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THORACIC INCISIONS. PRESENTER: DR ANEFU, N. E MODERATOR: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

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thoracic incisions

THORACIC INCISIONS

PRESENTER: DR ANEFU, N. E

MODERATOR:DR S. EDAIGBINI

AHMADU BELLO UNIVERSITY TEACHING HOSPITAL,ZARIA,NIGERIA

outline
OUTLINE
  • INTRODUCTION
  • HISTORICAL PERSPECTIVES
  • ANATOMY OF THE CHEST
  • BASIS
  • GENERAL PRINCIPLE
  • TYPES OF THORACIC INCISIONS
  • CURRENT TREND
  • FUTURE TREND
  • CONCLUTION
introduction
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
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
chest wall
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
slide8

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
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
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
Analgesia CTU-ABUTH
  • Taken very seriously
  • Intra-op =I.V pentazoxine
  • Post-op =Triple px
    • Opioid; pentazoxine
    • NSAIDs;diclofenac
    • Acetaminophen;PCM
prophylactic antibiotics ctu
Prophylactic Antibiotics-CTU
  • Intra-op =3rd generation cephalosporin e.gceftriaxone + metronidazole, repeated after 8hrs,
  • Post-op =same extended X 2-3/7
surgical principles
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
slide14

Optimal approach depends on

Bony anatomy

Location & extent of pathology

Location of the hilum

Objective of the procedure

Chest drainage

types of thoracic incisions
Types of thoracic incisions
  • Sternotomy
  • Thoracotomy
  • Axillarythoracotomy
  • Anterior mediastinotomy
  • Thoracoabdominal incision
types cont
Types cont…
  • Bilateral Trans-sternalthoracotomy( clam-shell incision)
  • Extra-thoracic approaches to the thorax
sternotomy incisions
Sternotomy incisions
  • Partial
    • Hemisternotomy (spares 6-8cm skin)
  • Complete
    • Suprasternalnotchxyphoid process
    • Cosmetically appealing type of incision e.ginframammary (bikini type) incision
median sternotomy
Median sternotomy

Indications

exposure of ant. & middle mediast

lower cervical procedures

Tracheal resection& reconstruction

indications
Indications
  • Excision of thyroid masses & parathyroid adenomas
  • Excision of cervical oesophagealtumours
  • Exposure of heart & great vessels
  • In cardiopulmonary bypass
a dvantages
Advantages
  • Quick to perform
  • Excellent exposure
  • Safe
  • Heals quickly
  • Less incisional pain
disadvantages
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
Technique
  • Standard sternotomy
  • Open sternotomy
  • Re-operative sternotomy
  • Partial sternal split
less invasive sternotomy incisions
Less invasive sternotomy incisions
  • Hemisternotomy- suprasternalnotch,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
post op care
Post-op care
  • ICU MANAGEMENT/MONITORING
  • O2 DELIVERY VIA NEBULIZER
  • PAIN MANAGEMENT( I.Vanalgesics,Eidural nr block)
  • PHYSIOTHERAPY
complications
COMPLICATIONS
  • Anaesthetic:- arrhythmias, laryngeal spasm

Specific :- Early;

haemorrhage,injury to contiguous structures, pneumothorax, haemothorax,

Late;

infection, empyemathoracis, post surgery pain

complications1
Complications
  • Mediastinitis (S.aureu31%,E.coli3%,enterococcus 2%)
  • Sternalosteomyelitis
  • Brachial plexus injury,incidence:1.4-6.5%
thoracotomy
Thoracotomy
  • Standard thoracotomy incisions
  • Defined arbitrarily in relation to the

position of Latissismusdorsi

muscle,which is laterally sited on the chest wall

types of thoracotomy incisions
Types of thoracotomy incisions
  • Lateral
  • Anterior
  • Anterolateral
  • Posterolateral
  • Posterior
  • others
indications for posterolateral incision
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
Advantages
  • Flexibility of the incision
  • Wide range of intra-thoracic exposure
  • Proven experience with these incisions has

made them the standard thoracic incisional approach

disadvantages1
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
Technique (posterolateral)
  • Induction using single/double lumen tube
  • Appropriate monitoring
  • Anaesthesia-G.A+ETT
  • Positioning –lateral decubitus position
  • Cleaning/drapping
slide38

Crescent or “lazy-S”incision, transversely

  • Dissected down & scapular retracted
  • Pleural space entered
  • Pleural/mediastinal drainage
  • Thoracotomy closure
slide40

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
Anterior & anterolateralthoracotomy
  • Indications
  • Has greater use historically
  • Used for pulmonary resection
  • Cardiac procedures
  • Management of mediastinal masses
  • Oesophageal pathology
technique1
Technique
  • Monittoring
  • Anaesthesia are same as posterolatral
  • Supine position
  • Chest elevated at 30-45
  • Curved submammary incision, extended laterally(anterolateral)
lateral thoracotomy
Lateral thoracotomy
  • Within confines of latissimusdorsi
  • Transverse incision
  • 1-2cm inferior to the scapular
complications2
Complications
  • Post thoracotomy incision pain
  • Wound infection
  • Wound dehiscence
  • Bronchopleural fistula-8%
  • Empyema thoracis-2.2%
muscle sparing thoracotomy
Muscle-sparing thoracotomy
  • Indications
    • As in std thoracotomy
    • Variant of std thoracotomy
    • Well established
    • Has less complications
advantages1
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
Axillarythoracotomy
  • Indications
    • 1st rib disection
    • Apical bleb Dx
    • Mgt of spontaneous pneumothorax with apical pleurectomy or pleurodesis
    • Staging of lung cancer
advantages2
ADVANTAGES
  • Small incision
  • Quickly performed
  • Muscle sparing
  • Cosmetically appealing
  • Ideal for pt with poor pulmonary function
disadv
Disadv
  • Limited exposure
  • Intercostobrachial nerve injury
  • Proximal lung thorcic nerve injury
complications3
Complications
  • Very minimal
  • Infection-0.7%
  • Limited shoulder mobility-0.5%
anterior mediastinotomy chamberlain procedure
Anterior mediastinotomy (chamberlain procedure)
  • Used in scalene lymph node biopsy
  • Exploratory thoracotomy
  • In cases of lung cancer( inoperable)
left thoracoabdominal incision
Left thoracoabdominal incision
  • provides excellent exposures for procedures involving
  • the spleen
  • Stomach
  • L hemidiaphragm
  • Aorta
  • lower oesophagus
current trend
Current trend

Towards minimally invasive procedures

Thoracic- VATS (video asst thoracoscopic surgery) e.g TEF LIGATION

Cardiac- OPCAB (off-pump coronary art. Bypass)

MIDCAB (mini invas dir coron art. Bypass)

conclusion
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.