UG SERIES SURGERY SHORT NOTE CHEST

1. THORAX pt.2
NUR FARRA NAJWA
08201510035

2. 1.Presentation On Lung Diseases
2.Malignant Lung Tumor
3.Benign Lung Tumor
4.Chest Trauma
5.Chest Wall

3. PRESENTATION OF LUNG DISEASE
1. HAEMOPTYSIS
2. AIRWAY OBSTRUCTION
3. INHALED FOREIGN BODIES

4. 1. HAEMOPTYSIS

5. Repeated
haemoptysis
Investigation Haemoptysis from
trauma
Common
associated chest
symptoms
• Carcinoma
• Bronchiectasis
• Carcinoid
tumours
• Some infections
• Severe mitral
stenosis (rare)
• Chest
radiography
• Bronchoscopy
• Lung contusion
• Injury to a major
airway.
• Treatment
depends on the
underlying
cause.
• Cough with or
without sputum
• Pain
• Breathlessness
• Hoarseness
• Fatigue
• Loss of weight
• Palpitation (atrial
fibrillation)

6. INVESTIGATION
Bronchoscopy
Rigid
Flexible
Other
Percutaneous
needle biopsy
Endobronchial
ultrasound
Open-lung
biopsy

7. BRONCHOSCOPY

10. Flexible Bronchoscopy
• Performed with the patient awake
• Oropharynx anaesthetised with topical lignocaine
• The bronchoscope is passed into the nose or mouth and
through the vocal folds under direct vision.
• Scope is flexible, its tip can be directed into the
segmental bronchi with ease.
• Tissue and sputum samples may be obtained for
diagnostic purposes.
• Greater range of movement
• Biopsies are
– Relatively small and suction limited

11. Rigid Bronchoscopy
• General anaesthesia required.
• Ideal for therapeutic manoeuvres
– Removal of foreign bodies
– Aspiration of blood and thick secretions
– Intraluminal surgery
• Essential
– Continuous electrocardiography (ECG) and pulse
oximetry monitoring

12. Technique
• Operator standing behind the patient and lifting the maxilla by the upper
teeth, using the middle finger and forefinger of the left hand.
• The bronchoscope rests on the left thumb as it is introduced over the
tongue in the midline.
• Care must be taken not to trap the lips or tongue between the teeth and
the bronchoscope, and the fulcrum should be the left thumb and not the
teeth.
• The bronchoscope is passed under direct vision into the oropharynx,
behind the epiglottis, until the vocal folds are seen.
• Turning the instrument through 90° will help to negotiate the vocal folds,
only then should the neck be extended.
• The tracheal rings and the carina should be easily seen.
• Advancing the bronchoscope into the right and left main bronchus reveals
the orifices of the more peripheral bronchi.
• Operability of an endobronchial tumour may be assessed in terms of its
location

14. COMPLICATIONS
• Bleeding
• Pneumothorax
• Laryngospasm
• Arrhythmia

15. Other techniques of biopsy of
intrathoracic lesions
• Options
– Percutaneous needle biopsy under radiological control
– Endobronchial ultrasound
– Open-lung biopsy
• Necessary to
– Confirm diagnosis
– Stage disease
– Plan treatment
 To reduce the requirement for
invasive assessment
 Use of high-quality, contrast-
enhanced, multi-slice helical
CT scanning

16. 2. AIRWAY OBSTRUCTION
1. Tracheal obstruction
2. Inhaled foreign bodies

17. TRACHEAL OBSTRUCTION
• Present acutely as a life-threatening
emergency
• Little symptoms until critical narrowing and
stridor occur

18. Treatment
• Depends on cause.
Tracheostomy Tracheal replacement
with artificial
substitutes
Sleeve resections of
the major bronchi
• To overcome the
obstruction
• Unsuccessful
• But resection of up
to 6 cm of trachea
is now possible
• Also possible

19. 3. INHALED FOREIGN BODIES
• Common in small children
• Marked by a choking incident that then apparently passes.
• Large objects can be inhaled and become lodged in the
wider calibre and more vertically placed right main
bronchus.
• Possible presentations:
– Asymptomatic
– Wheezing, persistent cough and signs of obstructive
emphysema
– Pyrexia, productive cough
• Chest x-ray is vital
• Experienced anaesthetist is required.
• The procedure may be very difficult if there is a severe
inflammatory reaction.

20. MALIGNANT LUNG TUMOURS
1. Primary lung tumor
2. Risk factor
3. Histological classification
4. Clinical feature
5. Common symptom
6. Treatment
7. Survival
8. Diagnosis and staging
9. Non-invasive investigation
10. Invasive investigation
11. Surgical approaches

21. PRIMARY LUNG CANCER
• Most common cancers throughout the world.
• Surgical resection
– Limited role in curative treatment
– Many cases are locally advanced or widely
disseminated and are beyond surgical cure.
• Thoracic surgeon (in a cancer team) role
– Diagnosis, staging and palliation apart from resection
in appropriate cases.
• Risk factor
– Cigarette smoking (85–95 per cent of all cases)
– Atmospheric pollution and certain occupations

22. RISK IS RELATED TO THE LIFETIME
BURDEN OF CIGARETTE SMOKING
• Commonly quoted as ‘pack-year’
• A ‘pack’ being 20 cigarettes
– The number of packs smoked per day multiplied
by the number of years of exposure.

23. PATHOLOGICAL TYPES
(RATIO OF ABOUT 1:4)
Small cell
(also known as oat cell)
Pattern of disease,
prognosis, results of
treatment for small cell
carcinoma differ from other
Managed differently based
on the histological
classification.
Non-small cell lung cancer
(NSCLC)
Pathological staging is
critical to treatment and
outcome.
Subdivisions of NSCLC
according to histological
characteristic less important

24. HISTOLOGICAL CLASSIFICATION OF
LUNG CANCER
1. Small cell lung cancers
2. Adenocarcinoma
3. Squamous carcinoma
4. Large cell undiffrentiated
5. Bronchioalveolar carcinoma

25. 1. SMALL CELL LUNG CANCERS
• Known as oat cell cancers
• Packed nature of small dense cells.
• 20 per cent of all lung cancer.
• Tend to metastasise early to lymph nodes and
by blood-borne spread.
• The median survival = months.
• Very responsive to chemotherapy
• Rarely
– Cured
– Surgery needed

26. 2. ADENOCARCINOMA
• Most common of the NSCLC types
• Overtake squamous cell carcinoma
• Increasing incidence
– Due to an increasing incidence in women and
– Lower-tar cigarettes that are inhaled more deeply
to get the same effect.

27. 3. SQUAMOUS CARCINOMA
• A cavitating tumour.

28. 4. LARGE CELL UNDIFFERENTIATED
• Discrete histological type of NSCLC
• Included within neuroendocrine tumours.

29. 5. BRONCHIOALVEOLAR CARCINOMA
• Distinct pattern of growth following the pre-
existing pulmonary architecture
• Less dense
• Appears as a patchy diffuse shadow (‘ground
glass’) on the radiograph
• After resection, it can appear in another lobe
or the other side.

30. CLINICAL FEATURES
• Depend on
1. The site of the lesion
2. The invasion of neigh-bouring structures
3. The extent of metastases.

31. COMMON SYMPTOMS
• Persistance cough, weight loss, dyspnoea and non-specific chest pain
• Haemoptysis
• Cough, or a changed cough
• Severe localised pain (intercostal nerve, brachial plexus, leading to
pancoast’s syndrome)
• Dyspnoea
• Pleural effusion
• Clubbing and hypertrophic pulmonary osteoarthropathy
• Invasion of the mediastinum may result
– Hoarseness
– Dysphagia
– Superior vena caval obstruction.
• Myopathies
– Eaton–lambert syndrome

32. TREATMENT OF LUNG CANCER
• The internationally agreed tumour–node–
metastasis (TNM) staging system
• Tumours graded up to T3, N1, M0
– Within an anatomical surgical resection
– Improved prognosis when treated surgically
• A non-tumour factors
– General fitness
– Lung function tests
• Incurable disease
– Palliative

33. SURVIVAL
• Carcinoma of the bronchus
– Low survival rate
• Factors determining prognosis
1. Histological type of the tumour
2. The spread (stage)
3. General condition of the patient.

35. DIAGNOSIS AND STAGING

36. NON-INVASIVE INVESTIGATIONS
1. Chest x-ray
2. Computed tomography
3. Positron emission tomography
4. Sputum cytology

37. 1. CHEST X-RAY
• Detect most lung cancers
• Early curable tumours, are hidden by other
structures.
• Secondary effects
– Pleural effusion
– Distal collapse
– Raised hemidiaphragm

38. 2. COMPUTED TOMOGRAPHY
• first investigation in suspected lung cancer
• To know
– Primary is resectable (T stage)
– Any lymph nodes are involved (N stage).
– Any remote distant metastases (M stage)

39. Lymph node
• Size more than 2 cm are involved in the disease
(70 per cent)
• Size less than 10 mm are unlikely to be involved.
• Presence of cancer in the nodes, need to do
– Positron emission tomography with radiolabelled
fluorodeoxy-glucose (fdg-pet) or
– Biopsy

40. 3. POSITRON EMISSION TOMOGRAPHY
• Radiolabelled FDG, taken up by all metabolising
cells but more avidly by cancer cells.
• The FDG enters the kreb’s cycle but cannot
complete it and accumulates in proportion to the
glucose avidity of the cells.
• High accumulation is associated with lung cancers
and secondaries.
• Fdg avid
– Infection
– Inflammation
– Lymphadenopathy secondary to it

41. 4. SPUTUM CYTOLOGY
• Reveal malignant cells

42. INVASIVE INVESTIGATIONS
1. Bronchoscopy
2. Endobronchial ultrasonography
3. Computed tomography-guided biopsy
4. Surgical diagnosis and staging

43. 1. BRONCHOSCOPY
• Usually use a flexible bronchoscopy
• Under sedation
• In centrally placed lung cancers
• Allows
– Assessment of the segmental airway,
– Cytological testing
– Transbronchial needle aspiration (tbna).

44. 2. ENDOBRONCHIAL ULTRASOUND
• Assessment of suspicious mediastinal lymph
• To aid TBNA
• Endos-copic ultrasound
– Passing down the oesophagus
– Allows fine needle aspiration (FNA)
– Less approachable mediastinal lymph nodes

46. 3. COMPUTED TOMOGRAPHY-GUIDED
BIOPSY
• Good yield of cells for cytological examination.
• Core of tissue obtained for formal histology.
• Best for larger and more peripheral lesions.
• Pneumothorax is common (30 per cent), but
rarely requires intercostal tube drainage.
• Contraindications include poor respiratory
reserve

47. 4. SURGICAL DIAGNOSIS AND STAGING
1. Mediastinoscopy
2. Mediastinotomy
3. VATS or thoracotomy lymph node/lung
biopsy

48. Cont.
• To establishing a tissue diagnosis and
assessing the degree of spread
• Determines resectability.
• Histological status of mediastinal nodes
– To avoid unnecessary thoracotomy for incurable
cancers
– To not deny surgery to patients whose lymph
nodes are enlarged but benign

49. A) Mediastinoscopy
1. Performed under general anaesthesia
2. Patient supine
3. His or her neck extended
4. A transverse incision is made 2 cm above the sternal notch and
deepened until the strap muscles are reached.
5. These are retracted laterally
6. Thyroid isthmus is retracted superiorly to reveal the pretracheal
fascia.
7. Careful blunt dissection in this plane allows access to the
paratracheal and subcarinal nodes.
8. A mediastinoscope is introduced for direct visualisation and
biopsy.
9. Great caution should be used in the presence of superior vena
caval obstruction.
10. Complications include pneumothorax and haemorrhage

51. B) Mediastinotomy
1. An incision is made through the second
intercostal space to gain access to some of the
mediastinal lymph nodes on the affected side.
2. On the left, this includes lymph nodes in the
para-aortic or sub-aortic fossa.
3. Damage to the internal mammary artery and
the phrenic nerve must be avoided.
4. Mediastinal extension of tumour can also be
assessed

53. Cont.
• These techniques may also be used in the
diagnosis of other mediastinal conditions,
including:
– Lymphoma
– anterior mediastinal tumours
– Thymoma
– Sarcoid
– tuberculosis
– or any other cause of lymphadenopathy

54. C) VATS Mediastinal Lymph Node and
Lung Biopsy
1. For inaccessible mediastinal lymph nodes
2. For diagnosis of the lung tumour has not
been possible through radiological or
bronchoscopic techniques
• Performed through two or three ports
• Allows diagnosis of the tumour, staging of the
mediastinum
• Gives the opportunity to assess the likely
operability of the lung cancer.

56. SURGICAL APPROACH TO LUNG
CANCER RESECTION
1. Thoracotomy
2. Emergency thoracotomy
3. Video-assisted thoracoscopic
surgery

57. 1. THORACOTOMY
• Standard route into the thoracic cavity
– A posterolateral thoracotomy.
• Access to the
– Lung and major bronchi
– Pleura
– Thoracic aorta
– Oesophagus
– Posterior mediastinum.
• A double-lumen endotracheal tube used
– To allow ventilation of one lung while the other is collapsed
– To facilitate surgery
– To protect the non-operated lung
– To retain control of ventilation

58. Techniques
1. The patient is turned to the lateral position with the affected side
up
2. The lower leg is flexed at the hip and the knee, with a pillow
between the legs.
3. Table supports are used to maintain the position and additional
strapping is used at the hips for stability.
4. The patient’s hips are placed below the break point of the
operating table to allow opening of the intercostal spaces as the
table is angulated.
5. The upper arm may be supported by a bracket in a position of 90°
flexion.
6. The lower arm is flexed and positioned by the head.
7. It is important for both the surgeon and the anaesthetist to be
completely satisfied with the position of the patient and the tube
and lines at this stage

60. Cont.
1. The incision passes 1–2 cm below the tip of the scapula, and extends posteriorly
and superiorly between the medial border of the scapula and the spine.
2. The incision is deepened through the subcutaneous tissues to the latissimus
dorsi.
3. This muscle is divided with coagulating diathermy, taking care over haemostasis.
4. A plane of dissection is developed by hand deep to the scapula and serratus
anterior.
5. The ribs can be counted down from the highest palpable rib (which is usually the
second) and the sixth rib periosteum is scored with the diathermy near its upper
border.
6. A periosteal elevator is used to lift the periosteum off the superior border of the
rib or alternatively the intercostal muscle is cut with diathermy just above the rib
7. This reveals the pleura, which may be entered by blunt dissection. A rib spreader
is inserted between the ribs and opened gently to prevent fracture.
8. Exposure may be facilitated by dividing the rib at the costal angle or by dividing
the costotransverse ligament.
9. Resection of a rib is not usually required.
10. The anaesthetist is now able to deflate the affected lung to allow a better view of
the intrathoracic structures.

62. 2. EMERGENCY THORACOTOMY
• For penetrating wounds of the heart
• More anterior approach
• No specialised supporting equipment is required
• Incision is taken down to the fourth or fifth rib with a
scalpel, using scissors the pleural cavity opened.
• Rapid access to the left pleural cavity in cases of
massive left haemothorax and the pericardium if
cardiac tamponade is supected.
• Left anterior thoracotomy can be quickly converted to
a clamshell or bilateral thoracotomy if necessary

63. FOLLOWING THE OPERATION
• 24–28 fr chest drain/s are placed,
– Seventh or eighth intercostal space
– Anterior to the mid-axillary line
• Thoracotomy is closed using paracostal sutures placed around the rib
above and below to reapproximate the ribs or alternatively
intercostal muscle is sutured to the intercostal muscle below the
stripped rib with a continuous absorbable suture.
• The fascia and muscle layer are closed in layers using an absorbable
suture.
• Skin closure is a matter of personal preference.
• Analgesia
– Started prior to thoracotomy with an epidural catheter or
– Intraoperatively by infiltrating the intercostal nerves in the region of the
incision

65. 3. VIDEO-ASSISTED THORACOSCOPIC
SURGERY
• To gain access to the chest cavity and facilitate
lung resection.
• Technique
– Avoids rib-spreading
– Reduce postoperative pain, length of stay
– Aids a speedier recovery

67. SURGICAL MANAGEMENT OF
LUNG CANCER
1. Introduction
2. Choices
3. Complication
4. Postoperative care

68. INTRODUCTION
• Principle
– To remove all cancer
– But to conserve as much lung as possible.
• Selection of patients
– Stage of lung cancer
– Ftness for surgery
• Surgery with curative intent
– In early stage lung cancer (T1–3, N0–1)
• Assessment of a patient’s (risk scores)
– Thorascore, cardiovascular function and lung function
• Selecting the type of procedure (dyspnea)
– Lung function will aid

71. CHOICE OF LUNG RESECTION
1. Segmentectomy and wedge resection
2. Lobectomy
3. Pneumonectomy

73. A) Segmentectomy and Wedge
Resection
• Performed small tumours and with borderline
fitness
• Via thoracotomy or VATS.
• Segmentectomy
– Anatomical dissection
– Ligation of the segmental pulmonary artery, vein and
bronchus
• Wedge resection combined with removal of
regional lymph nodes.
– Non-anatomical excision

74. B) Lobectomy
• In early stage lung cancer.
• Via thoracotomy or vats.
1. Dissection of the fissure and hilar structures,
2. Isolated and ligated the branches of the pulmonary artery and
veins to the lobe
3. The bronchus is usually stapled but can be sewn.
4. At the end of the operation, the remaining lung is reinflated.
• Some air leak is common and usually settles within a few days.
• One or two intercostal drains are inserted.
• The patient does not routinely need intensive care and
postoperative ventilation is best avoided.
• The average length of stay is around 5–7 days.

75. C) Pneumonectomy
• Removal of a whole lung
• Higher mortality rate
• Patient must fit for procedure
• Reserved for centrally placed tumours involving the
main bronchus or those that straddle the fissure.
• At thoracotomy, do an inspection of the lung and
direct palpation of the mass
1. Irresectability.
– Fixation of the tumour to the aorta, heart or oesophagus
2. Poor prognosis
– Involvement of the mediastinal lymph node chain

76. COMPLICATIONS OF LUNG RESECTION
• Bleeding.
– Careful surgical technique
– Severe in dense adhesions.
• Respiratory infection.
– Ex-smokers due to basal collapse and hypoxaemia
postoperatively.
• Persistent air leak.
• Bronchopleural fistula.

78. Bronchopleural fistula.
• Serious complication.
• Has a high morbidity and mortality rate.
• Unlikely to resolve spontaneously
• Management is highly specialised.
• Following pneumonectomy, the space left behind is initially filled with air.
• This is slowly reabsorbed and the space fills with tissue fluid.
• The fluid level rises until the air is finally reabsorbed.
• Dehiscence of the bronchial stump leads to the development of a
bronchopleural fistula and the fluid in the space is expectorated in large
quantities.
• Nursed sitting up and turned so that the affected space is dependent, to
prevent infected fluid from entering the remaining lung
• Arrangements are made to site a pleural drain.
• This should be connected to an underwater seal, but not suction.

79. POSTOPERATIVE CARE
A. Following lung resection, limited respiratory reserve
B. Infection and fluid overload are to be avoided.
1. Remove the drain when air leaks have settled
2. Mobilisation, breathing exercises and regular physiotherapy
3. Postoperative pain - 3 strategies
– Patient-controlled analgesia (PCA) with intravenous boluses of opiates
– Paravertebral/extrapleural or epidural catheter-delivered local
anaesthetic
– Background oral analgesia with paracetamol.
4. Avoidable chronic pain
– Rib fracture
– Entrapment of intercostal nerves

80. BENIGN LUNG TUMOURS
1. Introduction
2. Bronchopulmonary carcinoid
tumours

81. BENIGN TUMOURS
• Less than 15 per cent of solitary lesions
• Seen on chest x-rays.
• A peripheral tumour
– No symptoms until it is large
• A central tumour
– Haemoptysis and signs of bronchial obstruction while small.
• Benign
– Not increased in size on chest x-rays for more than two years
– It has some degree of calcification
• Benign nodules
– Granulomas (tuberculosis or histoplasmosis).
• Most common benign tumour
– Hamartoma
• Diagnosis and definitive treatment
– Excision of the lesion.

82. BRONCHOPULMONARY CARCINOID
TUMOURS
• Carcinoid tumours
• Currently classified within a spectrum of
neuroendocrine tumours.
• From the neuroendocrine cells of bronchial
glands.
• Most found in the major bronchi
• Characteristically slow growing and highly
vascular.
• 15 % metastasise.

83. Cont.
• Presents with a history of recurrent pneumonia
or haemoptysis
• Carcinoid syndrome is rare
• Prognosis following complete resection is
excellent
Surgical excision is preferred
1. Segmental or wedge resection = small peripheral
tumour
2. Lobectomy or pneumonectomy = central
tumours.

84. THE CHEST TRAUMA
1. Approaches to trauma
2. Indications for emergency room thoractomy
3. Thoracotomy approaches
4. Early deaths after thoracic trauma

85. APPROACH TO TRAUMA
• Methodical and exact
• General principles of resuscitation and ATLS
(advanced trauma and life support) must be
followed.

86. INDICATIONS FOR EMERGENCY ROOM
THORACTOMY IN BLUNT CHEST TRAUMA
1. Massive haemothorax
2. Suspected cardiac tamponade
3. Witnessed cardiac arrest in the resuscitation
area.

87. STANDARD APPROACH
• Left anterior thoracotomy
• Penetrating injury is in the right chest
– Extend the incision to bilateral thoracotomies or a
clam-shell incision.

88. EARLY DEATHS AFTER
THORACIC TRAUMA
1. Hypoxaemia, hypovolaemia and tamponade.
2. Diagnose and treat as early as possible
3. Remain highly suspicious
4. Early consultation is advised.
5. Essential that experienced help is
summoned.

89. THE CHEST WALL
1. Chest wall tumors
2. Cervical ribs
3. Thoracic outlet syndrome
4. Pectus

90. TUMOURS OF THE CHEST WALL
• Any component of the chest wall
– Bone, cartilage and soft tissue.
• Treated similarly to those that occur in other
sites
• Major resection and chest wall reconstruction
are contemplated.

91. CERVICAL RIB
• Fibrous band
• From the seventh cervical vertebra
• Inserting onto the first thoracic rib
• Variety of symptoms from compression of
– Subclavian artery
– Brachial plexus

93. THORACIC OUTLET SYNDROME
• Compression of lower trunk of the plexus
(mainly T1)
– Wasting of the interossei
– Altered sensation in the T1 distribution.
• Compression of the subclavian artery
– A post-stenotic dilatation with thrombus and
embolus formation.

95. PECTUS CARINATUM (PIGEON CHEST)
• During the growth spurt at adolescence
• Sternum is elevated above the level of the ribs
• Treatment offered for cosmetic reasons.
• Surgery is best left until the late teens
• Surgery involves mobilising the sternum

96. PECTUS EXCAVATUM
• The sternum is depressed
• Dish-shaped deformity of the anterior
portions of the ribs on one or both sides.
• Never a cause of respiratory problems.
• Repaired to improve cosmetic appearance
– Open procedure (the ravitch procedure)
– A minimally invasive technique, the nuss
procedure.