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. Refer to Thoracic I Lecture Notes
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. Medications 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

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

51. Patient Preparation and Positioning
Shave is anterior and posterior, including anterior thorax, abdomen, bilateral groins, to knees, and the back
Prep is betadine soap (x 10 minutes if time permits) and betadine paint
Position is Left Posterolateral or thoracoabdominal

52. Posterior Lateral Position
Headrest
Axillary roll (prevent brachial plexus injury)
Beanbag (on bed before patient) with suction)
Padded armboard for lower arm
Padded mayo for upper arm or airplane arm sling
Padding under lower leg and pillows between knees and feet
Will expose left groin by slightly frog legging left leg

53. Draping Towel Drape over epidural catheter
Towels for perimeter of surgical site
Drying towels
Ioban Drape
Universal Drapes or CV Drape
(will expose left groin)

54. Equipment Bair hugger (lower body) Cell saver Bovie Extra suction
Beanbag
Defibrillator
Bypass machine (partial bypass usually employed)
Saline Warmer
Cryothermia Unit (available) surgeon choice

55. Instrumentation Chest tray Cardiovascular tray or Major Tray
Aortic clamps (surgeon choice)
Open Heart tray
Long medium and large clip appliers
Extra long instruments
Tube holder, allis, or edna clamps to secure bypass tubing
Chest Retractor of surgeon choice
Internal Defibrillator Paddles (external available) BOTH STERILE

56. Supplies Cautery Open heart specialty tray Major Basin Tray
Magnetic Drape
Miscellaneous prolene suture
Miscellaneous silk ties
Cutting free needles
Straight Woven Dacron Grafts (Miscellaneous sizes)
Femoral arterial and venous cannuli
Tourniquet snares or rommels
Vessel loops or umbilical tapes
Warm NS with antibiotic of choice
Heparinized saline
Topical hemostatic agents
Chest tubes

57. Procedure
Left groin exposure for atrial to femoral bypass by centrifugal pump for lower aortic vessel perfusion
Scalpel
Metz/cautery
Weitlander
Right angle
Vessel loops or umbilical tapes
Rommel or tourniquets (if using 18F robnel catheters will have cut short about three inches long during your set-up)
Patient is heparinized
Peripheral debakeys x 2
11 blade for arteriotomy, arterial cannula, tubing clamps (one for arterial cannula one will be on pump tubing)
Care is taken to NOT introduce air to line, may fill with NS slowly

58. Procedure
Vascular clamp or tonsils x 2 may be used to grab femoral vein, 11 blade venous cannula, tubing clamps (same as arterial sequence)
May secure cannuli with heavy silk sutures on cutting needles to patient’s skin

59. Procedure Incision made with #10 or #20 blade on #3 knife handle
Thoracotomy
Incision made with #10 or #20 blade on #3 knife handle
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 alexander 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

60. Procedure Place chest retractor of surgeon choice Dissect to aorta
May isolate with a long polyester tape or 1” penrose and clamp with a kelly
Will measure aorta to determine graft size needed
Obtain graft requested
Surgeon may request more heparin be given
Aorta is cross clamped with aortic clamps x 2
Aortic arteriotomy made with blade of choice on long knife handle
Aneurysm tissue and clot are removed

61. Procedure
Graft will be sewn in with prolene suture (should have what surgeon uses ready to go (this is a surgery where time is of the essence, you will be MOVING) proximal end then distal end
Clamps are removed, proximal first
Suture will be tied down after removal of clamp to allow aorta to vent (avoids air being left in aorta)
Surgeon may want his hands wet to tie
Protamine is given and patient is taken off bypass when stabilized
Have peripheral debakey clamps and tubing clamps ready, as well as prolene suture to close femoral artery and vein of surgeon choice

62. Procedure Irrigation of wounds
Femoral incision packed temporarily with antibiotic soaked raytex until closed
Chest tube placement with anchor sutures
Suction them out before connecting to Pleurevac
Chest will be closed as per thoracotomy incisions (periostium, muscles, fascia, subcutaneous, subcuticular)
Groin will be closed
Dressings per surgeon choice

63. Other Aortic Aneurysms
Type I
Type II
Type III
Discussion

64. Coronary Angioplasty (PTCA)
Discussion

65. Cell Salvage by Cell Saver

66. Cell Salvage Blood recovered during surgery and reinfused
Is directly suctioned, filtered, anticoagulated, and reinfused with little RBC damage
May be aspirated directly or via squeezed out sponges into a basin

67. Contraindications for Cell Saver
No hemostatics-may clot blood rendering it useless
Certain antibiotics (ex. Bacitracin)
may lyse cells, damaging them
No exposure to gastric contents, amniotic fluid, or fluid potentially containing cancerous cells
No local or systemic infection

68. Cardiopulmonary Bypass

69. Cardiopulmonary Bypass (CPB)
Method used to divert blood from the heart and lungs to provide a stationary bloodless field and optimal organ tissue function during heart surgeries
OPCAB (off pump coronary artery bypass) heart is beating and bleeding; visibility challenging; preferred for patient’s at risk of complications from CPB; must be to be ready to go on bypass if the patient cannot tolerate CABG procedure without having an arrested heart

70. CPB Process
Blood is removed from the right atrium via the inferior vena cava
Can be accomplished using inferior vena cava cannulation alone or with both SVC and IVC cannulation called bi-caval cannulation
Is routed to the CPB machine for oxygenation
Blood is returned via the aortic cannula or femoral arterial cannula to provide oxygenated blood to the patient’s body

71. CPB Machine Components
Oxygenator-removes carbon dioxide and delivers oxygen
Heat exchange coil-can heat or cool the blood
Pump-moves the blood
Filters-removes particulate, air, microemboli
Sensors-detect air bubbles, low oxygen saturation, and low blood volume collection

72. CPB Continued Heparin is given intravenously for anticoagulation
Cannuli and CPB circuits may also be heparin-bonded

73. CPB Perfusionist
Control many physiologic variables along with anesthesia and the surgeon:
Hemodilution ↓ blood viscosity =↓clot
HCT ↓ = ↓ clotting
Hypothermia = ↓ cellular oxygen consumption/demand = ↓ chance of organ damage
Core temperature is ↓ from 28 to 30° C

74. Summary A & P of descending aorta Pathology Diagnosis
Patient preparation (positioning, prep, draping)
Equipment, Instrumentation, Supplies
Thoracotomy for descending thoracic aneurysm (groin incision for femoral bypass)

75. Summary Continued Other Aortic Aneurysm Types (I, II, III) PTCA CPB
Cell Salvage