1. Thoracic Surgery By
Mike Poullis

2. Overview
What is it ?
What do you need to know as a nurse on the ward ?

3. What do you need to know as a nurse on the ward ?
Different pathologies
Different operations
Chest drains
Post operative care

4. Different pathologies
Lung cancer
Pneumothorax
Pleural effusions
Lung biopsies
Trauma
Oddities

5. Different operations Bronchoscopy (oesophagoscopy) Mediasteinoscopy
Mediasteinotomy / Chamberlains
Thoracoscopy VATS
Mini thoracotomy
Full thoracotomy
Pneumonectomy / Lobectomy / Wedge

6. Anatomy
Trachea
2 bronchi
2 Lungs
2 lobes on left
3 lobes on right

7. The Right Lung
A brief review of the lobar architecture of both lungs is necessary to better understand the bronchial and segmental anatomy presented later in detail.
Right Lung: right upper lobe (RUL) occupies the upper 1/3 of the right lung. Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib. The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum. The right lower lobe (RLL) is the largest of all three lobes, separated from the others by the major fissure. Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Review of the lateral plain film surprisingly shows the superior extent of the RLL; there is considerable overlap between the more anterosuperiorly located RUL and the RLL. Similarly, the deep posterior gutters extend considerably inferiorly; with full inspiration, the lower lobe can extend may as low as L2, becoming superimposed over the upper poles of the kidneys. Grossly, these lobes can be separated from one another by two fissures which anatomically correspond to the visceral pleural surfaces of those lobes from which they are formed. The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes. The minor fissure is oriented horizontally, extending ventrally from the chest wall, and extending posteriorly to meet the major fissure. Generally, the location of the minor fissure is approximately at the level of the fourth vertebral body and crosses the right sixth rib in the midaxillary line. The right major fissure is more expansive in size than the minor fissure, separating the right upper and middle lobes from the larger right lower lobe. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body. The major fissure extends anteroinferiorly, intersecting the diaphragm at the anterior cardiophrenic angle.

8. The Left Lung
The lobar architecture of the left lung is slightly different than the right. Because there is no defined left minor fissure, there are only two lobes on the left; left upper and left lower lobes. These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.
It is important to understand that in most individuals, interlobar fissures are usually not completely formed; in some individuals there may be complete absence of a fissure thus losing the demarcation between lobes on gross examination. Review of autopsy materials have revealed that complete development of the minor fissure is seen less than 20% of the time. Similarly, complete development of the right major fissure is seen in less than 30% of the population. Conversely, approximately 1% of individuals have complete absence of an interlobar fissure. Furthermore, at the level of the hilum (or pulmonary root) the pulmonary lobes are not routinely separated from one another, again due to incomplete development of the interlobar fissures medially.
In general, fissures are not readily identifiable on plain films, with only small portions typically visualized at best. This is because fissures which are composed of only two layers of visceral pleura, may not present a significant radiographic interface and will not produce a shadow. However, if there is fluid within the pleural space or if the visceral pleura is thickened, fissures may be seen in their entirety.
Neither the major or minor fissures are definitively demonstrated on CT. In fact, because of the axial orientation of the right minor fissure, exact delineation of the border between the right middle and upper lobes is almost impossible on CT. The approximate locations of the major fissures are inferred from areas of relatively sparse pulmonary vascularity. While separation of pulmonary lobes solely on the basis of fissure location remains rather difficult even on CT, fissural anatomy is not helpful at all in the identification of bronchopulmonary segments. For these reasons, an understanding of bronchial anatomy is the easiest and most reliable way to identify individual pulmonary segments.

9. Bronchial system
It is now time to turn our attention to the specific bronchial supply for each lobe and segment. Individual segmental bronchi are named after the particular pulmonary segment which it supplies, and are given numerical designations, using the letter "B" for bronchus. For example, the B10 bronchus supplies the S10 segment (posterior basal segment). B10 can also be referred to more formally as the posterior basal bronchus. It should be pointed out that considerable anatomical variation may exist between individuals. Often, two or three bronchi may arise from a common trunk rather than having separate and discrete origins.

10. Compartments of the chest

11. Lung cancer Small cell Non small cell Squamous Adeno Large cell
Undifferentiated

12. Lung cancer
Except for small cell carcinoma of the lung it is generally accepted that surgery is the most effective therapy for lung carcinoma

13. Small Cell Lung Cancer

14. Assessment of Patient Fitness for surgery
Operability of the tumour - Staging

15. Staging TNM T size and position of tumour N lymph node status
M metastasis

16. 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)

18. Survival Stage 5 year Survival 1 A, B 60-85% II A,B 40-60% III A
10-40%
III B
<10% IV
<5%

19. Fitness for Surgery Age Pulmonary function Cardiovascular function
Medical conditions
Nutritional Status
Performance status

20. Assessment of Operability
CT scan
Bone scan
PET scan
Mediastinoscopy
Anterior Mediastinotomy
VATS

21. Pleural effusions Fluid in chest Due to underlying cause
Usually malignant, but what ?
Drain for
Symptoms
Diagnosis

23. Pneumothorax What is a pneumothorax ? How do you treat them ?
Who requires surgery ?
What does surgery entail ?
Thoracotomy
Sternotomy
Mini thoracotomy
VATS

25. Lung biopsies
Need tissue to diagnose “Interstitial lung disease”

26. Bronchoscopy

27. oesophagoscopy

28. Mediastinoscopy

29. Mediastinoscopy

30. Mediastinotomy / Chamberlains

31. Mediastinotomy

32. Thoracoscopy

33. Video Assisted Thoracic Surgery

34. Thoracotomy
Posterolateral
Lateral
Anterolateral
Mini thoracotomy

35. Thoracotomy - Posterolateral

36. Thoracotomy - Anterolateral

37. Mini thoracotomy
Small incision thoracotomy

38. Lung Resection
Pneumonectomy
Lobectomy
Wedge

39. Lung Resection – Pneumonectomy
Intrapericardial
Extrapericardial
No reserve
Sputum
pO2
Fluid balance
Infiltrates
Temperature AF

40. Lung Resection – Lobectomy
3 Lobes on RT
RUL
RML
RLL
(not RUL & RLL)
2 lobes on LT
LUL
LLL

41. Wedge resection

42. Chest drains What are they ? Why use them ? Suction and its role
What drain do you take out MARK IT

44. 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

45. 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

46. Chest Drain

47. Suction What does it do? Air or blood drains more easily out of chest
Makes the external pressure negative
Air or blood drains more easily out of chest
Dangers
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

48. 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

49. Drain Removal and Timing of Drain Removal

50. 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

51. On Inspiration Easy to hold breath on maximal inspiration
Pleural pressure most negative therefore air more likely to move into pleural space

52. Valsalva Manoeuvre Forced expiration against a closed glottis
Creates a positive intrapleural pressure
Easy for patient to hold

53. Post operative care Blood pressure Blood gases / saturation
Urine output
Bleeding
Sputum
Analgesia

54. Any Questions ?