General thoracics operating

Set-up considerations

• Single-lung ventilation/double-lumen ETT
• RSI

Positioning

• Principles
  • Adequate access to port sites externally
  • Triangulation of ports to limit interference
  • Using gravity to your advantage
  • Use bean bag positioner in all positions other than supine
• Supine
  • Can be used for hemi-clamshell and clamshell (transverse thoracosternotomy)
• Semi-supine (30-45 degrees)
  • VATS approaches to anterior mediastinum - thymectomy and excision of anterior mediastinal masses
• Lateral decubitus
  • Generally patient tilted slightly posterior and ports are placed slightly anterior of midline - wider intercostal spaces, spare latissimus dorsi, utility port placed in axilla instead of posterior chest
  • Anterior axillary thoracotomy also preferred by many as the best way to avoid muscles
  • Arm positioned with shoulder at about 100 degrees flexion and elbow at 90 degrees of flexion

Open incisions:

• Thoracotomy
  • Posterior/posterolateral
    • Principles
      • Typically 5th interspace for lung resections
      • Excellent visualisation, but time-consuming and transects a lot of muscle
      • For operations on mid and upper thorax
      • Right side is better for mid/upper oesophagus, otherwise aortic arch will intervene
      • Left is better for distal oesophagus/stomach
    • Technique
      • Lateral position, with side to be entered facing up
      • Expose the chest wall
        • Oblique incision joining the dots between 1) anterior axillary line (three fingers below nipple) 2) two fingers below the inferior angle of the scapula 3) upwards as far as needed, in the line midway between medial scapula and vertebral column
        • Divide latissimus dorsi and serratus anterior, plus maybe part of trapezius/rhomboids posteriorly, maybe part of pec major anteriorly
        • Divide the posterior-most fascial attachments to serratus, allowing the muscle to be spared and retracted anteriorly
      • Select and incise through the deeper muscles
        • Intercostal muscle divided off lower rib with diathermy
        • Consider rib excision
        • Check for adhesions with finger
        • Rib spreader placed gently
  • Axillary
    • Vertical, anterior to latissimus dorsi
    • Enter through 4th interspace
    • Good for hilar visualisation
  • Anterior
    • Principles
      • Usually fourth or fifth interspace for oesophagus
    • Technique
      • Supine position with arm board
      • Curvilinear incision, from sternal edge to axilla, under the inferior border of pectoralis major at the inframammary fold (in females sub-mammary; in males directly over the interspace to be entered)
      • Through pectoralis major which is reflected upwards with the skin
      • Through intercostals and puncture pleura
      • 1-3 costal cartilages can be divided just lateral to internal thoracic artery if it is necessary to improve access to the chest
  • Median sternotomy
    • Usually close the sternum with stainless steel wire
  • Transverse sternotomy ('clamshell')
    • Largest and least comfortable incision
    • Combines two anterior thoracotomy incisions in the inframammary fold with transverse division of the sternum at the 4th intercostal space
    • Need to ligate both internal mammary arteries
    • Ideal for accessing both left and right hilum, large mediastinal tumours, bilateral hilar dissections, bilateral lung transplantation, or posterior-based metastases on both lungs
• Thoracoabdominal
  • Transversely from halfway between xiphisternum and umbilicus, to intersect the costal margin and the level of the seventh or eighth interspace, then following the interspace obliquely upwards to mid-axillary line
  • Rectus muscle and abdominal wall muscles divided and the abdomen entered
  • A 1cm piece of costal margin may be resected to enter the interspace

Principles of tracheal operations

• Maximal amount that can be resected is 5cm
• Contraindications to tracheal repair:
  • Inadequately treated laryngeal problem
  • Need for ventilatory support or permanent tracheostomy
  • Use of high-dose steroids
  • Inflamed or recent tracheostomy
• May need dilation prior to intubation