Open Chest Surgery

Outline

A & P of descending aorta Pathology Diagnosis Anesthesia Medications Patient preparation (positioning, prep, draping) Equipment, Instrumentation, Supplies Thoracotomy for descending thoracic aneurysm (groin

incision for femoral bypass) Other Aortic Aneurysm Types (I, II, III) PTCA CPB Cell Salvage

Anatomy & Physiology of the

Thoracic CavityRefer to Thoracic I Lecture

Notes

Pathology

Lungs Carcinoma=a new growth or malignant tumor Lung cancer #1 cause of death r/t cancer Tumors Divided into 4 Groups: Small Cell Carcinoma or Oat Cell (malignant) Large Cell Carcinoma (malignant) Adenocarcinoma (malignant) of bronchi = primarily smokers of bronchioles = 50%smokers &

50%nonsmokers Squamous Cell Carcinoma (benign) formed from

epithelial or squamous cells which line mucous membranes)

90% malignant lung cancers r/t smoking

Pathology

All tumor types with the exception of small cell (oat cell), have a good prognosis with medical and or surgical intervention

Surgical Interventions include: Wedge/Tumor Resection with margins Lobectomy Pneumonectomy Medical Interventions include: Chemotherapy Radiation

Initial Diagnosis

Cytology of sputum sample Will determine the type of cells that

are present in the respiratory system

Will show presence of cancer cells but not where they actually came from in the lungs

Most preliminary of all tests Chest X-ray must follow to narrow

down location of tumor or mass

Initial Diagnosis

Chest X-ray may be found on routine exam

(asymptomatic) may be ordered after presents with

symptoms:CoughBloody sputum (hemoptysis)Dyspnea

Diagnosis

Cell type determines the course of treatment Tumors are looked at in terms of “staging” Staging means,” how developed is the tumor”? Is it in the lymph nodes, has it metastasized to

another area, or is it localized Staging is accomplished by sending a tissue sample

to pathology and having it analyzed for type Tissue samples are obtained by biopsy Tissue samples can be of lymph nodes or lung

tumor, done with a biopsy needle or actual wedge resections of the lung

Biopsy can be done by bronchoscopy or mediastinoscopy

Specimens

Specimens must be handled appropriately

Mishandling could damage a sample causing it to not be analyzable

There are two types of tissue samples in the OR related to node or tissue:

Fresh frozen Permanent

Specimens

Fresh Frozen Identifies type of tumor Determines margins Will entail waiting on path report Depending on path report may be done

and close or have to reopen or proceed Sent when tumor has not been previously

identified by mediastinoscopy, bronchoscopy, or needle biopsy

Permanent Must ID the type of tumor before it

can be stained to determine staging There are different stains required

for different types of tumors Would send a wedge or lobe for

permanent if the tumor type had already been Identified by a previous biopsy (from mediastinoscopy, bronchoscopy, or needle biopsy)

Specimens

Sometimes may hear “send this for Fresh” and the doctor will want cytology run

Cytology identifies an infectious process:

Fungal Bacterial AFB (acid fast bacillus) checks for

TB

Other Diagnostic Tests for Review

CT scan or MRI Shows location of tumor so that if a

thoracotomy is done, the surgeon knows where to operate to excise the lesion

Preoperative Patient Preparation

Chest X-ray, MRI, AND or CT Scans should be in the OR before the patient arrives. They May accompany the patient. They should be displayed in the x-ray box for the surgeon.

Type & cross should be done in the event that the patient experiences extreme blood loss and needs blood replacement during surgery

These procedures are risky (large vessels are present in the thorax & mediastinum, and could be accidentally injured

Anesthesia

CVP (anesthesia preference) Arterial line Epidural Blood available

Medications

NS Sterile Water Antibiotic in the Irrigant Local: Lidocaine Marcaine With or without Epi

Bone Wax Surgicel Avitene Thrombin and Gelfoam Focal-Seal Other Fibrin Sealants: Bio-Glue Hema-Myst

Thoracic Incisions

Posterolateral Thoracotomy Anterolateral Thoracotomy Thoracoabdominal Incision Median Sternotomy Alternative: Transaxillary,

supraclavicular, cervical mediastinotomy, anterior approach

Thoracotomy

Surgical incision into the thorax or chest wall:

Two Types: Posterolateral Thoracotomy Anterolateral Thoracotomy

Posterolateral Thoracotomy

Lateral chest position for patient Maximum exposure to lung, esophagus,

diaphragm, and descending aorta Anterior submammary fold about nipple

level to scapular tip May be as high as spine of scapula For pulmonary resections (lobectomy,

pneumonectomy, wedge resection), hiatal hernia repair, and thoracic esophagus

Anterolateral Thoracotomy

Supine position Support under affected side to shoulder

20 to 45° for posterior incision extension Hips may be rotated by buttock padding Submammary incision just below breast

from anterior midline to mid or posterior axillary line

Access at fourth intercostal space For pulmonary cyst or localized lesion

resection or open lung biopsy

Thoracoabdominal Incision

Lateral position Incision from posterior axillary line to

abdominal midline 7th or 8th intercostal space Exposure to upper abdomen,

retroperitoneal area, and lower chest Repair of hiatal hernia, esophagectomy,

espophagogastrectomy, retroperitoneal tumors, and thoracic aneurysm resection

Factors Influencing Thoracic Incision Location

Exposure Physiologic intrapleural pressure changes Chest movement Maintenance of chest wall integrity and

diaphragm Lung and underlying pleura condition Minimizing invasiveness of procedure

Patient Positioning

Posterolateral Operative side up Beanbag (surgeon preference) under drawsheet Pillow under head Upper arm on padded mayo Lower arm on padded armboard Axillary roll (protect brachial plexus) Padding under bottom leg Pillows between legs (peroneal nerve) and feet Safety strap and tape across mid pelvic area Lower body Bair hugger sheet, cover with blanket

Prep

Towel drape over epidural catheter Base of neck to hips and side to side

to bed Begin at incision site work around in

circle, prepping axilla last Usually betadine soap followed by

betadine paint

Draping

Towels x 4 or five Drying towels Ioban Universal sheet or laparotomy sheet

Equipment

ECU Suction x 2 (1 for surgery & 1 for

beanbag) Bair Hugger Bronchoscopy Cart Stapler Cart

Instrumentation

CV or Major Tray Chest Tray Chest Retractor of Surgeon Choice

(Finochettio, Tuffier, Burford) Extra long instrument tray Doctor specials Long medium and large clip appliers

Chest Tray Instruments

Bronchus clamps Duval Lung clamps Allison lung retractor (whisk) Davidson scapular retractor Doyan raspatories (pigtails) right & left Elevators (Cameron, Alexander, periostial,

other) Box cutter, Bethune rib shears, Guillotine Bailey rib approximator

Supplies

Basic or Cardiovascular pack Minor or Major basin set Transverse Laparotomy or Universal drape pack Gowns, Gloves, Towels Chest tubes (various are surgeon preference) Clip cartridges Suture (prolene, silk, heavy fascia/muscle layer

suture, vicryl, other nonabsorbable, skin suture) For chest tubes, cutting needles with heavy silk

ties Magnetic pad/drape Bovie with extension Suction tubing, yankaur tip, cell saver (optional)

Supplies Continued

Kittners Raytex for sponge sticks Laparotomy sponges Long umbilical tapes

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Incision made with #10 or #20 blade on #3 knife handle(made at 4th intercostal space for UL/5th or 6th for ML or LL) Cautery used to bovie bleeders and open the fascia and

muscle layer Surgeon will used his hand to loosen fascia Surgeon assistant will hold a scapular retractor so surgeon

can free up entire area May want forceps (debakeys) and cautery or metz to open

muscle layer If removing a rib will use periosteal elevator such as a

cameron or alexanders to scrape away fascia and cartilage from rib

Will use doyan pigtail to completely free rib Will cut rib at either end to remove it with a guillotine or

rib shear

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Self-retaining retractor of choice is placed after rib removal

If does not remove a rib will place self-retaining retractor of choice

May use a burford (short or long blades or one of each) or tuffier or finochettio

Once retractor is in, will change bovie tip to long extention tip and give the surgeon and his assistant long debakeys (may want extra long debakeys/have extra long instrument set available)

Will begin dissection of lobe to be removed or entire lung

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Will use right angle and 0 silk ties to tie off vein and arteriole branches, as well as long medium and large clips

May also request silk or prolene suture on a 3-0 or 4-0 taper needle

Will dissect with long metz alternating with the cautery, debakeys and a long kittner on a long kelly

May request lung retractor (whisk or egg-beater) and or a sponge on a stick to the assistant for exposure

Will request one or two lovelace lung clamps when ready to staple bronchi or lobe tissue

Staplers used for Lobectomies and Pneumonectomies

Linear staplers (old name GIA) Come in 55mm and 75mm May want bovine pericardial or synthetic peri-strips

applied to stapler (used to reinforce suture line made by the stapler)

Thoracotomy staplers (are U-shaped) Come in 35mm, 60mm, and 90mm staple line length 35mm and 60mm may be 3.5mm (blue) or 4.8mm

(green) staple width and have reloads in those sizes White staple reloads are thicker than the blue or green 35mm also come in a vascular style (red) for bronchi Manufacturers recommend a new stapler be used after

reloading three times (This is often not done for cost saving reasons)

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Once a stapler is fired a 15 blade on a long #3 knife handle will be used to free the tissue from the staple line

Several stapler applications may be needed Once the wedge, lobe or lung is removed the

chest cavity will be irrigated with warm NS or Water using an asepto or cytal pitcher and suction

Irrigant will be left in momentarily to determine air leaks in the suture line (there will be bubbling)

Repair suture may be needed (silk or prolene) Hemostatic or synthetic sealant agents may be

used

Irrigation

NS is used when there is no cancer Water is used if there is cancer present Water causes lyses of cancer cells, which

can allow those cells to be suctioned out of thorax

NS could lead to metastasis or spreading of the cancer cells to other areas if those cells that are present are not lysed and suctioned out

These patients often will receive radiation or chemotherapy post-hospitalization

Specimen

If a lobe or wedge is removed, it will be sent for frozen with margins

Clarify specimen type and what the specimen is with the surgeon

NEVER pass off lung tissue or lymph nodes to go in formaldehyde (permanent specimen) unless CERTAIN that is what surgeon wants!

Ask before you pass it off Waiting will be involved to determine if margins

are clear If margins are not clear, you will go back and

remove more lung tissue

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Once the irrigant is suctioned out, chest tubes of the surgeon’s choice will be placed using a 10 blade on a #3 knife handle (incisions are made below the thoracotomy incision), cautery may be used, a tonsil or kelly will be used to pass the chest tube through the chest wall for placement in the thoracic cavity

These will be sewn in using a large cutting eyed-needle with a #1 silk tie for each chest tube inserted

These should be cut for approximately 5 inches of length, a Y connector inserted for two, and hooked up to the pleurevac

Pleurevac should be filled with NS to appropriate level Chest tubes must be secured with tape or plastic tie

bands

Pleurevacs

Pleurevacs (water seal drainage with suction)

Pneumovac or pneumonectomy pleurevac (pressure control chambers/NO suction)

Pneumonectomy pleurevacs are used only for pneumonectomies

May not use any chest tubes with a pneumonectomy

Regular pleurevacs are used for chest drainage for all other chest procedures

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Pericostal closure of the thoracotomy incision will begin with one or two bailey rib approximators for rib reapproximation

Heavy (#1) absorbable suture (vicryl, dexon, or PDS) on a CTX or TP-1 taper needle for intercostal muscle closure

These are usually interrupted sutures (have mayo scissors ready to cut and hemostats)

They are usually placed, needle cut, and tagged with a hemostat

They are tied after they are all placed

Thoracotomy with Lobectomy or Pneumonectomy (Procedure)

Remaining muscle/fascia will be closed with a running #1 PDS or Vicryl on a CTX taper needle

Subcutaneous tissue will be closed with a 2-0 or 0 Vicryl on a CT-1 or CTX tapered needle

Subcuticular layer will be with 4-0 Vicryl or Monocryl on a PS-1 cutting needle

Skin staples may be used in some institutions Dressing is drain sponges or 4x4s for the chest

tubes, telfa, 4x4s, and Primapore Other dressing choices may be used Watch when patient is being moved to make

certain that chest tubes are clear and not pulled out!

Descending Thoracic Aneurysm

Anatomy and Physiology of Thoracic Aorta

Thoracic aorta extends to the diaphragm

Thoracic aorta supplies chest wall, diaphragm, esophagus, bronchus, and the spinal cord

Aneurysm

Localized abnormal dilation of an artery resulting in pressure of the blood on the vessel wall that has been weakened

Pathology of Aneurysms

Develop at sites of arterial weakness Causes: 1. Atherosclerosis 1° cause 2. Congenital weakness Marfan’s syndrome Ehlers Danlos syndrome (both are hereditary disorders that affect

the elastic connective tissues which lead to weakening or thinning of the aorta)

3. Acquired Trauma

Aneurysms

Three types:1. True-arterial wall weakness aneurysmal

sac involves one or all layers of the arterial wall

2. False-results from trauma, causes leakage into a layer of the arterial wall creating a blood clot or hematoma

3. Dissecting-as intima of artery tears, blood escapes which can lead to hemorrhage and sudden death

Thoracic Aneurysm

Origin point at or below the left subclavian artery

Depending on extensiveness of aneurysm, can be operative or inoperable

Most frequent complication is paralysis

Diagnosis

Majority are Asymptomatic until they become enlarged

Discovered on routine chest x-rays Routine physicals when an abdominal bruit is

auscultated or a pulsatile mass is palpable Symptoms include neck, chest, lower back,

abdominal, or flank pain that extends to the groin Depending on aneurysm involvement can cause

symptoms associated with structures supplied with blood at that section of the aorta

Diagnostics/Preoperative Testing

Confirmed with: Ultrasound CT MRI Aortograms

Anesthesia

Arterial line Swan ganz catheter NG tube TEE to check placement of bypass

cannuli (some places may use C-Arm)

Epidural Catheter BLOOD available (may want in

room)

Medications

NS irrigation with antibiotic of choice

Topical hemostatic agents of choice

Patient Preparation and Positioning

Shave is anterior and posterior, including anterior thorax, abdomen, bilateral groins, to knees, and the back

Prep is betadine soap (x 10 minutes if time permits) and betadine paint

Position is Left Posterolateral or thoracoabdominal

Posterior Lateral Position

Headrest Axillary roll (prevent brachial plexus injury) Beanbag (on bed before patient) with suction) Padded armboard for lower arm Padded mayo for upper arm or airplane arm sling Padding under lower leg and pillows between

knees and feet Will expose left groin by slightly frog legging left

leg

Draping

Towel Drape over epidural catheter Towels for perimeter of surgical site Drying towels Ioban Drape Universal Drapes or CV Drape (will expose left groin)

Equipment

Bair hugger (lower body) Cell saver Bovie Extra suction Beanbag Defibrillator Bypass machine (partial bypass usually

employed) Saline Warmer Cryothermia Unit (available) surgeon

choice

Instrumentation

Chest tray Cardiovascular tray or Major Tray Aortic clamps (surgeon choice) Open Heart tray Long medium and large clip appliers Extra long instruments Tube holder, allis, or edna clamps to

secure bypass tubing Chest Retractor of surgeon choice Internal Defibrillator Paddles (external

available) BOTH STERILE

Supplies

Cautery Open heart specialty tray Major Basin Tray Magnetic Drape Miscellaneous prolene suture Miscellaneous silk ties Cutting free needles Straight Woven Dacron Grafts (Miscellaneous sizes) Femoral arterial and venous cannuli Tourniquet snares or rommels Vessel loops or umbilical tapes Warm NS with antibiotic of choice Heparinized saline Topical hemostatic agents Chest tubes

Procedure

Left groin exposure for atrial to femoral bypass by centrifugal pump for lower aortic vessel perfusion

Scalpel Metz/cautery Weitlander Right angle Vessel loops or umbilical tapes Rommel or tourniquets (if using 18F robnel catheters will have

cut short about three inches long during your set-up) Patient is heparinized Peripheral debakeys x 2 11 blade for arteriotomy, arterial cannula, tubing clamps (one

for arterial cannula one will be on pump tubing) Care is taken to NOT introduce air to line, may fill with NS

slowly

Procedure

Vascular clamp or tonsils x 2 may be used to grab femoral vein, 11 blade venous cannula, tubing clamps (same as arterial sequence)

May secure cannuli with heavy silk sutures on cutting needles to patient’s skin

Procedure

Thoracotomy Incision made with #10 or #20 blade on #3 knife handle Cautery used to bovie bleeders and open the fascia and

muscle layer Surgeon will used his hand to loosen fascia Surgeon assistant will hold a scapular retractor so surgeon

can free up entire area May want forceps (debakeys) and cautery or metz to open

muscle layer If removing a rib will use periosteal elevator such as a

cameron or alexander to scrape away fascia and cartilage from rib

Will use doyan pigtail to completely free rib Will cut rib at either end to remove it with a guillotine or

rib shear

Procedure

Place chest retractor of surgeon choice Dissect to aorta May isolate with a long polyester tape or 1”

penrose and clamp with a kelly Will measure aorta to determine graft size needed Obtain graft requested Surgeon may request more heparin be given Aorta is cross clamped with aortic clamps x 2 Aortic arteriotomy made with blade of choice on

long knife handle Aneurysm tissue and clot are removed

Procedure

Graft will be sewn in with prolene suture (should have what surgeon uses ready to go (this is a surgery where time is of the essence, you will be MOVING) proximal end then distal end

Clamps are removed, proximal first Suture will be tied down after removal of clamp to

allow aorta to vent (avoids air being left in aorta) Surgeon may want his hands wet to tie Protamine is given and patient is taken off bypass

when stabilized Have peripheral debakey clamps and tubing

clamps ready, as well as prolene suture to close femoral artery and vein of surgeon choice

Procedure

Irrigation of wounds Femoral incision packed temporarily with

antibiotic soaked raytex until closed Chest tube placement with anchor sutures Suction them out before connecting to

Pleurevac Chest will be closed as per thoracotomy

incisions (periostium, muscles, fascia, subcutaneous, subcuticular)

Groin will be closed Dressings per surgeon choice

Other Aortic Aneurysms

Type I Type II Type III Discussion

Coronary Angioplasty (PTCA)

Discussion

Cell Salvage by Cell Saver

Cell Salvage

Blood recovered during surgery and reinfused

Is directly suctioned, filtered, anticoagulated, and reinfused with little RBC damage

May be aspirated directly or via squeezed out sponges into a basin

Contraindications for Cell Saver

No hemostatics-may clot blood rendering it useless

Certain antibiotics (ex. Bacitracin) may lyse cells, damaging them No exposure to gastric contents,

amniotic fluid, or fluid potentially containing cancerous cells

No local or systemic infection

Cardiopulmonary Bypass

Cardiopulmonary Bypass (CPB)

Method used to divert blood from the heart and lungs to provide a stationary bloodless field and optimal organ tissue function during heart surgeries

OPCAB (off pump coronary artery bypass) heart is beating and bleeding; visibility challenging; preferred for patient’s at risk of complications from CPB; must be to be ready to go on bypass if the patient cannot tolerate CABG procedure without having an arrested heart

CPB Process

Blood is removed from the right atrium via the inferior vena cava

Can be accomplished using inferior vena cava cannulation alone or with both SVC and IVC cannulation called bi-caval cannulation

Is routed to the CPB machine for oxygenation

Blood is returned via the aortic cannula or femoral arterial cannula to provide oxygenated blood to the patient’s body

CPB Machine Components

Oxygenator-removes carbon dioxide and delivers oxygen

Heat exchange coil-can heat or cool the blood

Pump-moves the blood Filters-removes particulate, air,

microemboli Sensors-detect air bubbles, low oxygen

saturation, and low blood volume collection

CPB Continued

Heparin is given intravenously for anticoagulation

Cannuli and CPB circuits may also be heparin-bonded

CPB Perfusionist

Control many physiologic variables along with anesthesia and the surgeon:

1. Hemodilution ↓ blood viscosity =↓clot2. HCT ↓ = ↓ clotting3. Hypothermia = ↓ cellular oxygen

consumption/demand = ↓ chance of organ damage

Core temperature is ↓ from 28 to 30° C

Summary

A & P of descending aorta Pathology Diagnosis Patient preparation (positioning, prep,

draping) Equipment, Instrumentation, Supplies Thoracotomy for descending thoracic

aneurysm (groin incision for femoral bypass)

Summary Continued

Other Aortic Aneurysm Types (I, II, III)

PTCA CPB Cell Salvage