1. Intermediate Format: Cervical Rib Resection
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
STST p. 877: Thoracic Outlet Syndrome refers to a variety of symptoms associated with the structures listed above…they follow a path to the upper extremity thru the cervicoaxillary canal. Usually compression of the neurovascular bundle occurs in the proximal portion of the canal. What symptoms does the pt have? Arm pain, vasomotor symptoms, parasthesia of fingers, atrophy of hand muscles. Some causes of thoracic outlet syndrome: drooping shoulder girdle, an adventitious fibrous band, cervical rib, continual hyperabduction of the arm, or most commonly, an abnormal first rib.
There are 3 classifications of Thoracic Outlet Syndrome: a. Arterial thoracic b. Neurological c. Venous thoracic.
Arterial: subclavian artery compression which results in severe ischemia of arm
Neurological: often a result of hyperextension of the neck or upper back and causes symptoms of throbbing pain in the extremity and paraesthesia of the neck and arms.
Venous thoracic: involves external compression of the axillosubclavian vein Symptoms include pain, cyanosis, and arm swelling.
Fuller (4th ed) p. 823 : the various names given to thoracic outlet syndrome usually refer to the compression of the neurovascular structures to the upper extremities.
Thoracic outlet syndrome occurs when the brachial plexus and the subclavian vein or artery are compressed as they pass from the neck into the upper extremity (in the region between the thoracic outlet and the insertion of the pectoralis minor muscle). Structures that may be compressed: first rib and clavicle, the pectoralis minor tendon, cervical rib. Cervical ribs are rare anatomically, occurring in about 1% of the population—they are usually bilateral. When present, they are removed during the procedure, which often includes removal of the first rib. To prevent recurrent symptoms, complete rib resection is necessary.

7. From http://tellmeabouttos.com/surgery1.html

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
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
Sarot bronchus clamp
Davidson scapula retractor

14. Allison Lung Retractor
Lovelace lung grasping forceps

15. Thoracic Instruments Alexander p. 1053 Overholt elevators # 1, 2, 3
Langenback periosteal elevator
Matson rib elevator and stripper
Alexander costal periosteotome
Doyen rib raspatories, Rt and Lt
Lebsche sternal knife
Sternal saw
Sauerbruch rib shear
Giertz (first rib) guillotine
Bethune rib shears
Stille-Luer bone rongeur
Sauerbruch rib rongeur
Sille-Liston bone-cutting forceps, straight
Bailey rib spreader
Davidson scapula retractor
Fineocheitto rib retractor
Burford rib retractor wth 2 sets of detachable blades
Bailey rib retractor

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
MAVCC Unit 12

22. For visualization of the pleurae, lower and middle mediastinum, and pericardium, the surgeon would need a:
Thorascope
Mediastinoscope
Bronchoscope
Laryngoscope
Ans: A. A thoroscope is inserted between the ribes into the chest cavity to view the lungs, pleurae, pericardium, and lower and middle mediastinum. Visualization is limted to the upper medistinum with a mediastinoscopy. The laryngoscope facilitates visualization inside the larynx, and the bronchoscope is used to visualize inside the bronchi or the trachea.

23. Percutaneous Transluminal Coronary Angioplasty
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
A. Chest tubes are inserted and connected to a water-seal drainage system whenever the pleural space is entered. Lobectomy, removal of a lobe of the lung, requires entry into the pleural cavity. A Scalene Node Biopsy is the removal of tissue from above the clavicle. PTCA is a procedure performed in the cardiac catheterization laboratory where a balloon catheter is inserted into the femoral or brachial artery, advanced to the coronary arteries, and used to dilate an atherosclerotic vessel. A pacemaker generator is implanted in the subcutaneous tissue with leads passed through a vein to the heart.

24. Which of the following retractors would be most useful in a posteriolateral Thoracotomy?
Balfour
O’Sullivan-O’Connor
Davidson scapula
Weitlaner
Ans C. The Davidson scapula retractor is needed to raise the scapula when a posterolateral Thoracotomy is performed. The Balfour is designed for a vertical incision in the abdomen, the O’Sullivan-O’Connor for a transverse incision in the abdomen, and the Weitlaner for superficial surgery.

25. Wedge Resection of the Lung Decortication of the Lung
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
Ans B. Bleeding is to be expected during a decortication of lung as the fibrosed tissue is peeled off. Little bleeding occurs when staples are used to remove lung tissue. With closure of a patent ductus arteriosus on an infant, bleeding should be minimal.

26. The removal of a lung is referred to as a/an: Pneumonectomy
Endarterectomy
Blalock-Hanlon operation
Cryoablation
Ans A Surgical removal of a lung, Pneumonectomy, is performed for extensive lung disease or cancer.

27. Cervical Rib Resection is performed to relieve:
Thoracic Inlet Syndrome
Thoracic Outlet Syndrome
Adult Respiratory Distress Syndrome
pneumothorax
Ans B. Cervical Rib Resection is performed to relieve compression of the brachial plexus neurovascular bundle, a condition called Thoracic Outlet Syndrome.

28. Pulmonary Decortication
The procedure performed to remove a fibrous covering from the lung following empyema formation is:
Aneurysmectomy
Thoracostomy
Thymectomy
Pulmonary Decortication
Ans A. Pulmonary decortication is the surgical procedure where the fibrous covering over the lung resulting from empyema (pus formation in the pleural space) is removed to permit re-expansion of an entrapped lung.

29. Evacuate air/re-establish negative pressure
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
Ans: A. When two chest tubes are placed into the pleural space, the uppermost tube is used to evacuate air. Thelower chest tube is used to evacuate fluids, such as blood. The removal of air and fluid collection from the pleural space and re-establishment of negative pressure is necessary to inflate the lungs for proper respiration.

30. When a rib is removed, the remaining bone edges are trimmed with a:
Doyen raspatory
Bethune shear
Lebsche knife
Stille-Luer rongeur
Ans D. A Sille-Luer rongeur is used to trim the edges of a rib following rib resection.

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
Ans C. When transporting a patient with closed water seal drainage, chest tube clamps should always accompany the patient for use in the event that the tube separates from the drainage device. This separation will permit air to enter the pleural space causing pneumothorax and can be life threatening. The drainage device should be kept at or below the level of the patient’s chest to promote proper drainage. Chest tubes are only clamped when ordered by the physician or in case of separation of the drainage device from the chest tube. Patients with chest tubes should be placed in the semi-Fowler (sitting) position to promote and ease respiratory effort.

32. Mediastinoscopy is usually performed with the patient in what position?
Lateral
Sims
Dorsal recumbent
prone
Ans C Medistinoscopy is usually performed with the patient in dorsal recumbent or semi-Fowler position with the neck hyperextended for access to the area just above the suprasternal notch.

33. Removal of air or fluid from the pleural cavity via needle aspiration is:
Thoracoscopy
Thoracotomy
Hemocentesis
Thoracentesis
Ans D. Thoracentesis is the procedure performed to remove air or fluid from the pleural space. It is performed by inserting a large gauge (13 g or 15 g) 3 inch needle into the pleural space by passing the needle through an intercostal space. A 60-cc syringe is used to withdraw the air or fluid. Once the needle is removed from the chest wall, an air-occlusive dressing is applied.