thoracic incisions presenter: dr anefu, n. e moderator:dr s. edaigbini ahmadu bello university...
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THORACIC INCISIONS
PRESENTER: DR ANEFU, N. EMODERATOR:DR S. EDAIGBINI
AHMADU BELLO UNIVERSITY TEACHING HOSPITAL,ZARIA,NIGERIA
OUTLINE
• INTRODUCTION• HISTORICAL PERSPECTIVES• ANATOMY OF THE CHEST
• BASIS• GENERAL PRINCIPLE• TYPES OF THORACIC INCISIONS• CURRENT TREND• FUTURE TREND• CONCLUTION
INTRODUCTION
• Incision;- Is a surgical wound made by a surgeon on the skin, with intension of gaining access to a lesion beneath or cavity.• Such wounds created anywhere on
the chest (thoracic) wall is thoracic incision
Historical perspective
• Development evolution thoracic incision is closely related to the development of thoracic surgery
• Used in ancient time for draining abscesses in the chest
Anatomy of the chest
CHEST WALL
• Bony rib cage;- manubrum, sternum, 12 pair of rib, coastal cartilage & thoracic vertebrae
• Soft tissue covering:- muscles, neurovascular bundles, other connective tissues
• Two aperture• Superior=root of the neck• Inferiorly=separated from abdominal cavity by
diaphragm
Lungs surface markings in the ribcage
• In spite of the large intra-thoracic space, separate pleural spaces &rigid- ribbed chest wall, its anatomy makes specific incision selection crucial to the ease & safety of a given thoracic procedure
• Respiration is still possible; due to the nature of the joint & muscular attachments
General principles
• Patient evaluation & clinical assessment– History, P.E, Lab & Radiological investigations-LFT,
Spirometric measurement,SPO2,CXR,– Performance score rating
• Patient education/counseling/consent• Start Chest physiotherapy• Peri-op monitoring/medications
Gen. principles
• Anaesthesia(G.A,double lumen ETT or single lung intubation)
• Analgesia( epidural catheters,intercostal nerve block)
• Surgery• Antibiotics prophylaxis• Follow-up
Analgesia CTU-ABUTH
• Taken very seriously• Intra-op =I.V pentazoxine• Post-op =Triple px– Opioid; pentazoxine– NSAIDs;diclofenac– Acetaminophen;PCM
Prophylactic Antibiotics-CTU
• Intra-op =3rd generation cephalosporin e.g ceftriaxone + metronidazole, repeated after 8hrs,
• Post-op =same extended X 2-3/7
Surgical principles
• To allow a successful surgical outcome• Adequate exposure • Preserve chest-wall function & appearance• Incision along langers line or positioned to
minimize visibility• Closure-rigid approximation & strict layered
closure
• Optimal approach depends onBony anatomyLocation & extent of pathologyLocation of the hilumObjective of the procedure
Chest drainage
Types of thoracic incisions
• Sternotomy• Thoracotomy• Axillary thoracotomy• Anterior mediastinotomy• Thoracoabdominal incision
Types cont…
• Bilateral Trans-sternal thoracotomy( clam-shell incision)• Extra-thoracic approaches to the
thorax
Sternotomy incisions
• Partial–Hemisternotomy (spares 6-8cm skin)
• Complete–Suprasternal notchxyphoid process–Cosmetically appealing type of incision
e.g inframammary (bikini type) incision
Median sternotomy incision
Sternal spreader applied
Median sternotomy
Indicationsexposure of ant. & middle mediastlower cervical proceduresTracheal resection& reconstruction
Indications
• Excision of thyroid masses & parathyroid adenomas• Excision of cervical oesophageal
tumours• Exposure of heart & great vessels• In cardiopulmonary bypass
Advantages• Quick to perform• Excellent exposure• Safe• Heals quickly• Less incisional pain
Disadvantages
• Many finds the vertical incision unsighty
• Gives limited exposure of the lower chest & posterior mediastinum
• May lead to post-op complications-unsteable sternum, infections
Technique
• Standard sternotomy
• Open sternotomy
• Re-operative sternotomy• Partial sternal split
CLOSURE:Interlucking wire suture technique
Less invasive sternotomy incisions
• Hemisternotomy- suprasternal notch,tee-off to the R at interspace 4 or xyphoid,tee-off,R, at interspace 2
• Full sternotomy with skin sparing• Bikini-type (inframammary) incision- cosmesis
Less invasive sternotomy incisions
Post-op care
• ICU MANAGEMENT/MONITORING
• O2 DELIVERY VIA NEBULIZER
• PAIN MANAGEMENT( I.Vanalgesics,Eidural nr block)
• PHYSIOTHERAPY
COMPLICATIONS
• Anaesthetic:- arrhythmias, laryngeal spasm
Specific :- Early;haemorrhage,injury to contiguous
structures, pneumothorax, haemothorax, Late;infection, empyema thoracis, post
surgery pain
Complications
• Mediastinitis (S.aureu31%,E.coli3%,enterococcus 2%)
• Sternal osteomyelitis• Brachial plexus injury,incidence:1.4-6.5%
Thoracotomy
• Standard thoracotomy incisions
• Defined arbitrarily in relation to the position of Latissismus dorsi muscle,which is laterally sited on the chest wall
Types of thoracotomy incisions
• Lateral • Anterior • Anterolateral• Posterolateral• Posterior• others
The numenclature for std thoracotomy incisions
Indications for posterolateral incision
• Standard thoracotomy incisions can be used for a wide range of surgical procedures involving;
• The Heart• Oesophagus• Mediastinum• Ipsilateral lung
Advantages
• Flexibility of the incision
• Wide range of intra-thoracic exposure
• Proven experience with these incisions has made them the standard thoracic incisional approach
Disadvantages
• Has potential for poor exposure ,if wrong interspace is chosen
• Unilateral hemithorax exposure• Incisional pain• Disability related to division of chest wall
muscles• Detrimental effect on pulmonary function
Technique (posterolateral)
• Induction using single/double lumen tube
• Appropriate monitoring• Anaesthesia-G.A+ETT
• Positioning –lateral decubitus position
• Cleaning/drapping
• Crescent or “lazy-S”incision, transversely• Dissected down & scapular retracted• Pleural space entered• Pleural/mediastinal drainage• Thoracotomy closure
Option for entering the pleural space after posterolateral thoracotomy
• Intercostal approach-incising i.c muscles
• Utilizing intercostal incision but to divide one or more ribs
• To resect a rib, enter through its periosteal bed
Anterior & anterolateral thoracotomy
• Indications• Has greater use historically• Used for pulmonary resection• Cardiac procedures• Management of mediastinal masses• Oesophageal pathology
Technique
• Monittoring
• Anaesthesia are same as posterolatral
• Supine position• Chest elevated at 30-45• Curved submammary incision, extended
laterally(anterolateral)
Anterolateral thoracotomy incisions
Lateral thoracotomy
• Within confines of latissimus dorsi
• Transverse incision
• 1-2cm inferior to the scapular
Complications
• Post thoracotomy incision pain• Wound infection• Wound dehiscence• Bronchopleural fistula-8%• Empyema thoracis-2.2%
Muscle-sparing thoracotomy
• Indications –As in std thoracotomy–Variant of std thoracotomy–Well established–Has less complications
Muscle sparing anterolateral thoracotomy incision
Advantages
• Less early post-op pains• Greater shoulder girdle strength• Most result in quick closure• Preserve chest wall muscle• Prevent chest wall deformity
Axillary thoracotomy
• Indications–1st rib disection–Apical bleb Dx–Mgt of spontaneous pneumothorax
with apical pleurectomy or pleurodesis–Staging of lung cancer
Patient positioning & incision for a vertical axillary incision
ADVANTAGES
• Small incision• Quickly performed• Muscle sparing• Cosmetically appealing• Ideal for pt with poor pulmonary
function
Disadv
• Limited exposure• Intercostobrachial nerve injury• Proximal lung thorcic nerve injury
Complications
• Very minimal
• Infection-0.7%
• Limited shoulder mobility-0.5%
Anterior mediastinotomy (chamberlain procedure)
• Used in scalene lymph node biopsy
• Exploratory thoracotomy
• In cases of lung cancer( inoperable)
Anterior mediastinotomy(Chamberlain)
Thoracosternotomy(Clam shell)
Left thoracoabdominal incision
• provides excellent exposures for procedures involving
• the spleen• Stomach• L hemidiaphragm • Aorta• lower oesophagus
Current trend
Towards minimally invasive proceduresThoracic- VATS (video asst thoracoscopic
surgery) e.g TEF LIGATIONCardiac- OPCAB (off-pump coronary art.
Bypass)MIDCAB (mini invas dir coron art.
Bypass)
• Endoscopic aortic/mitral valve replacement
Conclusion• Great achievement has been made in
cardiothorcic surgery• Emphasy now is on minimally
invasive/thoracoscopic procedures• We still use thorcic incisions due to
our own limitations• There is great hope for the future.
Thank you for listening
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