THORACIC SURGERY LECTURES

Dr. Muthanna AlassalConsultant Thoracic & Vascular Surgeon

Costo –phrenic angle is the angle between the costal &diaphragmatic pleura.Cardio –phrenic angle is the angle between the heart &diaphragmatic pleuraInferior pulmonary ligament is the anterior & posterior reflection of the pleura between the root of the lung & the diaphragmatic surface

The function of the pleura is to maintain the environment of the pleural space in which the lung is function.

The bronchial arteries originate from the aorta or the intercostals arteries . Pulmonary veins drain into the left atrium .No bronchial veins. The Lymph nodes found along the lobar branches are termed(hilar LN).There are also Tracheal and tracheo-bronchial LN.Phrenic nerve located anteriorly while the vagus nerve located posteriorly in the thoracic cavity.

 

The Trachea is a fibro muscular tube (10-12 cm) in length and (13-22 mm) in width. Supported laterally and ventrally by (16-22) U-shaped hyaline cartilages . The trachea originates at the level of the cricoid cartilage down to its bifurcation at the level of the sternal angle where it divided into right and left main bronchi .The spur at the bifurcation is termed the (Carina) . The right main bronchus is (12-16 mm) in diameter ,the left is ( 10-16 mm) in diameter .The right main bronchus deviates less from the axis of trachea than the left ,this explains why foreign body is more common in the right main bronchus .The main bronchi are divided into the segmental bronchi which end into the terminal bronchiole which divided into the respiratory bronchiole which terminate into the alveoli.

Clinical manifestations of respiratory dieases

1-Cough 2-Dyspnea or breathlessness , it is an unpleasant

subjective awareness of the sensation of breathing. 3-Chest pain in diseases with pleural or chest wall

involvement. 4-Haemoptysis.

Investigations-: 1-Chest X-Ray

2-CT chest 3-MRI mediastinum

4-US chest to detect any effusion. 5-Pleural aspiration.

6-Bronchoscopy flexible or rigid.

Pulmonary Function Tests 1-Tidal Volume (TV)

Is the amount of air inspired or expired per single breath.  

2-Functional residual Capacity (FRC) The amount of gas contained in the lung at the end of quiet expiration.

 3-Inspiratory reserve volume-;

Is reached when the patient makes a maximum inspiration and increased the lung volume ,compared with that contained at the peak tidal volume.

 4-Vital capacity-:

The volume expired from maximal inspiration to maximal expiration. 

5-residual volume-: Is the amount of air remaining in the lung after maximal expiration.

6-FEV1 Is the volume of air expired in one second.

THE CHEST WALL.lnk

THE CHEST WALLDr. Muthanna Al-assal

Thoracic & Cardiovascular Surgeon

Aljirahat hospital /Medical CityLecturer at Alkindy medical school

Baghdad Unv.

diseases of the chest wallCongenital abnormalities are often incidental findings of CXR (bifid rib) but there are some important exceptions.The Cervical rib. This rib is often a fibrous band originating from the seventh cervical vertebra and inserting onto the first thoracic rib.

It may be asymptomatic but because the axillary artery and brachial course over it a variety of symptoms may occur. lower trunk of the plexus (mainly T1) is cornd leading to wasting of the interossei and altered sensation in the T1 distribution.

Compression of the axillary artery may result in a poststenotic dilatation.

with thrombus and embolus formation. Treatment is by division or removal of the rib by a supraclavicular,posterior or axillary approach.Pectus excavatum.

Pectus carinatum (pigeon chest).

Pectus excavatum Is the most common congenital deformity of

the anterior wall of the chest, in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest. It is usually present at birth and progresses during the time of rapid bone growth in the early teenage years, but in rare cases does

not appear until the onset of puberty .

Pectus excavatum is sometimes considered to be cosmetic, however it can impair

cardiac and respiratory function, and cause pain in the chest and back. People with the

abnormality may experience negative psychosocial effects, and avoid activities

that expose the chest.

Signs and symptoms

The hallmark of the condition is a -sunken appearance of the sternum . -The heart is displaced (and rotated.(

-Mitral valve prolapse may also be present . -Base lung capacity is decreased.

TreatmentMedical treatment :- which is limited.

Surgery :-Before operation several tests should be performed. These include-:

- CT scan. - Pulmonary function tests.

- Cardiology exams (such as auscultation ECGs, and Echocardiography).

Sx=Ravitch op.(sternal turn over), correction osteotomy ,&

Nuss procedure.

Pectus carinatum (pigeon breast) .

Less common. It consist of protrusion of the sternum caused

by an upward curve in the lower costal cartilages .

Generally the 4th to 8th cartilages pushing the sternum forward.…

Surgery is the treatment of choice in the symptomatic patients.

Tumours of the chest wallThese can be tumours of any component of the chest wall, i.e. bone, cartilage and soft tissue .

The most common tumour is that of the rib (chondroma or osteoma) and presentation is as a hard swelling over the rib .

Malignant tumours are painful end destructive and require wide resection. Even so, there is a tendency for tumours to recur and histological classification is difficult .Tumours of the sternum are usually malignant.

Lung and pleural tumours may involve ribs and destroy them.Most lesions may be seen on a chest radiograph but occasionally CTscan or isotope bone scanning is required.

Excision biopsy is often the best way to deal with a rib neoplasm because the differentiation between benign and malignant growths may be difficult. This avoids the risk of ‘spillage’ and tumour seeding in the wound of an incision biopsy .

If a major resection is to be planned, it may be preferable to know the nature of the lesion before surgery.

The principle of surgery is to remove the rib along with the rib immediately above and below, and for a length well from the margins of the tumour .

Reconstruction is possible using a prosthetic material (Marlex or acrylic mesh) to provide some stability to the chest wall. Myocutaneous flaps are occasionally employed to more extensive tissue defects and therefore prior ;discussion with a plastic and reconstructive surgeon may be useful.

For lesions that are not amenable to resection, chemotherapy or radiotherapy, although unlikely to be curative, may provide symptomatic relief.

Infections of the chest wall These are unusual but may occur following osteo

myelitis of the underlying rib . An empyema of the underlying thoracic cavity

may discharge through the chest wall (empyema necessitans) leaving a chronic sinus.

Sterile pus should arouse the clinician that tuberculosis is present .

Treatment of the chest wall infection depends on adequate treatment of the underlying condition

THANK YOU

Diseases of the pleura

Is the accumulation of air inside the pleural cavity , occurring without any known etiology .More in males ,more on the right side .It can be bilateral

1-Spontaneous pneumothorax

Causes 1- Ruptured pulmonary bleb.2-Ruptured of a cystic defect in the pleura.3-Teared visceral pleura 4-No cause can be demonstrated in (15-20%).Complications:-1-pleural effusion2-empyema 3-tension pneumothorax which leads to mediastinal shift &circulatory collapse.4-Respiratory failure in elderly patient with COAD.

Treatment-:

1-Bed rest ,O2 administration &observation in limited pneumothorax.2-Aspiration

3-Chest tube (thoracostomy tube or ICD intercostal drain in a safety triangle which is bounded by pectoralis muscle anteriorly &lattismus muscle posteriorly and the superior border of the nipple.in the fifth intercostal space just anterior to the mid axillary line to avoid the long thoracic nerve.

4-bronchoscopy is indicated if the lung fail to expand 5-Chemical pleurodesis.by injecting sclerosing agent as Tetra cycline

6-Surgery pleurectomy by thoracotomy or thoracoscopically if the lung fail to re expand

2-Spontaneous haemothorax

Is the presence of blood inside the pleural cavity Causes-:

1-pulmonary causes ----------TB , AV malformation2-pleural causes -----------torn vascular adhesion

3-pulmonary malignancy ….primary or metastatic 4-blood dyscrasia ……………..hemophilia

5-abdominal pathology ……….. haemo peritoneum6-thoracic causes ………ruptured great vessels

Clinical featuresdyspnea , chest pain ,syncopesigns of hypovolaemic shock blood inside the pleural cavity may leads to deposition of fibrin on the pleural surface leading to fibrosis (trapped lung syndrome).

Treatment 1-Resuscitation

2-Tube thoracostomy 3-May needs thoracotomy if excessive bleeding

initial bleeding more than 1.5 literOr continuous bleeding more than 200 ml/hour for more than 4 hours •