In this ppp I have described three new original thoracic surgical operations which I have devised myself, used for many years and published in reputed international journals.These are very useful and simple operatins for complex chest problems and will benefit every thoracic surgon for treating his patients

1. INNOVATIONS IN
THORACIC SURGICAL
TECHNIQUES
Dr R.S.Dhaliwal
MBBS,MS,DNB(Surg),M.Ch,DNB(CTV Surg),
FACS,FCCP,FNCCP,FICA, FIACS
Former Prof & Head, Depart. Of Cardiovascular
& Thoracic Surgery
PGIMER, Chandigarh,India

2. Introduction
 In this power point presentation I have
described Three Original New Thoracic
Surgery Operations.which I have
devised,used and published .
 These are technically simple operations
for complicated and dangerous thoracic
diseases common in India and most of
the Afro Asian developing countries,still
found uncommonly in the West
 Every Thoracic surgeon should know
and use these techniques. These will
help him very much in treating his
patients

3. PHYSIOLOGICAL LUNGPHYSIOLOGICAL LUNG
EXCLUSIONEXCLUSION
A LIFE SAVING PROCEDUREA LIFE SAVING PROCEDURE
FOR MASSIVE or RECURRENTFOR MASSIVE or RECURRENT
HEMOPTYSISHEMOPTYSIS
( Europ. Jr Card. Thorac. Surg.( Europ. Jr Card. Thorac. Surg.
2001, Vol 20, No1, 25-29 )2001, Vol 20, No1, 25-29 )

5. INTRODUCTION
 MASSIVE HEMOPTYSIS-
Expectoration of >600 ml blood in
24 hrs
ETIOLOGY -
Pulmonary Tuberculosis
Bronchiectasis
Lung Abcess , Br. Carcinoma,
Aspergilloma , Mitral Stenosis
AV Malformations

6. TREATMENT
 Medical Treatment - Embolism Therapy
 LUNG RESECTION IS TREATMENT OF CHOICE
 Lung Resection may be Hazardous or not
Possible due to-
Dense Fibrosis, Vascular Adhesions &
Calcification in pleural cavity
* ALTERNATIVE LIFE SAVING PROCEDURE IS
PHYSIOLOGICAL LUNG EXCLUSION

7. Experience
1994 TO 2014
 Total Patients 208
 Sex M: F 110:98
 Age Range 15- 69 Yrs
 DIAGNOSIS
Pulm. Tuberculosis 120
Bronchiectasis 88

8. Clinical Presentation
 Massive Hemoptysis 82
 Recurrent Hemoptysis 126
 Purulent Sputum 38
 Insulin Dependent DM 42

9. INVESTIGATIONS
X- Ray Chest & CT Scan Chest
 Fibro Cavitary Pulm TB 82
 Bronchiectasis 72
 Aspergiloma 24
 PFT - Moderate To Severe
Restriction

10. Bronchiectsis right lower lobe

11. Tuberculosis Lt Upper Lobe

12. Tubercular cavities

13. Bronchiectasis Aspergilloma

14. PHYSIOLOGICAL BASIS
 INVOLVED PART OF LUNG ISOLATED BY
DIVISION OF
* PULMONARY ARTERY
* BRONCHUS & BRONCHIAL ARTERIES
* VIABILITY OF ISOLATED LUNG MAINTAINED
BY
* VASCULAR ADHESIONS WITH CHEST
WALL SUPPLYING BLOOD TO LUNG
* INTACT PULMONARY VEINS FOR
DRAINAGE

15. SURGICAL TECHNIQUE
 ANTERO LATERAL THORACOTOMY
 J STERNOTOMY
 MINIMUM LUNG MOBILISATION NEAR
HILUM
 PULMONARY ARTERY LIGATION
DONE EXTRA OR INTRAPERICARDIALLY
* INVOLVED BRONCHUS DIVIDED AND
CLOSED
* PULMONARY VEINS PRESERVED

16. ANTERO LATERAL THORACOTOMYANTERO LATERAL THORACOTOMY

17. J STERNOTOMYJ STERNOTOMY

18. Post Lung Exclusion X-rays

19. CONCLUSIONS
PHYSIOLOGICAL LUNG EXCLUSION
IS
AN EFFECTIVE ALTERNATIVE OPERATION
FOR
CONTROL OF MASSIVE OR RECURRENT
HEMOPTYSIS
WHEN
LUNG RESECTION IS HAZARDOUS
DUE TO
DENSE FIBROSIS, VASCULAR ADHESIONS &
CALCIFICATION IN PLEURAL CAVITY

20. ONE STAGE SURGICAL
PROCEDURE FOR
BILATERAL LUNGS AND
LIVER HYDATID CYSTS
(Ann. Thorac. Surg.
1997 ; 64: 338- 41)

22. INTRODUCTION
 USUAL APPROACH FOR B/L LUNGS &
LIVER HYDATID CYSTS -
THREE STAGED SURGERY– TWO
THORACOTOMIES AND A LAPAROTOMY
 DISADVANTAGES -
- SIGNIFICANT MORBIDITY
- INCREASED COST
- REPEATED HOSPITALISATION
 SOLUTION – ONE STAGE
SURGICAL
PROCEDURE

23. 1995 – 2014
 78 PTS 46 M 32 F
 AGE 14- 66 YRS
 SYMPTOMS - DULL PAIN CHEST OR
ABDOMEN COUGH HEMOPTYSIS
. INVESTIGATIONS
X-RAYS CHEST CT SCAN , CASONI’S
AND IMMUNOLOGICAL TEST
Experince

25. SURGICAL PROCEDURE
 Double Lumen Endotracheal
tube essential
 MIDSTERNOTOMY-Pleura opened
 Lung Cysts- Removed by
BARRET’S
TECHNIQUE
 Liver Cysts– Are Removed
Through Phrenotomy (Diaphragm)

28. RESULTS
 No Mortality
 Minimal Morbidity
 No BPF, Empyema or Sternal
Infection
 No Recurrance of Cyst

29. CONCLUSIONS
 Single Stage Surgical Procedure is
much better than Classical Three
Staged Procedure as it
DECREASES
 Morbidity
 Repeated Hospitalisation
 Is Economical

30. CLOSURE OF BRONCHIAL
DEFFECTS USING
GLUTARALDEHYDE TREATED
PERICARDIUM
(Asian Cardiovasc & Thorac.
Annals 2001: 9; No3 pp204-207)

32. INTRODUCTION
 BRONCHIAL DEFFECTS FOLLOWING
TRAUMATIC INJURIES OR LUNG
RESECTIONS REQUIRE COMPLEX
BRONCHOPLASTY PROCEDURES
 PROBLEMS -
TECHNICALLY DEMANDING
DISPARITY IN SIZE OF BR. STUMPS
EXCESSIVE LENGH OF PUL. ARTERY
P.O. AIR LEAK BPF GRANULOMA
BRONCHIAL STENOSIS

33. SURGICAL TECHNIQUES
 Pedicled Muscle Flaps –
Lattismus Dorsi Or Pectorlis Major
 Pedicled Pericardial Flap
 ? Ringed Vascular Grafts
SIMPLE ALTERNATIVE
 GLUTARALDEHYDE –TREATED FREE
PERICARDIAL PATCH
BRONCHOPLASTY

34. METHODS
 1992 – 2014 44 PTS
 TRAUMATIC BR DEFFECTS 20
FOLLOWING LUNG RESECTIONS
24
 INDICATIONS FOR PERICARDIAL
PATCH –1. BR . Deffects size > 2 cms
Close to or Going to Orrifice Of
Remaining Lobe bronchus
2- Traumatic Disruption With
Loss Of Br. Wall

35. SURGICAL TECHNIQUE
 Anterolateral or Postolateral
Thoracotomy
 Bronchial Deffect Defined after Lung
Resection or in Traumatic Disruption
 Equal Size Pericardial Patch
Taken, Fixed In 0.6% Glutaldehyde,
tightly stiched over the Deffect with
4 /O Prolene. Pericardial Deffect is
Closed
 P O Fiber Optic Bronchoscopy , X-ray
Chest, CT Scan

36. RESULTS
 No Mortality
 No P O Air Leakage, Lung/Lobe fully
expanded
 No Bronchial Narrowing
 No Local Tumour Recurrance
 P O FOB, X-ray Chest, CT Scan
 Follow Up 3 MONTHS – 15YRS

37. CONCLUSIONS
 GLUTARALDEHYDE – TREATED FREE
PERICARDIAL FLAP
BRONCHOPLASTY IS A SIMPLE ,
EFFECTIVE, SAFE METHOD FOR
CLOSURE OF BRONCHIAL DEFFECTS
AFTER LOBECTOMY OR TRAUMATIC
BRONCHIAL TEARS INSTEAD OF
COMPLEX BRONCHOPLASTY
METHODS WITH SIGNIFICANT
EARLY AND LATE COMPLICATIONS