Cardiothoracic Surgery

I. Definition Cardiothoracic surgery is the surgery concerned with all structure that lie within the thoracic cage like, ribs, lungs, heart, esophagus… Cardiothoracic surgery is the surgery concerned with all structure that lie within the thoracic cage like, ribs, lungs, heart, esophagus…

II. Types A. Cardiac Operation : 1)Closed Cardiac, as ( closed mitral valvotomy ‘CMV’ and closure of patent ductus arteriosus PDA ) 2)Open Cardiac :Using cardiopulmonary by pass machine as in repair of congenital heart disease and coronary heart by pass graft..

: B. Non Cardiac Operation: As lung resection (pneumonectomy, lobectomy ) As lung resection (pneumonectomy, lobectomy ) and thymectomy, and thymectomy,

III. Incision : Thoracotomy: Thoracotomy: 1- Definition : It is an incision into the thoracic cavity to gain access to lungs, bronchi, heart and oesophagus. 1- Definition : It is an incision into the thoracic cavity to gain access to lungs, bronchi, heart and oesophagus.

2-Types Lateral Incision : A. Antero Lateral. B. Postero Lateral. Anterior Incision A.Transverse. B. Vertical.

Anterolateral: - Start close to midline in front, follows along the line of a rib below the breast to the posterior axillary line. - Used for approaching anterior thoracic structures, as in closed mitral valvotomy and pleurectomy. -The muscle cut are pectoralis major and minor, serratus anterior, internal and external intercostals. -The intercostals space is entered through the upper border of the six or the fifth rib.

Posterolateral -Follow the vertebral border of the scapula and the line of a rib ( 5,6,7 or 8 ). -Used in dealing with posterior structures as in lung operations. -The muscle cut are trapezius, latissimus dorsi, rhomboids, serratus anterior, intercostals and erector spinae. -A rib may be removed, so that when other ribs are retracted there is sufficient space for access to the thorax

Transverse. - Submammary and bilateral, through the fourth intercostal space and transversely divide the sternum. - The pectoralis major is divided together with internal and external intercostals.

Vertical -The incision passes through the meeting of the two pectoralis major in front of the sternum and opening of the linea alba (meeting of the two recti) then sawing of the sternum. -Used for doing more than 95% of open heart surgery and in thymectomy.

IV. Drainage System: 1- Pleural cavity is a closed space with negative pressure -3 to -5 to prevent collapse of the lung. 1- Pleural cavity is a closed space with negative pressure -3 to -5 to prevent collapse of the lung. 2- Pericardial sac protect the heart. 2- Pericardial sac protect the heart. Any collection of fluid or air will cause impairment of respiration and cardiac function in proportional to collected amount. Any collection of fluid or air will cause impairment of respiration and cardiac function in proportional to collected amount. - Drainage : Removal of unwanted fluid and air from the thorax following surgery or trauma.

*Types: A.Closed : -Simple air – tight system is used to allow drain and prevent air entry. -Rubber tube introduced into the interthoracic space and fixed with suture. -The other end connected to calibrated glass tube which terminates under the water. - The oscillations of water inside the under water pipe represents the respiratory movement. B. Opened : A tube may be inserted into a pocket of pus which then drain out onto a dressing. A tube may be inserted into a pocket of pus which then drain out onto a dressing.

* Causes of intra-thoracic Collection 1)After any thoracic operation. 2)Traumatic 3)Inflammatory. 4)Neoplastic.

*What will be drained 1)Air : Pneumo -thorax. 2)Blood : Haemo - thorax. 3)Serous : Hydro – thorax 4)Pus : Pyo – Thorax.

*Area of drain: 1- Pleural. 2- Mediastinal. A) Pericardial. A) Pericardial. B) Retrosternal. B) Retrosternal.

*Points to be noted: 1.Amount and type of drainage: -200 ml in the first 24 hours. -Air can be seen as a bubbles in the water. -If bubbles stop, it may because of : a) all air has been removed. a) all air has been removed. b) the tube is locked. b) the tube is locked.

2- Swing of water: -The level of water fall in inspiration and rises in expiration. -If swing stop: a) Lung is fully expanded. a) Lung is fully expanded. b) tube is blocked. b) tube is blocked.

3-Suction: -Pull the water level in the bottle up Creating a negative pressure Creating a negative pressure Pull the water in the tube down Pull the water in the tube down Creating suction effect on the air or fluid in the pleural cavity. Creating suction effect on the air or fluid in the pleural cavity.

4- The Tubes : Fixed to the thoracic wall by a stitch and should not detached from the patient or from the bottle. Fixed to the thoracic wall by a stitch and should not detached from the patient or from the bottle.

5-Clamps: Used when the bottle is to be changed or removed. Used when the bottle is to be changed or removed.

*When remove the drain When the drained fluid is completely clear and its amount is less than 300 cc per day. When the drained fluid is completely clear and its amount is less than 300 cc per day.