thoracic surgery


Thoracic Surgery

 

Definition

Thoracic surgery is the repair of organs located in the thorax, or chest. The thoracic cavity lies between the neck and the diaphragm, and contains the heart and lungs (cardiopulmonary system), the esophagus, trachea, pleura, mediastinum, chest wall, and diaphragm.

Purpose

Thoracic surgery repairs diseased or injured organs and tissues in the thoracic cavity. General thoracic surgery deals specifically with disorders of the lungs and esophagus. Cardiothoracic surgery also encompasses disorders of the heart and pericardium. Blunt chest trauma, reflux esophagitis, esophageal cancer, lung transplantation, lung cancer, and emphysema are just a few of the many clinical indications for thoracic surgery.

Precautions

Patients who have blood-clotting problems (coagulopathies), and who have had previous standard thoracic surgery may not be good candidates for video-assisted thoracic surgery (VATS). Because VATS requires the collapse of one lung, potential patients should have adequate respiratory function to maintain oxygenation during the procedure.

Description

Thoracic surgery is usually performed by a surgeon who specializes in either general thoracic surgery or cardiothoracic surgery. The patient is placed under general anesthesia and endotracheally intubated for the procedure. The procedure followed varies according to the purpose of the surgery. An incision that opens the chest (thoracotomy) is frequently performed to give the surgeon access to the thoracic cavity. Commonly, the incision is made beginning on the back under the shoulder blade and extends in a curved arc under the arm to the front of the chest. The muscles are cut, and the ribs are spread with a retractor. The surgeon may also choose to open the chest through an incision down the breastbone, or sternum (sternotomy). Once the repair, replacement, or removal of the organ being operated on is complete, a chest tube is inserted between the ribs to drain the wound and reexpand the lung.Video-assisted thoracic surgery (VATS) is a minimally invasive surgical technique that uses a thoracic endoscope (thoracoscope) to allow the surgeon to view the chest cavity. A lung is collapsed and 3-4 small incisions, or access ports, are made to facilitate insertion of the thoracoscope and the surgical instruments. During the procedure, the surgeon views the inside of the pleural space on a video monitor. The thoracoscope may be extracted and inserted through a different incision site as needed. When the surgical procedure is complete, the surgeon expands the lung and inserts a chest tube in one of the incision sites. The remaining incisions are sealed with adhesive.The thoracic surgeon may also use a mediastinoscope or a bronchoscope to explore the thoracic cavity. Mediastinoscopy allows visualization of the mediastinum, the cavity located between the lungs. The bronchoscope enables the surgeon to view the larynx, trachea, and bronchi. These instruments may be used in a separate diagnostic procedure prior to thoracic surgery, or during the surgery itself.

Preparation

Except in the case of emergency procedures, candidates for general thoracic surgery should undergo a complete medical history and thorough physical examination prior to surgery. Particular attention is given to the respiratory system. The patient's smoking history will be questioned. If the patient is an active smoker, encouragement is always given for the patient to quit smoking prior to the surgery to facilitate recovery and reduce chances of complications.Diagnostic tests used to evaluate the patient preoperatively may include, but are not limited to, x rays, MRI, CT scans, blood gas analysis, pulmonary function tests, electrocardiography, endoscopy, pulmonary angiography, and sputum culture.Candidates for thoracic surgery should be fully educated by their physician or surgeon on what their surgery will involve, the possible risks and complications, and requirements for postoperative care.Patients are instructed not to eat 10 to 12 hours prior to a thoracic surgery procedure. A sedative may be provided to relax the patient prior to surgery. An intravenous line (IV) is inserted into the patient's arm or neck to administer fluids and/or medication.

Aftercare

After surgery, the patient is taken to the recovery room, where vital signs are monitored; depending on the procedure performed, the breathing tube may be removed. The patient typically experiences moderate to severe pain following surgery. Analgesics or other pain medication are administered to keep the patient comfortable. Chest tubes are monitored closely for signs of fluid or air accumulation in the lungs that can lead to lung collapse. A urinary catheter will remain in the patient for 24 to 48 hours to drain urine from the bladder.The hospital stay for thoracic surgery depends on the specific procedure performed. Patients who undergo a thoracotomy may be hospitalized a week or longer, while patients undergoing VATS typically have a shorter hospital stay of 2-3 days. During the recovery period, respiratory therapists and nurses work with the patient on deep breathing and coughing exercises to improve lung function.

Risks

Respiratory failure, hemorrhage, nerve injury, heart attack, stroke, embolism, and infection are all possible complications of general thoracic surgery. The chest tubes used for drainage after thoracic surgery may cause a build-up of fluid or the accumulation of air in the pleural space. Both of these conditions can lead to total lung collapse. Other specific complications may occur, depending on the procedure performed.

Normal results

Normal results of thoracic surgery are dependent on the type of procedure performed and the clinical purpose of the surgery.

Resources

Organizations

American Thoracic Society. 1740 Broadway, New York, NY 10019. (212) 315-8700. http://www.thoracic.org.

Key terms

Blood gas analysis — A blood test that measures the level of oxygen, carbon dioxide, and pH in arterial blood. A blood gas analysis can help a physician assess how well the lungs are functioning.Electrocardiography — A cardiac test that measures the electrical activity of the heart.Embolism — A blood clot, air bubble, or clot of foreign material that blocks the flow of blood in an artery. When blood supply to a tissue or organ is blocked by an embolism, infarction, or death of the tissue that the artery feeds, occurs. Without immediate and appropriate treatment, an embolism can be fatal.Emphysema — A lung disease characterized by shortness of breath and a chronic cough. Emphysema is caused by the progressive stretching and rupture of alveoli, the air sacs in the lung that oxygenate the blood.Endoscopy — The examination of organs and body cavities using a long, tubular optical instrument called an endoscope.Intubation — Insertion of an endotracheal tube down the throat to facilitate airflow to the lung(s) during thoracic surgery.Pericardium — The sac around the heart.Pleural space — The space between the pleural membranes that surround the lungs and the chest cavity.Pulmonary angiography — An x-ray study of the lungs, performed by insertion of a catheter into a vein, through the heart, and into the pulmonary artery. Pulmonary angiography is performed to evaluate blood circulation to the lungs. It is also considered the most accurate diagnostic test for detecting a pulmonary embolism.Sputum culture — A laboratory analysis of the fluid produced from the lungs during coughing. A sputum culture can confirm the presence of pathogens in the respiratory system, and help to diagnose certain respiratory infections, including bronchitis, tuberculosis, and pneumonia.

thoracic

 [thŏ-ras´ik] pertaining to the chest (thorax); called also pectoral.thoracic outlet syndrome compression of the brachial plexus" >brachial plexus nerve trunks and subclavian vessels, with pain in the upper limbs, paresthesia of fingers, vasomotor symptoms, and weakness and wasting of small muscles of the hand; it may be caused by drooping shoulder girdle, a cervical rib (cervical rib syndrome) or fibrous band, an abnormal first rib, continual hyperabduction of the arm (as during sleep), or compression of the edge of the scalenus anterior muscle.thoracic surgery surgical procedures involving entrance into the chest cavity. Until techniques for anesthesia" >endotracheal anesthesia were perfected, this type of surgery was extremely dangerous because of the possibility of lung collapse. By administering anesthesia under pressure through an endotracheal tube it is now possible to keep one or both lungs expanded, even when they are subjected to atmospheric pressure. Thoracic surgery includes procedures involving the lungs, heart, and great vessels, as well as tracheal resection, esophagogastrectomy, and repair of hiatal hernia. In order to give intelligent care to the patient before and after surgery, one must have adequate knowledge of the anatomy and physiology of the chest and thoracic cavity. It is especially important to know the difference in pressures within and outside the thoracic cavity. (See also discussion of Mechanics of Inflation and Deflation, under lung" >lung.)Patient Care. Prior to surgery the care of the patient will depend on the specific operation to be done and the particular disorder requiring surgery. In general, the patient should be given an explanation of the operative procedure anticipated and the type of equipment that will be used in the postoperative period. The patient will be taught the proper method of coughing to remove secretions accumulated in the lungs. Although coughing may be painful in the immediate postoperative period and may require analgesic medication to relieve the discomfort, if the patient understands the need for coughing up the secretions he or she will be more cooperative. Special exercises may be given to preserve muscular action of the shoulder on the affected side and to maintain proper alignment of the upper portion of his or her body and arm. Usually the physical therapist supervises these exercises, but the nursing staff must coordinate them with other aspects of patient care.

Narcotics are rarely given before thoracic surgery because they can depress respiration. Usually the preoperative medication is atropine in combination with a barbiturate.
The development of intensive care units has sharply improved the care of the post-thoracotomy patient. The availability of monitors, ventilators, and special assist devices has increased not only the safety of the operation but also the comfort of the patient. Many patients return from the operating room with endotracheal tubes still in place, ventilated by machines, and monitored with such special equipment as Swan-Ganz catheters for observation of cardiac output, oxygenation, and level of hydration.
During the postoperative period, alteration in respiratory status is a major potential problem for patients having thoracic surgery. Impaired gas exchange can result from atelectasis, pneumothorax, mediastinal shift, bronchopulmonary fistula, pneumonia, pleural effusion, pulmonary edema, narcotics, or abdominal distention. To identify any change in respiratory status, the patient's arterial blood gases are serially monitored, breath sounds are auscultated, and the rate and character of respirations are assessed. To facilitate removal of obstructive mucus and other secretions in the air passages the patient is encouraged to deep breathe and cough every one to two hours. Chest physical therapy may be ordered to help mobilize the secretions so that they are more easily coughed up. The amount and character of sputum is noted and recorded. If necessary, nasotracheal suctioning may be done to help clear the air passages. Oxygen may be administered to prevent anoxia.
The patient is also periodically assessed for pain, abdominal distention, and alteration in cardiac function related to decreased cardiac output, arrhythmias, or cardiac tamponade. If the pericardial sac becomes filled with fluid and produces an acute cardiac tamponade, an emergency pericardiocentesis may be necessary.
Almost all patients having thoracic surgery will have chest tubes. (One exception is the patient who has had a lung removed. In this case fluid is deliberately allowed to accumulate in the pleural space to prevent mediastinal shift.) Chest tubes are attached to closed drainage systems to avoid pneumothorax and allow for drainage of the pleural space and gradual reexpansion of the lung. (See chest tube for care.)
As the operative site heals and the lung expands, the chest tubes can be safely removed. After their removal an airtight bandage is applied to the area. As a precaution against leakage of air into the chest cavity, the physician may apply petrolatum to the edges of the wound before applying the dressing.