesion beneath or cavity. • Such wounds created anywhere on the chest (thoracic) wall is thoracic incision

  4. Historical perspective • Development evolution thoracic incision is closely related to the development of thoracic surgery • Used in ancient time for draining abscesses in the chest

  5. Anatomy of the chest

  6. CHEST WALL • Bony rib cage;- manubrum, sternum, 12 pair of rib, coastal cartilage & thoracic vertebrae • Soft tissue covering:- muscles, neurovascular bundles, other connective tissues • Two aperture • Superior=root of the neck • Inferiorly=separated from abdominal cavity by diaphragm

  7. Lungs surface markings in the ribcage

  8. In spite of the large intra-thoracic space, separate pleural spaces &rigid- ribbed chest wall, its anatomy makes specific incision selection crucial to the ease & safety of a given thoracic procedure • Respiration is still possible; due to the nature of the joint & muscular attachments

  9. General principles • Patient evaluation & clinical assessment • History, P.E, Lab & Radiological investigations-LFT, Spirometric measurement,SPO2,CXR, • Performance score rating • Patient education/counseling/consent • Start Chest physiotherapy • Peri-op monitoring/medications

  10. Gen. principles • Anaesthesia(G.A,double lumen ETT or single lung intubation) • Analgesia( epidural catheters,intercostal nerve block) • Surgery • Antibiotics prophylaxis • Follow-up

  11. Analgesia CTU-ABUTH • Taken very seriously • Intra-op =I.V pentazoxine • Post-op =Triple px • Opioid; pentazoxine • NSAIDs;diclofenac • Acetaminophen;PCM

  12. Prophylactic Antibiotics-CTU • Intra-op =3rd generation cephalosporin e.gceftriaxone + metronidazole, repeated after 8hrs, • Post-op =same extended X 2-3/7

  13. Surgical principles • To allow a successful surgical outcome • Adequate exposure • Preserve chest-wall function & appearance • Incision along langers line or positioned to minimize visibility • Closure-rigid approximation & strict layered closure

  14. Optimal approach depends on Bony anatomy Location & extent of pathology Location of the hilum Objective of the procedure Chest drainage

  15. Types of thoracic incisions • Sternotomy • Thoracotomy • Axillarythoracotomy • Anterior mediastinotomy • Thoracoabdominal incision

  16. Types cont… • Bilateral Trans-sternalthoracotomy( clam-shell incision) • Extra-thoracic approaches to the thorax

  17. Sternotomy incisions • Partial • Hemisternotomy (spares 6-8cm skin) • Complete • Suprasternalnotchxyphoid process • Cosmetically appealing type of incision e.ginframammary (bikini type) incision

  18. Median sternotomy incision

  19. Sternal spreader applied

  20. Median sternotomy Indications exposure of ant. & middle mediast lower cervical procedures Tracheal resection& reconstruction

  21. Indications • Excision of thyroid masses & parathyroid adenomas • Excision of cervical oesophagealtumours • Exposure of heart & great vessels • In cardiopulmonary bypass

  22. Advantages • Quick to perform • Excellent exposure • Safe • Heals quickly • Less incisional pain

  23. Disadvantages • Many finds the vertical incision unsighty • Gives limited exposure of the lower chest & posterior mediastinum • May lead to post-op complications-unsteable sternum, infections

  24. Technique • Standard sternotomy • Open sternotomy • Re-operative sternotomy • Partial sternal split

  25. CLOSURE:Interlucking wire suture technique

  26. Less invasive sternotomy incisions • Hemisternotomy- suprasternalnotch,tee-off to the R at interspace 4 or xyphoid,tee-off,R, at interspace 2 • Full sternotomy with skin sparing • Bikini-type (inframammary) incision- cosmesis

  27. Less invasive sternotomy incisions

  28. Post-op care • ICU MANAGEMENT/MONITORING • O2 DELIVERY VIA NEBULIZER • PAIN MANAGEMENT( I.Vanalgesics,Eidural nr block) • PHYSIOTHERAPY

  29. COMPLICATIONS • Anaesthetic:- arrhythmias, laryngeal spasm Specific :- Early; haemorrhage,injury to contiguous structures, pneumothorax, haemothorax, Late; infection, empyemathoracis, post surgery pain

  30. Complications • Mediastinitis (S.aureu31%,E.coli3%,enterococcus 2%) • Sternalosteomyelitis • Brachial plexus injury,incidence:1.4-6.5%

  31. Thoracotomy • Standard thoracotomy incisions • Defined arbitrarily in relation to the position of Latissismusdorsi muscle,which is laterally sited on the chest wall

  32. Types of thoracotomy incisions • Lateral • Anterior • Anterolateral • Posterolateral • Posterior • others

  33. The numenclature for std thoracotomy incisions

  34. Indications for posterolateral incision • Standard thoracotomy incisions can be used for a wide range of surgical procedures involving; • The Heart • Oesophagus • Mediastinum • Ipsilateral lung

  35. Advantages • Flexibility of the incision • Wide range of intra-thoracic exposure • Proven experience with these incisions has made them the standard thoracic incisional approach

  36. Disadvantages • Has potential for poor exposure , if wrong interspace is chosen • Unilateral hemithorax exposure • Incisional pain • Disability related to division of chest wall muscles • Detrimental effect on pulmonary function

  37. Technique (posterolateral) • Induction using single/double lumen tube • Appropriate monitoring • Anaesthesia-G.A+ETT • Positioning –lateral decubitus position • Cleaning/drapping

  38. Crescent or “lazy-S”incision, transversely • Dissected down & scapular retracted • Pleural space entered • Pleural/mediastinal drainage • Thoracotomy closure

  39. Option for entering the pleural space after posterolateralthoracotomy

  40. Intercostal approach-incising i.c muscles • Utilizing intercostal incision but to divide one or more ribs • To resect a rib, enter through its periosteal bed

  41. Anterior & anterolateralthoracotomy • Indications • Has greater use historically • Used for pulmonary resection • Cardiac procedures • Management of mediastinal masses • Oesophageal pathology

  42. Technique • Monittoring • Anaesthesia are same as posterolatral • Supine position • Chest elevated at 30-45 • Curved submammary incision, extended laterally(anterolateral)

  43. Anterolateralthoracotomy incisions

  44. Lateral thoracotomy • Within confines of latissimusdorsi • Transverse incision • 1-2cm inferior to the scapular

  45. Complications • Post thoracotomy incision pain • Wound infection • Wound dehiscence • Bronchopleural fistula-8% • Empyema thoracis-2.2%

  46. Muscle-sparing thoracotomy • Indications • As in std thoracotomy • Variant of std thoracotomy • Well established • Has less complications

  47. Muscle sparing anterolateralthoracotomy incision

  48. Advantages • Less early post-op pains • Greater shoulder girdle strength • Most result in quick closure • Preserve chest wall muscle • Prevent chest wall deformity

  49. Axillarythoracotomy • Indications • 1st rib disection • Apical bleb Dx • Mgt of spontaneous pneumothorax with apical pleurectomy or pleurodesis • Staging of lung cancer

  50. Patient positioning & incision for a vertical axillary incision

More Related