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Thoracic Surgery

Carla Gordon, 2007

cgordon@bendigohealth.org.au

Thoracic Surgery
Lung resection surgery. Lung volume reduction surgery (LVRS). Lung biopsy, video assisted thoracic surgery (VATS). Pleural surgery. Chest wall surgery. Mediastinal surgery. Chest trauma surgery. Cardiac surgery. Organ transplantation.

Lung Resection Surgery

Indications
Sequestrated lobe. Benign tumours. Bronchiectasis
Poorly controlled frequent exacerbations.

Lung Carcinoma

Video Assisted Thoracic Surgery

Four 1 inch incisions are made. A video scope which projects the image onto a screen is inserted. Enables biopsies, wedge resections and simple pleural procedures to be performed. Patient will still have an ICC and UWSD in situ post-operatively as the pleural cavity is entered.

Thoracic Surgery Incisions

Thoracotomy
Most common. Posterolateral
From vertebral border of the scapula following the line of the 6th rib. Along a rib line from near midline anteriorly to the posterior axillary line.

Anterolateral

Sternotomy Clam shell Thoraco abdominal Mini thoracotomy

Lung Resection Surgery

Lobectomy
Excision of one (or two) entire lung lobe(s). Most common form of lung resection If metastatic lung Ca, hilar lymph nodes may also be excised.

Lung Resection Surgery

Sleeve resection
Removal of a section of bronchus (usually with lobectomy). Primary bronchial re-anastomosis to preserve remaining lung tissue.

Segmental resection
Excision of one or more of the 10 broncho pulmonary segments.

Wedge resection
Excision of a small wedge shaped section of lung tissue (usually for biopsy or a small nonmalignant tumour).

Lung Resection
Surgical Procedure
Posterolateral incision most commonly used:
.

Post-operative Management
ICCs on UWSD (usually with suction) until any air leaks have resolved, up to 7 days. Analgesia
Narcotics: IM, IV (infusion or PCA). Epidural. Intercostal nerve blocks. Oral narcotics e.g. morphalgin. Oral simple analgesics (e.g. panadeine forte). PR (often NSAIDs).

Muscles incised include latissimus dorsi, serratus anterior, trapezius, rhomboids, intercostals.

Removal of lung tissue and suture bronchi. Test lung for air leaks. Insertion of intercostal catheter

Usually two

Basal for predominately drainage of haemo serous fluid. Apical for drainage of air.

Oxygen. Fluids, medications.

Complications
Pulmonary
Atelectasis, sputum retention, respiratory depression. Persistent air leak. Stump break down. Bronchopleural fistula. Empyema. Diaphragmatic paralysis.

Physiotherapy
Pre operative
Subjective information as for general surgery. Physical examination

Wound dehiscence. Surgical emphysema. Cardiovascular instability. Blood loss. Analgesia side effects
Nausea/vomiting. Urinary retention. Hypotension.

As for general surgery, only particular attention to trunk and UL ROM.

Treat existing lung issues (commonly occur). Advise patients on bed mobility: inability to push down with effected UL, need to bottom shuffle up the bed. Advise patients on post-operative exercise routine

Early mobilisation and SOOB (within limitations of ICC, UWSD and suction). Deep breathing, supported cough/huff. Foot and ankle exercises. UL exercises.

Physiotherapy
Post-operatively
Thorough assessment and treat as per findings and problem list. Positioning: Specific deep breathing exercises: Mobilisation:

Patient Case
A 35 year old, Day 3 post left lower lobectomy via left postero-lateral thoracotomy incision for cavitating abscess. Current history: History of non resolving pneumonia, asymptomatic until 6 months ago. Investigations revealed abscess. Smoker - 15 per day for 15 years No other respiratory history. Past History: IV drug user, Hep C positive. Medication: Methadone Post-operative Assessment:
Two ICCs connected to UWSDs in situ. Attached to 20cmH2O of suction. PCA - morphine infusion (no background infusion) 1mg/activation, 5 minute lockout, maximum 5mg/hr. Patient has used PCA 15 times in last 30 minutes. Subjective Assessment: Complaining of intense pain, reluctant to move. Physical Examination

Bed mobility. Early sitting out of bed and early ambulation (MOS, walking, stairs). Upper limb / thoracic cage exercises Elevation to point of discomfort.

Posture re-education.

Patient looks unwell, gray, sweaty, restless Vital observations BP 110/60 Temp 38.5C RR 30 breaths/min HR ST120 ABG's pH 7.34 PaO2 55 PaCO2 48 SaO2 82% HCO3 26 BE +1 on 35% O2 Now on 60% O2 via mask and fisher & paykel humidifier, with SpO2 of 97% CXR signs of patchy collapse & consolidation both lung fields (L) > (R). Breathing pattern marked use of accessory muscles, upper chest movement, decreased basal expansion (L) > (R) Auscultation: decreased breath sounds (R) and (L) base, more marked on (L). scattered crackles throughout (L) lung Cough: weak, moist

Measures Used in Assessment

Premorbid exercise tolerance SOB
On exertion Orthopnea, PND.

Problem List
1. 2. 3. 4.

Respiratory medications Social History Sputum production (Premorbid and current) Reassessment
SpO2 Cough Auscultation Breathing pattern (?)CXR

Pain Sputum retention Decreased ventilation Increased WOB Respiratory failure

Acidotic, hypoxic and hypercapnic

Special Considerations
Febrile
INFECTION!

Pneumonectomy
Removal of an entire lung.
Presents as a restrictive disorder post-operatively.

Also increased HR and RR (note: may also relate to pain and anxiety).

IV drug user
Analgesia issues Hep C positive

Surgery & post-operative orders

As for lobectomy, except Only one ICC, which is clamped. The patient must NOT cough when the ICC is not clamped. Huffing preferred to coughing to protect the stump.

Universal precautions

Possible psychosocial issues

Restless and unwell

Cooperative ?

Pneumonectomy
Haemo serous fluid collects within the hemithorax while remaining air is absorbed. ICC clamp is removed for 1-2 min every hour to control rate of fluid accumulation as per surgeons orders.
Prevents mediastinal and tracheal diversion.

Fluid begins to fibrose over the month postoperatively. By 2-3months the CXR shows an opaque hemithorax, crowded ribs, elevated hemidiaphragm and mediastinal shift to the pneumonectomy side.

Pneumonectomy
Physiotherapy management
As for lung resection surgery. However note that the ICC should NOT be draining.

Lung Volume Reduction Surgery (LVRS)

Surgery
Median sternotomy or clam shell. Suturing or stapling of bullae. Approximately 1/3 of the lung removed. Two ICC on each operative side.

Contraindications/precautions:
Positioning

Indications
COPD, particularly with hyperinflation and lung bullae.

Side lying on non-thoracotomy side

Apical bullae.

Bronchial stump may be bathed in fluid and potentiate stump break down.

Proposed mechanism of improvement

Removes areas of V/Q mismatch. Recruits regions of healthy lung tissue. Restores respiratory muscle dynamics.

Suctioning

Trauma to the bronchial stump.

Lung Volume Reduction Surgery (LVRS)

Specific Selection Criteria
Age < 70 years. Non-smoker > 3 months. Compliant with exercise program e.g. pulmonary rehabilitation. Lung function

Lung Volume Reduction Surgery (LVRS)

Post operative medical management
As for lung resection surgery. Often persistent air leak

ICCs may stay in situ for up to 10 days.

Complications
As for lung resection surgery.

FEV1 15-40% predicted. RV > 150%. DLCO > 30% predicted. PaCO2 < 55 mmHg. PAP < 50 mmHg. 6mwt distance > 150m.

Physiotherapy
Thorough assessment pre operatively.

Exercise tolerance

Functional status, exercise tolerance, lung status, compliance with exercise routine. Patient will often be included in a pre-operative pulmonary rehabilitation.

Lung Volume Reduction Surgery (LVRS)

Physiotherapy
Post operatively

Pleurodesis
Indications
Recurrent pneumothorax. Recurrent pleural effusion. Empyema. Pleural cancer e.g. mesothelioma.

As for lung resection. Addition of breathing control for dyspnea. Pulmonary rehabilitation. Manual hyperinflation. Oxygen therapy: hypoxic drive. High levels of intermittent positive pressure ventilation, invasive and non-invasive.

Contraindications

Closed pleurodesis
Chest drain or VATS. Chemical irritation of pleura. Two ICCs on UWSD suction post procedure.

Precautions

Pleurodesis
Open (Scrub) Pleurodesis or Pleurectomy
Anterior thoracotomy. Scrub Pleurodesis

Mesothelioma
Arises from the mesothelium lining of the serous membrane of the pleura.
Also can occur on pericardium and peritoneum.

Abrasive irritation of the pleura. Partial stripping of parietal pleura.

Pleurectomy

Two ICCs on UWSD suction post procedure.

Highly malignant and aggressive. Usually attributable to asbestos exposure. 20-30 year development time. Locally infiltrative (uncommon to find malignancies).

Mesothelioma
Presents as pleural effusion pleural thickening.
S + S = SOB and a dry painful cough.

Pleural Surgery
Post-operative medical and physiotherapy management, complications, and contraindications/precautions are as for a lung resection surgery.

Treatment
Pleurectomy and debulking decortication (removal of pleura). Radiotherapy and/or chemotherapy.

Mediastinal Surgery
Mediastinoscopy
Video assisted surgery examining the mediastinum. Two small incisions are made superior to the sternoclavicular joints. Lymph node excision/biopsy. Examination of the trachea and great vessels. No ICC needed post-operatively as the pleural cavity is not entered.