Thoracic Surgery

By

Mike Poullis

Overview

• What is it ?

• What do you need to know as a nurse on the ward ?

What do you need to know as a nurse on the ward ?

• Different pathologies

• Different operations

• Chest drains

• Post operative care

Different pathologies

• Lung cancer• Pneumothorax• Pleural effusions• Lung biopsies

• Trauma• Oddities

Different operations• Bronchoscopy (oesophagoscopy)• Mediasteinoscopy• Mediasteinotomy / Chamberlains• Thoracoscopy VATS• Mini thoracotomy• Full thoracotomy

• Pneumonectomy / Lobectomy / Wedge

Anatomy

• Trachea

• 2 bronchi

• 2 Lungs

• 2 lobes on left

• 3 lobes on right

The Right Lung

The Left Lung

Bronchial system

Compartments of the chest

Lung cancer

• Small cell

• Non small cell– Squamous– Adeno– Large cell– Undifferentiated

Lung cancer

• Except for small cell carcinoma of the lung it is generally accepted that surgery is the most effective therapy for lung carcinoma

Small Cell Lung Cancer

Assessment of Patient

• Fitness for surgery

• Operability of the tumour - Staging

Staging

• TNM

• T size and position of tumour

• N lymph node status

• M metastasis

Stages• Stage Grouping—TNM Subsets

• Stage 0 (TisN0M0)• Stage IA (T1N0M0)• Stage IB (T2N0M0)• Stage IIA (T1N1M0)• Stage IIB (T2N1M0, T3N0M0)• Stage IIIA (T3N1M0), (T(1–3)N2M0)• Stage IIIB (T4, Any N, M0) (Any T, N3M0)• Stage IV (Any T, Any N, M1)

Survival

Stage 5 year Survival

1 A, B 60-85%

II A,B 40-60%

III A 10-40%

III B <10%

IV <5%

Fitness for Surgery

• Age

• Pulmonary function

• Cardiovascular function

• Medical conditions

• Nutritional Status

• Performance status

Assessment of Operability

• CT scan

• Bone scan

• PET scan

• Mediastinoscopy

• Anterior Mediastinotomy

• VATS

Pleural effusions

• Fluid in chest

• Due to underlying cause

• Usually malignant, but what ?

• Drain for– Symptoms– Diagnosis

Pneumothorax

• What is a pneumothorax ?• How do you treat them ?• Who requires surgery ?• What does surgery entail ?

– Thoracotomy– Sternotomy– Mini thoracotomy– VATS

Lung biopsies

• Need tissue to diagnose “Interstitial lung disease”

Bronchoscopy

oesophagoscopy

Mediastinoscopy

Mediastinoscopy

Mediastinotomy / Chamberlains

Mediastinotomy

Thoracoscopy

Video Assisted Thoracic Surgery

Thoracotomy

Posterolateral

Lateral

Anterolateral

Mini thoracotomy

Thoracotomy - Posterolateral

Thoracotomy - Anterolateral

Mini thoracotomy

• Small incision thoracotomy

Lung Resection

• Pneumonectomy

• Lobectomy

• Wedge

Lung Resection – Pneumonectomy

Intrapericardial

Extrapericardial

No reserveSputumpO2Fluid balanceInfiltratesTemperatureAF

Lung Resection – Lobectomy

3 Lobes on RTRULRMLRLL(not RUL & RLL)

2 lobes on LTLULLLL

Wedge resection

Chest drains

• What are they ?

• Why use them ?

• Suction and its role

• What drain do you take out MARK IT

Function

• Conduit to remove fluid or air from the pleural

or pericardial spaces

• The fluid may be blood, pus or pleural effusion

• Allow the lungs and heart to work unrestricted

Spaces That Need Draining Following Thoracic Surgery

• Only a single pleural cavity opened

• Air and blood may collect in the space

• Two drains– Apical drain – Air– Basal drain – Blood

• Traditionally apical drain is placed anteriorly and basal drain at the back

Chest Drain

Suction

• What does it do?– Makes the external pressure negative

• Air or blood drains more easily out of chestDangers• If on to high tissues may get sucked into the

drain damaging them• If connected but not on similar effect to

clamping the drains • BEWARE PNEUMONECTOMY

Does and Don’ts of Chest Drains

• Do not clamp a functioning drain as this can lead to a tamponade or a tension pneumothorax

• If becomes disconnected, reconnect and ask patient to cough

• Always keep drain below level of patient– If raised above patient the contents may siphon

back into the chest

Drain Removaland

Timing of Drain Removal

On Expiration

• Pleural pressures at their highest

– But still less than atmospheric pressure

• Difficult to hold breath at full expiration

• Natural reaction to pain is to take a deep

breath in

On Inspiration

• Easy to hold breath on maximal inspiration

• Pleural pressure most negative therefore air

more likely to move into pleural space

Valsalva Manoeuvre

• Forced expiration against a closed glottis

• Creates a positive intrapleural pressure

• Easy for patient to hold

Post operative care

• Blood pressure

• Blood gases / saturation

• Urine output

• Bleeding

• Sputum

• Analgesia

Any Questions ?