Thoracic Surgery

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  • 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.
  • 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.
  • 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.
  • tumor 3cm or less surrounded by lung or visceral pleura. endobronchial tumour proximal to a lobar bronchus
  • >3cm in greatest dimension. AS ABOVE +- obstructive pneumopathy of less than one lung
  • N1 – hilar LN, peribronchial homolateral LN – interlobar, lobar, segmental,or to both by direct extension.
  • T3 : apical tumour endobronchial t < 2cm from carina but NOT invading it atelactasis of lung direct extension to –chest wall or mediastinal pleura.
  • N2: Homolateral mediastinal LN OR subcarinal LN
  • T4:Macro OR histological extension to mediastinum, heart, large vessels, obstn to SVC, trachea (or compression), oesophagus (or compression) or CARINA INVASION or vertebral body, malignant pleural or pericardial effusion, recurrent nv. involv. OR multiple neoplasticnodules in the same lobe
  • Thoracic Surgery

    1. 1. Thoracic Surgery By Mike Poullis
    2. 2. Overview <ul><li>What is it ? </li></ul><ul><li>What do you need to know as a nurse on the ward ? </li></ul>
    3. 3. What do you need to know as a nurse on the ward ? <ul><li>Different pathologies </li></ul><ul><li>Different operations </li></ul><ul><li>Chest drains </li></ul><ul><li>Post operative care </li></ul>
    4. 4. Different pathologies <ul><li>Lung cancer </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Pleural effusions </li></ul><ul><li>Lung biopsies </li></ul><ul><li>Trauma </li></ul><ul><li>Oddities </li></ul>
    5. 5. Different operations <ul><li>Bronchoscopy (oesophagoscopy) </li></ul><ul><li>Mediasteinoscopy </li></ul><ul><li>Mediasteinotomy / Chamberlains </li></ul><ul><li>Thoracoscopy VATS </li></ul><ul><li>Mini thoracotomy </li></ul><ul><li>Full thoracotomy </li></ul><ul><li>Pneumonectomy / Lobectomy / Wedge </li></ul>
    6. 6. Anatomy <ul><li>Trachea </li></ul><ul><li>2 bronchi </li></ul><ul><li>2 Lungs </li></ul><ul><li>3 lobes on left </li></ul><ul><li>2 lobes on right </li></ul>
    7. 7. The Right Lung
    8. 8. The Left Lung
    9. 9. Bronchial system
    10. 10. Lung cancer <ul><li>Small cell </li></ul><ul><li>Non small cell </li></ul><ul><ul><li>Squamous </li></ul></ul><ul><ul><li>Adeno </li></ul></ul><ul><ul><li>Large cell </li></ul></ul><ul><ul><li>Undifferentiated </li></ul></ul>
    11. 11. Lung cancer <ul><li>Except for small cell carcinoma of the lung it is generally accepted that surgery is the most effective therapy for lung carcinoma </li></ul>
    12. 12. Small Cell Lung Cancer
    13. 13. Assessment of Patient <ul><li>Fitness for surgery </li></ul><ul><li>Operability of the tumour - Staging </li></ul>
    14. 14. Staging <ul><li>TNM </li></ul><ul><li>T size and position of tumour </li></ul><ul><li>N lymph node status </li></ul><ul><li>M metastasis </li></ul>
    15. 15. Stage IA of Lung Cancer
    16. 16. Stage IB of Lung Cancer
    17. 17. Stage IIA of Lung Cancer
    18. 18. Stage IIB of Lung Cancer
    19. 19. Stage IIIA of Lung Cancer
    20. 20. Stage IIIB of Lung Cancer
    21. 21. Stage IV of Lung Cancer IV: Any T, Any N, M1 Synchronous tumours in different lobes are M1
    22. 22. Fitness for Surgery <ul><li>Age </li></ul><ul><li>Pulmonary function </li></ul><ul><li>Cardiovascular function </li></ul><ul><li>Medical conditions </li></ul><ul><li>Nutritional Status </li></ul><ul><li>Performance status </li></ul>
    23. 23. Assessment of Operability <ul><li>CT scan </li></ul><ul><li>Bone scan </li></ul><ul><li>PET scan </li></ul><ul><li>Mediastinoscopy </li></ul><ul><li>Anterior Mediastinotomy </li></ul><ul><li>VATS </li></ul>
    24. 24. Bronchoscopy
    25. 25. oesophagoscopy
    26. 26. Mediastinoscopy
    27. 27. Mediastinotomy / Chamberlains
    28. 28. Mediastinotomy
    29. 29. Thoracoscopy
    30. 30. Video Assisted Thoracic Surgery
    31. 31. Thoracotomy
    32. 32. Thoracotomy - Posterolateral
    33. 33. Thoracotomy - Anterolateral
    34. 34. Mini thoracotomy <ul><li>Small incision thoracotomy </li></ul>
    35. 35. Lung Resection <ul><li>Pneumonectomy </li></ul><ul><li>Lobectomy </li></ul><ul><li>Wedge </li></ul>
    36. 36. Lung Resection – Pneumonectomy
    37. 37. Lung Resection – Lobectomy (RUL)
    38. 38. Lung Resection – Lobectomy (RUL)
    39. 39. Wedge resection
    40. 40. Pleural effusions <ul><li>Fluid in chest </li></ul><ul><li>Due to underlying cause </li></ul><ul><li>Usually malignant, but what ? </li></ul><ul><li>Drain for </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul>
    41. 41. Pneumothorax <ul><li>What is a pneumothorax ? </li></ul><ul><li>How do you treat them ? </li></ul><ul><li>Who requires surgery ? </li></ul><ul><li>What does surgery entail ? </li></ul><ul><ul><li>Thoracotomy </li></ul></ul><ul><ul><li>Sternotomy </li></ul></ul><ul><ul><li>Mini thoracotomy </li></ul></ul><ul><ul><li>VATS </li></ul></ul>
    42. 42. Lung biopsies <ul><li>Need tissue to diagnose “Interstitial lung disease” </li></ul>
    43. 43. Open lung biopsy
    44. 44. Chest drains <ul><li>What are they ? </li></ul><ul><li>Why use them ? </li></ul><ul><li>Suction and its role </li></ul><ul><li>What drain do you take out MARK IT </li></ul>
    45. 45. Rocket bottle
    46. 46. Cardiac drain system
    47. 47. Post operative care <ul><li>Blood pressure </li></ul><ul><li>Blood gases / saturation </li></ul><ul><li>Urine output </li></ul><ul><li>Bleeding </li></ul><ul><li>Sputum </li></ul><ul><li>Analgesia </li></ul>

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