Thoracic Surgery By Mike Poullis. Overview What is it ? What do you need to know as a nurse on the...
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Transcript of Thoracic Surgery By Mike Poullis. Overview What is it ? What do you need to know as a nurse on the...
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Thoracic Surgery
By
Mike Poullis
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Overview
• What is it ?
• What do you need to know as a nurse on the ward ?
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What do you need to know as a nurse on the ward ?
• Different pathologies
• Different operations
• Chest drains
• Post operative care
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Different pathologies
• Lung cancer• Pneumothorax• Pleural effusions• Lung biopsies
• Trauma• Oddities
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Different operations• Bronchoscopy (oesophagoscopy)• Mediasteinoscopy• Mediasteinotomy / Chamberlains• Thoracoscopy VATS• Mini thoracotomy• Full thoracotomy
• Pneumonectomy / Lobectomy / Wedge
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Anatomy
• Trachea
• 2 bronchi
• 2 Lungs
• 2 lobes on left
• 3 lobes on right
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The Right Lung
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The Left Lung
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Bronchial system
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Compartments of the chest
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Lung cancer
• Small cell
• Non small cell– Squamous– Adeno– Large cell– Undifferentiated
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Lung cancer
• Except for small cell carcinoma of the lung it is generally accepted that surgery is the most effective therapy for lung carcinoma
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Small Cell Lung Cancer
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Assessment of Patient
• Fitness for surgery
• Operability of the tumour - Staging
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Staging
• TNM
• T size and position of tumour
• N lymph node status
• M metastasis
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Stages• Stage Grouping—TNM Subsets
• Stage 0 (TisN0M0)• Stage IA (T1N0M0)• Stage IB (T2N0M0)• Stage IIA (T1N1M0)• Stage IIB (T2N1M0, T3N0M0)• Stage IIIA (T3N1M0), (T(1–3)N2M0)• Stage IIIB (T4, Any N, M0) (Any T, N3M0)• Stage IV (Any T, Any N, M1)
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Survival
Stage 5 year Survival
1 A, B 60-85%
II A,B 40-60%
III A 10-40%
III B <10%
IV <5%
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Fitness for Surgery
• Age
• Pulmonary function
• Cardiovascular function
• Medical conditions
• Nutritional Status
• Performance status
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Assessment of Operability
• CT scan
• Bone scan
• PET scan
• Mediastinoscopy
• Anterior Mediastinotomy
• VATS
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Pleural effusions
• Fluid in chest
• Due to underlying cause
• Usually malignant, but what ?
• Drain for– Symptoms– Diagnosis
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Pneumothorax
• What is a pneumothorax ?• How do you treat them ?• Who requires surgery ?• What does surgery entail ?
– Thoracotomy– Sternotomy– Mini thoracotomy– VATS
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Lung biopsies
• Need tissue to diagnose “Interstitial lung disease”
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Bronchoscopy
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oesophagoscopy
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Mediastinoscopy
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Mediastinoscopy
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Mediastinotomy / Chamberlains
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Mediastinotomy
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Thoracoscopy
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Video Assisted Thoracic Surgery
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Thoracotomy
Posterolateral
Lateral
Anterolateral
Mini thoracotomy
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Thoracotomy - Posterolateral
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Thoracotomy - Anterolateral
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Mini thoracotomy
• Small incision thoracotomy
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Lung Resection
• Pneumonectomy
• Lobectomy
• Wedge
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Lung Resection – Pneumonectomy
Intrapericardial
Extrapericardial
No reserveSputumpO2Fluid balanceInfiltratesTemperatureAF
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Lung Resection – Lobectomy
3 Lobes on RTRULRMLRLL(not RUL & RLL)
2 lobes on LTLULLLL
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Wedge resection
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Chest drains
• What are they ?
• Why use them ?
• Suction and its role
• What drain do you take out MARK IT
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Function
• Conduit to remove fluid or air from the pleural
or pericardial spaces
• The fluid may be blood, pus or pleural effusion
• Allow the lungs and heart to work unrestricted
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Spaces That Need Draining Following Thoracic Surgery
• Only a single pleural cavity opened
• Air and blood may collect in the space
• Two drains– Apical drain – Air– Basal drain – Blood
• Traditionally apical drain is placed anteriorly and basal drain at the back
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Chest Drain
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Suction
• What does it do?– Makes the external pressure negative
• Air or blood drains more easily out of chestDangers• If on to high tissues may get sucked into the
drain damaging them• If connected but not on similar effect to
clamping the drains • BEWARE PNEUMONECTOMY
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Does and Don’ts of Chest Drains
• Do not clamp a functioning drain as this can lead to a tamponade or a tension pneumothorax
• If becomes disconnected, reconnect and ask patient to cough
• Always keep drain below level of patient– If raised above patient the contents may siphon
back into the chest
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Drain Removaland
Timing of Drain Removal
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On Expiration
• Pleural pressures at their highest
– But still less than atmospheric pressure
• Difficult to hold breath at full expiration
• Natural reaction to pain is to take a deep
breath in
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On Inspiration
• Easy to hold breath on maximal inspiration
• Pleural pressure most negative therefore air
more likely to move into pleural space
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Valsalva Manoeuvre
• Forced expiration against a closed glottis
• Creates a positive intrapleural pressure
• Easy for patient to hold
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Post operative care
• Blood pressure
• Blood gases / saturation
• Urine output
• Bleeding
• Sputum
• Analgesia
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Any Questions ?