見習醫學生模擬手術教案

Teaching Plan of Simulative Surgery for Clerk

目錄
壹、 術式名稱(Topic)： .................................................................................. 2

貳、 學習目標(Objectives of learning)............................................................ 2

參、 教學原則和方法(Principles and methods of teaching) .......................... 2

肆、 概觀(Overview) ....................................................................................... 2

伍、 準備和器械(Preparation and instruments) ............................................ 4

陸、 步驟(Procedures) .................................................................................... 5

柒、 參考文獻(References) ............................................................................ 7

捌、 評量(Evaluation of learning) ................................................................... 7

1
壹、術式名稱(Topic)：
Tube thoracostomy (chest tube)

貳、學習目標(Objectives of learning)
1. By the practice of tube thoracostomy, students will learn and understand the following:
A. Basic surgical anatomy of chest wall surface landmark identification.
B. Indication, contraindication, pre-operative preparation, surgery procedures, and post-operation
care of tube thoracostomy.
C. Build up the interest of surgery.
2. Through the whole teaching course done on Silent Mentor, students would learn the medicine
based on humanity and the spirit based on esteeming life.

參、教學原則和方法(Principles and methods of teaching)

1. Ask the students to prepare lessons, read handout, and review basic anatomy before class.
2. Pay respect to Silent Mentor in class.
3. Lead students to pray in silence before class (2 minutes).
4. Scan the chest surface to see the body landmark, previous op scar or other characteristics.
5. Should be performed in emergent conditions even without informed consent or in selective
condition with informed consent or in scheduled operation after well explanation.
6. Know the regional anatomy of chest wall.
7. Learn the blunt dissection by Pean or Kelly and confirmation of the tunnel by finger dissection.
8. Know the design of chest tube and the direction and length of tube needed for well drainage in the
chest cavity.
9. Fix the tube completely without pressure injury on skin neither by suture material nor by tube.
10. No clamp of tube in any situation except special condition judged by each doctor.

肆、概觀(Overview)
1. Terminology: tube thoracostomy, Fuhrman catheter, chest tube insertion.
2. History: The oldest known reference to thoracic drainage dates back to the fifth century B.C.E.
Hippocrates (c. 460-370 B.C) and tube thoracostomy was not accepted as the standard of care for
pneumothorax and hemothorax until the late 1950s.
3. The structure of chest tube (Figure 1):
Figure 1

A. For this catheter, there are 6 side holes and open end in the anterior 8 cm segment. (Figure 2)
Figure 2

2
 B. The last side hole on the radiopaque strip is mark 0. (Figure 3)
Figure 3

C. The size is 28 Fr. And the blind end will be cut for connecting with chest bottle. (Figure 4)
Figure 4

4. Chest wall anatomy: (A)clavicle bone, (B)ribs, (C)pectoris major, (D)serratus anterior, (E)latissimus
dorsi, (F)midclavicle line, (G)anterior axillary line, (H)middle axillary line.
5. For emergent tube thoracostomy, the insertion site is located in the safety triangle between:
(Figure 5) (A)Lateral border of pectoralis major, (B)Anterior border of latissimus dorsi, (C)Nipple
line.
Figure 5

6. The artery, vein and nerve run near the lower border of the rib, the thoracostomy tract should be
created along upper margin of the rib.
7. Two points connected by a straight line, so the holes on skin and pleural membrane decides the
direction of chest tube, either runs ventrally to lung parenchyma for pneumothorax or dorsally to
lung parenchyma for hemothorax and pleural effusion, and run supraphrenically for empyema.
8. Blunt dissection and dilatation by finger can confirm the patency of tract and no adhesion of
visceral and parietal membrane in the pleural cavity.

3
 ⚫ Indication:
A. Hemothorax
B. Pneumothorax
C. Empyema
D. Hydrothorax
E. Chylothorax
⚫ Contraindication:
A. Coagulopathy
B. Pulmonary bullae
C. Pulmonary, pleural, or thoracic adhesions
D. Lobulated pleural effusion or empyema
E. Skin infection over the chest tube insertion site
⚫ Complications:
A. Pain
B. Bleeding from muscle and subcostal vessels
C. Kinking of tube
D. Wrong position of tip
E. Infection
F. Re-expansion pulmonary edema
G. Lung injury

伍、準備和器械(Preparation and instruments)

1. Informed consent：Should be performed in emergent conditions even without informed consent
or in selective condition with informed consent.
2. Gloves, Cap, Protective gown, Face shield, Sterile drapes
3. Chlorhexidine or Povidone iodine
4. Gauze pads
5. 1% or 2% Lidocaine, 10ml syringes, Needle 23 Gauge 1.5 inch, for local anesthesia
6. Chest tube: 28-32 Fr for adult, 18 Fr for child, 12-14 Fr for infant and 10-12Fr for Neonate.
7. Scalpel with No. 10 or 11 blade
8. Suture or tying material 1-0 Nylon, No.797 or 1#PDS II
9. Large curved Mayo scissors
10. Chest tube drainage device with water seal
11. Suction source and tubing
12. Large and medium Kelly clamps
13. Gauze squares, 4 x 4 in (10)
14. Sterile adhesive tape, 4 inches wide

4
陸、步驟(Procedures)
1. Patient in the supine position with hand hung overhead. (Figure 6)
Figure 6

2. Apply Chlorhexidine or Povidone iodine for skin rubbing and disinfection.

3. Drape from head to toes and expose operation area includes 4-8th ICS between anterior and
middle axillary line.
4. Administrate local anesthesia subcutaneously, then upper border of rib and sub-pleural membrane
space. (Figure 7)
Figure 7

5. 3-4 cm skin incision above the rib next to the approaching ICS.
6. Dissection along the supra-rib border until pleural space is reached, the hole from skin to the
pleural membrane decide the direction of tube. (Figure 8)
Figure 8

5
7. Use finger dissection to confirm the tract is connected to the pleural space and no adhesion
between visceral and parietal pleural membrane. (Figure 9)
Figure 9

8. Rotate and insert the tube gently through the tract till the functional fenestrated segment (8 cm
for the demo tube in above figure) reach the predict site of pleural space. (Figure 10)
Figure 10

9. Fix the tube by 1-0 Nylon or 1#PDS II U shape suture. (Figure 11, Figure 12)
Figure 11 Figure 12

10. Cover the wound with 4x4 in. Y-shape gauze.

6
 11. The chest tube is connected to the collection bottle at “patient end” under water seal. (Figure 13)
Figure 13

12. Fix the tube apart from skin to prevent pressure injury.
!!Attention:
Tutors have to explain to the students:
The initial incision should be below the rib next to the selected ICS so that the skin and
bone will compress naturally the tract after removal of tube, and the dissection should along
the upper bone margin because the artery, vein and nerve run at lower margin of rib.
The 1-0 Nylon can fix the tube and preserve enough length for one step approximation
of skin when removing the tube, and the Nylon cannot tie too tightly to create pressure
injury on the local skin.
The tube should be fixed apart from skin to prevent pressure sore.
The drainage device cannot be placed higher than body and the tube is never clamped
notwithstanding transferring patient.
⚫ Post-procedure care:
A. Obtain a chest X-ray.
B. Keep drainage device lower than pleural cavity
C. Fix tube apart from skin for prevention from pressure injury

柒、參考文獻(References)
1. Jerome H. Abrams, Paul Druck, Frank B.Cerra. Surgical critical care 2nd edition 951-954.
2. Gilbert TB, McGrath BJ, Soberman M. Chest tubes: indications, placement, management, and
complications. J Intensive Care Med 1993; 8:73-86
3. Iberti TJ, Stern PM. Chest tube thoracostomy. Crit Care Clin 1992; 8:879-895
4. Quigley RL. Thoracentesis and chest tube drainage. Crit Care Clin 1995; 11:111-126

捌、評量(Evaluation of learning)
1. Pre and post course writing test
2. Pre and post course operational test
3. Class performance
A. Attitude
B. Skill

7
 C. Surgical landmark identification ability
D. Fluency and time control
4. 大體模擬手術測驗評分表：
測驗項目：Chest tube insertion
測驗時間：10 分鐘
評核內容：完全做到項目
打”✓”
評分項目
二次
前測 後測 註解
後測
1. 說出胸管置入術解剖構造：
Safety triangle borders：lateral border of pectoralis major, anterior
border of latissimus dorsi, nipple line ; anterior and middle axillary
line ; and the vessels and nerve run near the lower margin of the rib.
2. 說明tube thoracostomy的適應症：氣胸、血胸、膿胸、乳糜胸、
肋膜腔積水。
3. 說明病人擺位：手臂拉開，過肩固定。
4. 說明定位之方法：Sonoguide或X光(CXR 或CT)。
5. 準備所需器械、醫材：胸管、胸瓶、刀片、縫線、Kelly or
Pean、持針器、剪刀、局部麻醉藥、施打麻醉藥之針頭及 10ml
空針。
6. 淨空區域之刷皮及消毒，注意由內而外之消毒不能有缺漏未塗
抹消毒液，消毒範圍超過直徑 20 公分，並禁止橢圓形之塗抹動
作。
7. 正確穿戴髮帽、口罩、無菌衣及手套(因已著裝，直接評分當下
之著裝是否標準：無頭髮外露、口鼻無外漏、無菌衣四條綁帶
皆確實繫綁、手套完全包覆無菌衣無防水袖口)。
8. 鋪蓋無菌布單，頭至腳之最大無菌面(大洞巾或單切)，口述。
9. 皮下沿著肋上緣到肋膜下胸管所經路徑皆有適當局部麻醉。
10. 皮膚劃開 3-4 公分傷口。
11. 正確操作Kelly clamps or Pean clamp(沿著肋上緣、器械tip撐開組
織後必須離開身體後才能閉合)。
12. 手指確認胸壁通道進入肋膜腔。
13. 說明及執行胸管置入深度及引流位置的計畫。
14. 利用縫線確實固定胸管位置，且縫線不可綁太緊造成局部皮膚
壓瘡。
15. 說明胸管連接胸瓶之接頭，該接頭具連接管延伸至瓶內液面
下，觀察連接管水柱是否隨呼吸動作上下移動，如水柱無隨呼
吸動作上下移動，需調整胸管位置，並確認胸瓶連接大氣。
16. 針頭及相關耗材及器械正確丟棄或處置，預防同仁針扎。
17. 口述術後胸部X光確認位置，顯影線斷端為mark 0。
18. 拔管前先跟病人說明，並利用病人吐氣過程輕柔拔除胸管、綁
緊縫線。
19. 胸管拔除後，若皮膚邊緣對齊不良或太緊，請重新縫合傷口符
合皮膚縫合標準。
課程評比(勾選)：
前測：□ PASS(完全做到至少 18(含)項) □ FAIL(未做到 18 項)
後測：□ PASS(完全做到至少 18(含)項) □ FAIL(未做到 18 項)
8
您認為考生整體表現如何：
評核
整體 等第
A+ A A- B+ B B- C+ C C- D
表現
勾選

請詳述學員的優點及缺點：