Topic : Surgical Problems of

Respiratory System
Dr Abdul Mateen
 Definations
Rhinotomy: is an incision into the nasal cavity.
Tracheotomy : is an incision through the tracheal wall.
Tracheostomy: is the creation of a temporary or
permanent opening into the trachea to facilitate
airflow.
The permanent tracheostomy opening is called a
tracheostoma.
Tracheal resection and anastomosis: consists of
removal of a segment of trachea and reapposition of
the divided tracheal ends.
Ventriculocordectomy: (debarking or devocalization)
is resection of the vocal cords.
 Indications for Upper Respiratory
Tract Surgery
• Brachycephalic syndrome
• Devocalization
• Laryngeal collapse
• Laryngotracheal trauma
• Laryngeal paralysis
• Tracheal collapse
• Laryngeal masses
• Tracheal masses
• Nasal masses or infection
• Nasal trauma
• Foreign bodies
• Congenital abnormalities
 Rhinotomy
is an incision into the nasal cavity.
• . Dorsal approach to the nasal cavity.
• A, Make a skin incision from the caudal aspect of the
nasal planum to the medial canthus of the orbit (bold
dashed line). Elevate a bone flap (dashed rectangle) or use
rongeurs to remove bone.
• B, If a bone flap was made, suture it in place with wire or
sutures placed through predrilled holes in the bone flap
and adjacent bone.
• C, If rongeurs were used to remove bone, close the
periosteum and subcutaneous tissue, leaving a stoma at
the caudal aspect of the incision. Close the skin similarly,
leaving a stoma.
 Ventral approach to the nasal cavity
• A, Incise the mucoperiosteum of the hard palate. Remove the
palatine bone with a power-driven burr or rongeurs, and discard it.
• B, Close the nasal mucosa of the soft palate and the submucosa-
periosteum of the hard palate with absorbable suture in an
interrupted or continuous pattern. Close the oral mucosa of the
hard and soft palates with monofilament, nonabsorbable suture in
a simple continuous pattern.
 Lateral approach to the nasal cavity
• A, Make the incision for lateral rhinotomy in a dorsocaudal
direction from the nasal planum toward the nasomaxillary
notch. B, Direct the incision between the dorsal lateral
nasal cartilage and the ventral lateral nasal cartilage.
Transection of the accessory cartilage cannot be avoided.
 Tracheotomy
is an incision through the tracheal wall
• INDICATION : Tracheotomy is performed to gain access to
the tracheal lumen to remove obstructions, collect
specimens, or facilitate airflow.
• Approach the cervical trachea through a ventral cervical
midline incision. Extend the incision from the larynx to the
sternum as needed to allow adequate exposure. Separate the
sternohyoid muscles along their midline, and retract them
laterally . Dissect the peritracheal connective tissue from the
ventral surface of the trachea at the proposed tracheotomy
site. Take care to prevent traumatizing the recurrent laryngeal
nerves, carotid artery, vagosympathetic trunk, jugular vein,
thyroid vessels, or esophagus. Immobilize the trachea
between the thumb and the forefinger.
 Tracheotomy(Cotinue)
• . Make a horizontal or vertical incision through the wall of
the trachea . Place cartilage-encircling sutures around
adjacent cartilages to separate the edges and allow lumen
inspection or tube insertion. Suction blood, secretions, and
debris from the tracheal lumen. After completion of the
procedure, appose the tracheal edges with simple
interrupted 3-0 or 4-0 polypropylene sutures. To close the
tracheal incision, place sutures through the annular
ligaments encircling adjacent cartilages or through the
annular ligaments only. Lavage the surgical site with saline.
Appose the sternohyoid muscles in a simple continuous
pattern with 3-0 or 4-0 absorbable suture. Appose the
subcutaneous tissues and skin routinely.
 Tracheostomy
is the creation of a temporary or permanent opening into the
trachea to facilitate airflow.
• Tracheotomy is performed to insert a tube
(temporary tracheostomy) or create a stoma
(permanent tracheostomy) to facilitate airflow.
• 1-Tube tracheostomy. A, Make a transverse incision
through the annular ligament. Excise a small ellipse of
cartilage from each tracheal cartilage adjacent to the
tracheotomy incision to minimize tube irritation
(dotted line). Facilitate tube placement by (B)
depressing the proximal cartilages with a hemostat
and (C) elevating the distal cartilages with an
encircling suture. Insert a tracheostomy tube that
does not completely fill the lumen.
 Permanent tracheostomy.
• A, Deviate the trachea ventrally by apposing the sternohyoid muscles
with mattress sutures dorsal to the trachea. Excise a rectangular
segment of ventral tracheal wall without penetrating the mucosa.
Note the dotted line where the I-shaped incision is made after the
cartilage segment is removed. Excise loose skin adjacent to the
stoma. B, Use intradermal sutures to appose the skin to the annular
ligaments and peritracheal tissues (dashed lines). Appose the
tracheal mucosa to the skin with three or four interrupted sutures;
complete the closure in a simple continuous pattern.
 Tracheal Resection and Anastomosis
of removal of a segment of trachea and reapposition of
the divided tracheal ends.
• Removal of a tracheal segment may be necessary to treat
tracheal tumor, stenosis, avulsion, or trauma.
• Split cartilage technique :
• A, Place stay sutures cranial and caudal to the resection
sites. Split the cartilages with a No. 11 blade, and transect
the trachealis muscle with Metzenbaum scissors. B,
Appose the trachealis muscle with three or four
interrupted sutures, then approximate the split cartilages.
C, Place three or four tension-relieving sutures around
cartilages adjacent to the anastomosis.
 Ventriculocordectomy
is removal of the vocal cords to alter vocalization, remove
masses, or enlarge the ventral glottis for dogs with laryngeal
paralysis
Oral approach : A, Remove the central portion of the vocal fold
with laryngeal cup forceps or uterine biopsy forceps. B, For laryngeal
paralysis or devocalization, remove most of the vocal fold with
Metzenbaum scissors. Dorsal and ventral commissures remain intact.
Laryngotomy
approach, : position the
patient in dorsal recumbency
with the neck extended over
a rolled towel. Expose the
larynx, identify the midline
of the thyroid cartilage and
the cricothyroid ligament,
and then incise with a scalpel
blade (dashed lines). Expose
the vocal folds and excise
them. Close the defect by
apposing the mucosa in a
simple continuous
appositional suture pattern.
 TRAUMATIC DIAPHRAGMATIC HERNIA
• DEFINITION : A diaphragmatic hernia (DH) occurs when the
continuity of the diaphragm is disrupted such that
abdominal organs can migrate into the thoracic cavity
• SURGICAL TECHNIQUE
• Make a ventral midline abdominal incision. Replace the
abdominal organs in the abdominal cavity .If adhesions are
present, dissect the tissues gently from the thoracic
structures to prevent pneumothorax or bleeding. With
chronic hernias, debride the edge of the defect before
closure. Close the diaphragmatic defect in a simple
continuous suture pattern. If the diaphragm is avulsed from
the ribs, incorporate a rib in the continuous suture for added
strength .Remove air from the pleural cavity after closing the
defect. If continued pneumothorax or effusion is likely, place
a chest tube .
Epidermal Inclusion Cysts (Atheromas) :
located dorsolateral aspects of the nasal diverticulum, sebaceous cysts
and were referred to as atheromas. epidermal inclusion cysts, These
cysts are usually single, unilateral, spherical nodules that can vary from
3 cm to 5 cm in diameter.
Surgical extirpation can be performed on a standing horse with
sedation and local infiltration anesthesia. The skin and subcutaneous
tissue are incised over the lesion, and the cyst is removed by dissection.
Care is taken not to rupture the cyst wall. Closure of the incision is
routine, and the aftercare is minimal.
An alternative method The cyst is lanced into the nasal diverticulum
through a stab incision, and the cyst lining is everted using a roaring
burr. The lining is transected using scissors, and the wound is left to heal
by second intention.
 CONGENITAL ORONASAL FISTULA
(CLEFT PALATE)/palatoschisis
• An abnormal communication between the oral and nasal cavities
involving the soft palate, hard palate, premaxilla, and/or lip
• Primary cleft or cleft lip (harelip)
• consists of the lip and premaxilla
• Secondary cleft or cleft palate
• consists of the hard and soft palates
 SURGICAL TREATMENT
• Surgical treatment generally is delayed until the
patient is at least 8 to 12 weeks of age
• primary goal of repairing a cleft palate is to
reconstruct the nasal floor
Sliding bipedicle flap repair
• Mucoperiosteal incisions necessary to create two
sliding flaps
• Mucoperiosteum is elevated from the hard palate
with the major palatine artery
• Nasal mucosa and mucoperiosteum are apposed in
two layers over the defect
 Cleft palate in horses
• A ventral midline incision is made from the angle of the
mandible to the lip. Before splitting the symphysis, a hole
is prepared to facilitate realignment of the bones during
closure. The lip has been moved orally to avoid morbidity
associated with incising it.
• a, Mylohyoideus; b, mandibular lymph nodes;
• c, sternohyoideus and omohyoideus muscles.
• C, The mandibles are spread, and the rostral oral mucosa
is incised. The mylohyoid and geniohyoideus muscles are
incised near their tendinous origin.
• D, Care is taken to avoid the sublingual salivary gland
near the mandible and the lingual nerve near the tongue.
• E,. Two stay sutures are placed at the caudal corners of
the cleft
• F, a No.12 Bard-Parker blade is used to split the thickness of the tissue.
• G, A simple-continuous (or a Lembert) pattern is placed in the nasal side of
the split edge in a rostral-to-caudal direction.
.
• H, A continuous horizontal mattress pattern is placed in the oral side of the
split edge. Two to four widely spaced interrupted vertical mattress sutures
are placed to reduce tension on the primary suture line.
• I, Soft tissues are apposed and a lag screw or pin with figure-of-eight wire is
placed using the previously drilled hole. A cerclage wire around the rostral
mandible just caudal to the erupted incisors augments stability
 Guttural Pouch
• ANATOMY :
• Guttural pouches are paired extensions of the eustachian tubes that
connect the pharynx to the middle ear.
• The pouches are separated from each other on the midline by the rectus
capitis ventralis and the longus capitis muscles and the median septum.
• Each is in close contact rostrally with the basisphenoid bone; ventrally with
the retropharyngeal lymph nodes, pharynx, and esophagus; caudally with
the atlantooccipital joint; laterally with the digastricus muscle and the
parotid and mandibular salivary glands; and dorsally with the petrous part
of the temporal bone, tympanic bulla, and auditory meatus.
• Each guttural pouch is divided ventrally into a medial and a lateral
compartment by the stylohyoid bone, and it communicates with the
pharynx through the pharyngeal orifice of the eustachian tube.
• The capacity of guttural pouches in adult horses is 472 ± 12.4 mL and the
lateral compartment is approximately one third of the capacity of the
medial compartment.
Interior of medial compartment of the left guttural
pouch
a sagittal section of a horse’s head. The section is cut
through the styloid process of the petrous temporal bone on
a line that divides the guttural pouch into medial and lateral
compartments. IX, Glossopharyngeal nerve; X, vagus nerve;
XI, accessory nerve; XII, hypoglossal nerve; A, pharyngeal
branch of the glossopharyngeal nerve; B, pharyngeal branch
of the vagus nerve; C, cranial laryngeal nerve; D, cranial
cervical ganglion.
 THE GUTTURAL POUCH Tympany
• refers to the distention of the guttural
pouches with air under pressure,
sometimes accompanied with some fluid
accumulation. This condition is usually
unilateral but can be bilateral and is
more common in fillies than in colts.
• Surgical intervention is aimed at
providing a permanent means of
evacuating air, either through the
unaffected guttural pouch (fenestration
of median septum), through the guttural
pouch opening (removal of obstructing
membrane), or through an artifically
created opening into the pharynx
(salpingopharyngeal fistula).
 Surgical Techniques:
Right Flank Omentopexy
• Paravertebral/Invert-
ed L/ Line Block
• 20 cm vertical incision
in right paralumbar
fossa
• Left arm moves over
top of rumen to left
side of abdomen,
locates abomasum
 Right Flank Omentopexy
• Pull out omentum
through incision until
pylorus can be seen
• Mattress sutures
through peritoneum,
omentum, & muscle
• Continuous sutures on
inner layers of muscle
incorporating omentum