Thoracic Surgery

Lecture: 1

Thoracic Surgical Approaches

Most thoracic operations done with the patient

anesthetized and Double Lumen endotracheal tube
is used which enable separate ventilation of each
lung by blocking the ventilation from the side of
surgery so that surgeon can work on deflated lung.
Another benefit is that secretions and blood from
operated lung will not return to the contralateral
lung on which we depend during surgery for
ventilation.

1.Viedo Assisted Thoracic Surgery (VATS): - done

by using multiple thoracoscopic ports introduced
into thoracic cavity through multiple small access
incisions.
Advantages: -
1. less pain 2. Early recovery 3. Short hospital
stay 4.No muscle cutting incisions is required
VATS can be used to do Lobectomy, Segmental
lung resection, Sympathectomy, lung and Pleural
biopsy.
Patients who will benefit from VAST are: -
1. Patients with impaired Cardiopulmonary
function.
2. Advanced age.
3. Vascular problem
4. Extra thoracic malignancy
5. Recent or impending major operation
6. Impaired wound healing. e.g., D.M.
.Immunosuppression e.g., HIV .7

2. Posterolateral Thoracotomy: - Is the most

frequently used incision for open procedure, the
patient is placed in lateral position, the incision
begins in the anterior axillary line just below the
nipple and extends below the edge of scapula and
then up between the vertebral boarder of scapula
and spinous process of vertebrae, the Latissimus
Dorsi and serratus anterior muscles are divided and
the chest entered through 5th intercostal space.
After completeness of required procedure, Two
chest tubes are inserted before closure of chest, the
1st one is called Apical tube which is placed
through 7th intercostal space at anterior axillary line
and advanced to the apex of Hemithorax and the
2nd one put through 8th interspace at posterior
axillary line to the posteroinferior part of
Hemithorax to drain oozing blood and /or fluid and
called the Basal tube.

3. Anterolateral Thoracotomy: - the chest is entered

through the 4th interspace as the Pt. is in supine
position. It allows quick entry into thoracic cavity
and used in emergency conditions with
hemodynamic instability especially when cardiac
injury suspected.

Clam Shell Thoracotomy: it is combination of .4

bilateral anterior thoracotomy plus Transverse
.sternotomy used for Double Lung Transplantation

Trap Door Incision: it is combination of anterior .5

thoracotomy and partial Median sternotomy to gain
access to Mediastinal structures in the superior and
.anterior Mediastinum

Lung Abscess: Is localized area of pulmonary

parenchymal necrosis with tissue destruction and
cavity formation.
Etiology: -
1. Primary Lung Abscess:
a. Necrotizing Pneumonia caused by Staph. Aureus,
Klebsiella, Pseudomonas and Mycobacteria
infections.
b. Aspiration Pneumonia occur when consciousness
is impaired with suppress of cough reflex as
perioperative period, stroke, abuse of drug and
Alcohol.
c. Esophageal disorder like Achalasia, GERD.
d. Immunosuppression in which infection occurs by
opportunistic microorganisms as in carcinomas,
DM, Steroid therapy, Malnutrition,
Transplantations.
2. Secondary Lung Abscess:
a. Bronchial obstruction by Tumor, Foreign body
b. Systemic sepsis as in septic pulmonary
embolism, seeding pulmonary infarct.
c. Complications of pulmonary trauma e.g.,
infected hematoma, penetrating injuries.
d. direct extension from extra-parenchymal inf e.g.,
Empyema, Subphrenic abscess.

Microbiology: In community acquired pneumonia

is mostly due to Gram Positive organism while in
hospital acquired cases 60- 70% is from Gram
negative organism, in immunosuppressed cases
infection occur from opportunistic organism, while
in aspiration pneumonia there is polymicrobial
cause

Clinical Features: Productive cough, Fever >

38.9c, Chills, Increase WBC count, decrease
Weight, Pleuritic chest pain, dysphonia, Anemia.

Complications: 1. Massive hemoptysis. 2.

Endobronchial spread to the other lung. 3. Rupture
of pleura. 4. Development of hydropneumothorax.
5.Septic shock and respiratory failure. 6.Mortality
from 5-10% in normal patient reach to 30% in
immunocompromised
Chest Film:
1. Intact Abscess: Mass with thin wall cavity.
2. Ruptured Abscess with communication with
tracheobronchial tree: Air – Fluid level.
CT Scan: help to settle Dx and assess associated
mass or endobronchial obstruction.
DDx: 1. Loculated or interlobar Empyema. 2.
TB, Fungal infection 2. Infected lung cyst or
bullae.
Sputum for C and S is of limited value due to
contamination with upper respiratory tract flora
Bronchoscopy: help to exclude endobronchial
obstruction by tumor or Foreign body, also to take
bronchial wash for C and S.
Percutaneous Trans thoracic FNA for C/ S under U/
S or CT guide

Mx: start with Broad spectrum antibiotics

modified later according to results of C / S for 3
-12 Week till cavity resolve or serial CXR show
improvement.

Surgical drain is uncommon, but, it is indicated

in :-
1. Failure of medical treatment 2. Abscess under
tension
3. Increase in size despite treatment 4. Other lung
contamination 5. Abscess > 4-6 Cm in diameter
6. Inability to exclude cavitary carcinoma

Surgical drain either by: -

1.Chest tube or percutaneous drain catheter for
abscess in contact with chest wall.
2.Thoracotomy and surgical cavern-ostomy to
remove whole abscess cavity usually by lobectomy
especially with bleeding or hydropneumothorax
Important intraoperative consideration is to protect
the other lung with Double Lumen ETT.