Procedures

1. Procedures Intermediate Format: Cervical Rib Resection

2. Objectives • Assess the related terminology and pathophysiology of the lungs. • Analyze the diagnostic interventions for a patient undergoing a cervical rib resection • Plan the intraoperative course for a patient undergoing_____________. • Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives • Choose the appropriate patient position • Identify the incision used for the procedure • Analyze the procedural steps for cervical rib resection. • Describe the care of the specimen

4. Terms and Definitions • Thoracic outlet: formed by the first ribs, spine, and sternum

5. Definition/Purpose of Procedure • Decompression of the thoracic outlet through partial or entire removal of the rib • Surgical Goal: release compression of the neurovascular tissue and restore neurovascular function to the affected upper extremity, neck, or shoulder

6. Pathophysiology • Thoracic Outlet Syndrome • Compression of the subclavian vessels and the brachial plexus at the apex of the thorax. • Other names: cervical rib syndrome, first thoracic rib syndrome, costoclavicular syndrome, hyperabduction syndrome • Classifications • Arterial thoracic (result compression of subclavian artery and results in severe ischemia of arm) • Neurological • Venous thoracic

8. Surgical Intervention:Special Considerations • Patient Factors • Will be in pain; assist with transfer, etc. • Room Set-up • Anesthesia: General ; may add cervical-thoracic-paravertebral regional block for postop pain management

9. Surgical Intervention: Positioning • Position during procedure • Lateral decubitus (may be semilateral for axillary or anterolateral approach) • Supplies and equipment • Pillows, 3 in tape, foam padding, • Special considerations: high risk areas • Proper padding of bony prominences at hips, knees, ankles, upper body, axillary or chest rolls

10. Surgical Intervention: Special Considerations/Incision • Special considerations • State/Describe incision • Transaxillary incision between the pectoralis muscle and the latissimus dorsi muscle on the affected side

11. Surgical Intervention: Supplies • General • Specific • Suture & Blades • Bone wax • Medications on field (name & purpose) • Catheters & Drains—a drain will be placed

12. Surgical Intervention: Instruments • General: soft tissue and bone instrumentation (Chest set) • Specific: soft-tissue dissection instruments as well as rib cutters, elevators, and rongeurs are added to the set

13. Thoracic Instrumentation

15. Thoracic Instruments

16. Surgical Intervention: Equipment • General: ESU • Specific

17. Surgical Intervention: Procedure Steps • The skin and subcutaneous tissue are incised with scalpel and electrodissection. • Soft-tissue dissection continues, to identify neurovascular bundle. • Dissection is carried out to the level of the cervical rib (if present) or the first rib. If the first rib, it is meticulously dissected subperiosteally using the periosteal elevator. • STSR has available: rib elevator, stripper, and rib raspatories. Note: too much traction in the brachial plexus and damage to the subclavian artery or vein are avoided during dissection.

18. Surgical Intervention: Procedure Steps • A wedge is taken from the midportion, or the rib is removed entirely using rib shears. • A drain is placed, incision closed, and dressing applied.

19. Counts • Initial: sharps, sponges, instruments • First closing • Final closing • Sponges • Sharps • Instruments

20. Specimen & Care • Identified as portion of rib • Handled: routine (formalin)

21. Resources • Alexanders pp. 1053, 1074-1075 • STST Ch 22, p. 877 • Fullers (New 4th ed) Ch 29; 3rd ed Ch 24 • http://tellmeabouttos.com/surgery1.htm • www.vesalius.com • MAVCC Unit 12

22. For visualization of the pleurae, lower and middle mediastinum, and pericardium, the surgeon would need a: • Thorascope • Mediastinoscope • Bronchoscope • Laryngoscope

23. As the STSR, with which of the following procedures would you anticipate the use of chest tubes and a water-seal drainage system? • Lobectomy • Scalene Node Biopsy • Percutaneous Transluminal Coronary Angioplasty • Cardiac Pacemaker Insertion

24. Which of the following retractors would be most useful in a posteriolateral Thoracotomy? • Balfour • O’Sullivan-O’Connor • Davidson scapula • Weitlaner

25. With which of the following procedures would you expect the greatest amount of bleeding? • Wedge Resection of the Lung • Decortication of the Lung • Open Thoracotomy fro Closure of a Ruptured Bulla • Closure of a Patent Ductus Arteriosus

26. The removal of a lung is referred to as a/an: • Pneumonectomy • Endarterectomy • Blalock-Hanlon operation • Cryoablation

27. Cervical Rib Resection is performed to relieve: • Thoracic Inlet Syndrome • Thoracic Outlet Syndrome • Adult Respiratory Distress Syndrome • pneumothorax

28. The procedure performed to remove a fibrous covering from the lung following empyema formation is: • Aneurysmectomy • Thoracostomy • Thymectomy • Pulmonary Decortication

29. When two chest tubes are placed into the pleural space, the uppermost tube is used to: • Evacuate air/re-establish negative pressure • Evaluate blood/re-establish positive pressure • Evacuate serous fluid/re-establish positive pressure • Evacuate pus/re-establish negative pressure

30. When a rib is removed, the remaining bone edges are trimmed with a: • Doyen raspatory • Bethune shear • Lebsche knife • Stille-Luer rongeur

31. When transporting a patient with a closed water-seal drainage: • The bottle should be kept at or above the height of the patient’s chest • The chest tube should always be clamped • Chest tube clamps should accompany the patient at all times • The patient should be placed in Trendelenburg position

32. Mediastinoscopy is usually performed with the patient in what position? • Lateral • Sims • Dorsal recumbent • prone

33. Removal of air or fluid from the pleural cavity via needle aspiration is: • Thoracoscopy • Thoracotomy • Hemocentesis • Thoracentesis