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PRINCIPLES OF THORACIC SURGERY IN SMALL
ANIMALS
PRINCIPLES OF THORACIC SURGERY IN SMALL
ANIMALS
T. Németh, DVM, PhDT. Németh, DVM, PhD
Surgical Principles and Instrumentation
Surgical Principles and Instrumentation
• Surgical handling- manipulations effect respiratory and cardiovascular function
- contents of thoracal cavity are intolerant of crushing or clamping
- minimise pleural irritation in order to avoid po. adhesion
- surfaces should be kept moist with warm sterile solutions
- gentle handling of intrathoracic structures and surfaces
- careful hemostasis- suction rather than wiping
• Surgical handling- manipulations effect respiratory and cardiovascular function
- contents of thoracal cavity are intolerant of crushing or clamping
- minimise pleural irritation in order to avoid po. adhesion
- surfaces should be kept moist with warm sterile solutions
- gentle handling of intrathoracic structures and surfaces
- careful hemostasis- suction rather than wiping
Surgical Principles and Instrumentation
Surgical Principles and Instrumentation
• Surgical instrumentation- special thoracic set- retractors - self retaining retractors (Finochietto)- hand-held retractors- vascular (atraumatic) clamps
("de Bakey")- fine sharp instruments
(Metzenbaum scissors)- cutting and coagulating electrocautery - surgical suction device- moistened hemostatic gauze sponges and laparotomy pads
• Surgical instrumentation- special thoracic set- retractors - self retaining retractors (Finochietto)- hand-held retractors- vascular (atraumatic) clamps
("de Bakey")- fine sharp instruments
(Metzenbaum scissors)- cutting and coagulating electrocautery - surgical suction device- moistened hemostatic gauze sponges and laparotomy pads
Anaesthesia for Thoracic SurgeryAnaesthesia for Thoracic Surgery
• Instrumentation- manually and mechanically controlled
IPPV (intubation)- closed or semiclosed system- laryngeal suction unit- ECG- pulsoxymetry- capnography
• Instrumentation- manually and mechanically controlled
IPPV (intubation)- closed or semiclosed system- laryngeal suction unit- ECG- pulsoxymetry- capnography
Anaesthesia for Thoracic SurgeryAnaesthesia for Thoracic Surgery
• Preparation for anaesthesia- stabilisation of curculation, respiration,
acid-base and electrolyt status- remove any free gas or fluid from the
pleural space- remove hair from thoracotomy field
before anaesthesia- circulating warm water blanket or bottle
• Preparation for anaesthesia- stabilisation of curculation, respiration,
acid-base and electrolyt status- remove any free gas or fluid from the
pleural space- remove hair from thoracotomy field
before anaesthesia- circulating warm water blanket or bottle
Anaesthesia for Thoracic SurgeryAnaesthesia for Thoracic Surgery• Premedication
- sedation (benzodiazepines, 2 agonists)- analgesia (opiates: butorphanol,
buprenorphine, nalbuphine)• Induction
- iv. induction (thiopentone, ketamine, propofol)
- "mask" induction (isoflurane)• Maintenance
-isoflurane, sevoflurane/oxygene- nitrous oxide to be avoided
• Premedication- sedation (benzodiazepines, 2 agonists)- analgesia (opiates: butorphanol,
buprenorphine, nalbuphine)• Induction
- iv. induction (thiopentone, ketamine, propofol)
- "mask" induction (isoflurane)• Maintenance
-isoflurane, sevoflurane/oxygene- nitrous oxide to be avoided
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Surgical Approaches to the Thoracic Cavity
Surgical Approaches to the Thoracic Cavity
• Lateral thoracotomy
• Median sternotomy
• Lateral thoracotomy
• Median sternotomy
Surgical anatomyLeft side
Surgical anatomyLeft side
Surgical anatomyLeft side
Surgical anatomyLeft side
Surgical anatomyRight side
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Surgical anatomyRight side
Surgical Approaches to the Thoracic Cavity
Surgical Approaches to the Thoracic Cavity
• Lateral Thoracotomy (right or left sided)- exposes one half of the thoracal cavity- can be performed with or without rib resection- determine the location of the approach- intercostal, transmuscular incision and sharp
dissection- retractor placement- closure with suture around the surrounding ribs
- Polyglactin, Polydioxanone, Stainless steel- chest drainage (Heimlich-valve, one-way-suction drain)
• Lateral Thoracotomy (right or left sided)- exposes one half of the thoracal cavity- can be performed with or without rib resection- determine the location of the approach- intercostal, transmuscular incision and sharp
dissection- retractor placement- closure with suture around the surrounding ribs
- Polyglactin, Polydioxanone, Stainless steel- chest drainage (Heimlich-valve, one-way-suction drain)
Surgical Approaches to the Thoracic Cavity
Surgical Approaches to the Thoracic Cavity
Target of surgery Intercostal space- thoracic trachea 3 (r)- oesophagus (cran.) 3-4 (r,l)- oesophagus (at heart base) 4-5 (r)- oesophagus (caud.) 7-8 (r,l)- PDA, PRAA 4 (l)- cran. lung lobe, pericardium 5 (r,l) - middle lung lobe 6 (r)- caud. and acc. lung lobe 5-6 (r,l)
Target of surgery Intercostal space- thoracic trachea 3 (r)- oesophagus (cran.) 3-4 (r,l)- oesophagus (at heart base) 4-5 (r)- oesophagus (caud.) 7-8 (r,l)- PDA, PRAA 4 (l)- cran. lung lobe, pericardium 5 (r,l) - middle lung lobe 6 (r)- caud. and acc. lung lobe 5-6 (r,l)
Lateral thoracotomy
Lateral thoracotomyLateral thoracotomy Lateral thoracotomyLateral thoracotomy
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Lateral thoracotomyLateral thoracotomy Lateral thoracotomyLateral thoracotomy
Lateral thoracotomyLateral thoracotomy Lateral thoracotomy
Lateral thoracotomyLateral thoracotomy Lateral thoracotomyLateral thoracotomy
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Lateral thoracotomyLateral thoracotomy Lateral thoracotomyLateral thoracotomy
Lateral thoracotomyLateral thoracotomySurgical Approaches to the
Thoracic CavitySurgical Approaches to the
Thoracic Cavity
• Medial Sternotomy- ventral midline approach- gives access to both pleural spaces and the lungs, heart and mediastinum
- sternum is split with a power-driven oscillating saw
- closure with orthopaedic wire sutures
• Medial Sternotomy- ventral midline approach- gives access to both pleural spaces and the lungs, heart and mediastinum
- sternum is split with a power-driven oscillating saw
- closure with orthopaedic wire sutures
Median SternotomyMedian Sternotomy Median SternotomyMedian Sternotomy
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Median SternotomyMedian Sternotomy Median SternotomyMedian Sternotomy
Median SternotomyMedian Sternotomy Surgical Approaches to the Thoracic Cavity
Surgical Approaches to the Thoracic Cavity
• Medial Sternotomy- ventral midline approach- gives access to both pleural spaces and the lungs, heart and mediastinum
- sternum is split with a power-drivenoscillating saw
- closure with orthopaedic wire sutures
• Medial Sternotomy- ventral midline approach- gives access to both pleural spaces and the lungs, heart and mediastinum
- sternum is split with a power-drivenoscillating saw
- closure with orthopaedic wire sutures
Median SternotomyMedian Sternotomy Surgical conditions requiring thoracic surgery
Surgical conditions requiring thoracic surgery
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
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Surgical conditions requiring thoracic surgery
Surgical conditions requiring thoracic surgery
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
Introduction
• 15% of veterinary patients are traumatic (Kolata et al. 1974)
• 26 to 90% of traumatic cases are thoracic patients(Whitney & Mehlhaff 1987, Fullington & Otto 1997, Vnuk et al. 2004)
• Thoracic trauma = circulatory + respiratory distress(Kirby 2004)
Thoracic trauma
• „High rise syndrome”
Etiology
Thoracic trauma
• „High rise syndrome”
• Car accident
Etiology
Thoracic trauma
• „High rise syndrome”
• Car accident
• Bite
Etiology
Thoracic trauma
• „High rise syndrome”
• Car accident
• Bite
• Shot
Etiology
Thoracic trauma
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• „High rise syndrome”
• Car accident
• Bite
• Shot
Closed or openchest injury
Etiology
Thoracic trauma
Localisation
Thoracic trauma
• Upper airways (trachea, main stem bronchi)
Localisation
Thoracic trauma
• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
Localisation
Thoracic trauma
• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
Localisation
Thoracic trauma
• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
• Chest wall (simple or multiplex rib fracture, open chest injury)
Localisation
Thoracic trauma
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• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
• Chest wall (simple or multiplex rib fracture, open chest injury)
• (Cardiologic sequelae: arrhytmias, hemopericardium)
Localisation
Thoracic trauma
ARD
• # Acute Respiratory Distress
Thoracic trauma
ARD
• # Acute Respiratory Distress
• Clinical signs (6 phases):
1. Hyperventilation / hyperpnoe
Thoracic trauma
ARD
• # Acute Respiratory Distress
• Clinical signs (6 phases):
1. Hyperventilation / hyperpnoe
2. Tachypnoe
Thoracic trauma
ARD
• # Acute Respiratory Distress
• Clinical signs (6 phases):
1. Hyperventilation / hyperpnoe
2. Tachypnoe
3. Dyspnoe
Thoracic trauma
ARD
• # Acute Respiratory Distress
• Clinical signs (6 phases):
1. Hyperventilation / hyperpnoe
2. Tachypnoe
3. Dyspnoe
4. Breathing relieving posture
Thoracic trauma
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ARD
• # Acute Respiratory Distress
• Clinical signs (6 phases):
1. Hyperventilation / hyperpnoe
2. Tachypnoe
3. Dyspnoe
4. Breathing relieving posture
5. Labial breathing (cat!)
Thoracic trauma
ARD
• # Acute Respiratory Distress
• Clinical signs (6 phases):
1. Hyperventilation / hyperpnoe
2. Tachypnoe
3. Dyspnoe
4. Breathing relieving posture
5. Labial breathing (cat!)
6. Cyanosis
Thoracic trauma
ARD (cont’)
• Oxigenisation
Thoracic trauma
ARD (cont’)
• Oxigenisation
• Hypoxemia
Thoracic trauma
ARD (cont’)
• Oxigenisation
• Hypoxemia
• Tissue hypoxia
Thoracic trauma
ARD (cont’)
• Oxigenisation
• Hypoxemia
• Tissue hypoxia
• Respiratory acidosis
Thoracic trauma
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ARD (cont’)
• Oxigenisation
• Hypoxemia
• Tissue hypoxia
• Respiratory acidosis
• Asphyxia
Thoracic trauma
ARD (cont’)
• Oxigenisation
• Hypoxemia
• Tissue hypoxia
• Respiratory acidosis
• Asphyxia
SHOCKARD +
Thoracic trauma
• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
• Chest wall (simple or multiplex rib fracture, open chest injury)
• (Cardiologic sequelae: arrhytmias, hemopericardium)
Localisation
Thoracic trauma
Upper airway injuries
• Larynx, trachea
– Rupture
– Hematoma
– Laceration
Thoracic trauma
• Physical signs
– Open wound
– Stridor/stretor
– Subcutaneous emphysema
– Inspiratory dyspnoe: larynx and/or upper tracheal injury
– Expiratory dyspnoe: lower tracheal or main stem bronchial injury
Upper airway injuriesThoracic trauma
• Radiography
– Emphysema
– Pneumomediastinum
– Pneumoperitoneum
SHOCK
Upper airway injuriesThoracic trauma
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• Radiography
– Emphysema
– Pneumomediastinum
– Pneumoperitoneum
SHOCK
Upper airway injuriesThoracic trauma
• Radiography
– Emphysema
– Pneumomediastinum
– Pneumoperitoneum
SHOCK
Upper airway injuriesThoracic trauma
• Tracheobronchoscopy (!)
Dr. Psáder Roland gyűjteményéből
Upper airway injuriesThoracic trauma
• Conservative therapy
– oxigenisation (mask, nasotracheal tube, tracheostomy)
– sedation (ACE, benzodiazepine)
– iv. steroid (edema!)
– iv. furosemide
– analgesia (NSAID, opiate agonists/antagonists)
Upper airway injuriesThoracic trauma
• Surgery
– Surgical reconstruction
» debridement
» suturing
» tracheostomy
Upper airway injuriesThoracic trauma
• Surgery
– Surgical reconstruction
» debridement
» suturing
» tracheostomy
Upper airway injuriesThoracic trauma
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• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
• Chest wall (simple or multiplex rib fracture, open chest injury)
• (Cardiologic sequelae: arrhytmias, hemopericardium)
Localisation
Thoracic trauma
Injuries of the lung parenchyma
• Lung contusion
– edema
– hemorrhage
– laceration
Thoracic trauma
• Physical signs
– ARD
– Varied according to…
» severity (laceration+hemorrhage)
» extent (No of lung lobes)
» lateralisation (uni- or bilateral)
Injuries of the lung parenchymaThoracic trauma
• Radiology
– edema No 1
SHOCK
Interstitial pattern
Injuries of the lung parenchymaThoracic trauma
• Radiology
– edema No 2
– 2.
SHOCKAlveolar pattern
Injuries of the lung parenchymaThoracic trauma
• Radiology
– hemorrhage
SHOCK Interst.-alveol.pattern
Injuries of the lung parenchymaThoracic trauma
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• Radiology
– laceration (atelectasia+PTX)
Injuries of the lung parenchymaThoracic trauma
• Conservative therapy– oxigenisation (mask, nasotracheal tube, tracheostomy)– sedation (ACE, benzodiazepine)– iv. steroid (edema!)– iv. furosemide– analgesia (NSAID, opiate agonists/antagonists)– hypotensive resuscitation (infusion) therapy
» slow, low dose colloid+cristalloid» syringe pump
– therapy of the pleural space(see later)
Injuries of the lung parenchymaThoracic trauma
• Surgery
– ideal: unilateral, 1-2 lung lobe
» hemorrhage
» laceration
– thoracotomy/sternotomy
– partial lobectomy
Injuries of the lung parenchymaThoracic trauma
• Surgery
– ideal: unilateral, 1-2 lung lobe
» hemorrhage
» laceration
– thoracotomy/sternotomy
– total lobectomy
Injuries of the lung parenchymaThoracic trauma
• Surgery
– ideal: unilateral, 1-2 lung lobe
» hemorrhage
» laceration
– thoracotomy/sternotomy
– total lobectomy
Injuries of the lung parenchymaThoracic trauma
• Surgery
– ideal: unilateral, 1-2 lung lobe
» hemorrhage
» laceration
– thoracotomy/sternotomy
– total lobectomy
Injuries of the lung parenchymaThoracic trauma
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• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
• Chest wall (simple or multiplex rib fracture, open chest injury)
• (Cardiologic sequelae: arrhytmias, hemopericardium)
Localisation
Thoracic trauma
Injuries of the pleural space
• PTX
• Traumatic hemothorax
• Traumatic diaphragmatic hernia
Thoracic trauma
Injuries of the pleural space
• PTX
• Traumatic hemothorax
• Traumatic diaphragmatic hernia
Thoracic trauma
• PTX
– 20 to 63% of closed chest injuries (Vnuk et al. 2004, Whitney & Mehlhaff 1987)
– 100% of open chest defects
– closed vs. open vs. tension
– ARD
– tympanic percussion sound
– decreased respiratory sounds
Injuries of the pleural spaceThoracic trauma
• PTX
– Radiography
SHOCK
Injuries of the pleural spaceThoracic trauma
• PTX
– „tap before rad” vs. „rad before tap”
Injuries of the pleural spaceThoracic trauma
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• PTX
– „tap before rad” vs. „rad before tap”
– recommended therapeutic protocol:
1.thoracocentesis - tapping- recheck (rad)
Injuries of the pleural spaceThoracic trauma
• PTX
– „tap before rad” vs. „rad before tap”
– recommended therapeutic protocol:
1.thoracocentesis - tapping- recheck (rad)
2. chest drainage - intermittent/constant suction- recheck
...if fails…
Injuries of the pleural spaceThoracic trauma
• PTX
SHOCK
Injuries of the pleural spaceThoracic trauma Thoracic trauma
Chest drainageThoracic trauma
Chest drainage
Thoracic traumaChest drainage
Thoracic traumaChest drainage
Thoracic traumaChest drainage
Thoracic traumaChest drainage
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Thoracic traumaChest drainage
Thoracic traumaChest drainage
• PTX
– „tap before rad” vs. „rad before tap”
– recommended therapeutic protocol:
1.thoracocentesis - tapping- recheck (rad)
2. chest drainage - intermittent/constant suction- recheck
3. thoracotomy / sternotomy – lobectomy – chest drainage
...if fails…
...if fails…
Injuries of the pleural spaceThoracic trauma
• Upper airways (trachea, main stem bronchi)
• Lung parenchyma (contusion: edema, hemorrhage, laceration)
• Pleural space (PTX, hemothorax, diaphragmatic hernia)
• Chest wall (simple or multiplex rib fracture, open chest injury)
• (Cardiologic sequelae: arrhytmias, hemopericardium)
Localisation
Thoracic trauma
Chest wall injuries
• Bite !!! – Shamir et al (JSAP, 2002)
– 185 biten dogs, 11 biten cats
– Most relevant: male, 10 kg dogs with chest wall defect
• Shot
• Stab
Thoracic trauma
• Physical signs
– ARD + SHOCK
– Closed or open injury
– Skin defect chest status!!!
(Davidson 1998)
– Mortality = chest status!!!
(McKiernan et al 1984, Davidson 1998, Shamir
2002)
Chest wall injuriesThoracic trauma
• Radiology
– Double projection
Chest wall injuriesThoracic trauma
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• Radiology
– Double projection
Dr. Péter Csébi’s cortesy
Chest wall injuriesThoracic trauma
• Surgery
– „Triad”:
» ARD
» Chest wall defect
» Radiological signs
– Thoracotomy
– Lobectomy
– Chest wall reconstruction
– Chest-drainage
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Chest wall injuriesThoracic trauma
Surgical conditions requiring thoracic surgery
Surgical conditions requiring thoracic surgery
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
Esophageal ObstructionEsophageal Obstruction
Definition partial or complete blockage of esophageal
passage usually caused by foreign body localisation: pharyngeal, cervical and thoracal
• Incidence- dogs, cats, horses, cattles- young puppies, playful, greedy animals- bone, stone, potato, bolus
Definition partial or complete blockage of esophageal
passage usually caused by foreign body localisation: pharyngeal, cervical and thoracal
• Incidence- dogs, cats, horses, cattles- young puppies, playful, greedy animals- bone, stone, potato, bolus
Esophageal ObstructionEsophageal Obstruction
• History- apathy
- vomiting, regurgitation just aftereating in undigested form
- constant attemp to eat and drink- cough, aspiration
• History- apathy
- vomiting, regurgitation just aftereating in undigested form
- constant attemp to eat and drink- cough, aspiration
Esophageal ObstructionEsophageal Obstruction
• Diagnostics- anamnesis
- direct visualisation or palpation of theobstruction (pharyngeal, cervical)
- orogastric tube- X-ray (plain, contrast)- oesophagoscopy
• Diagnostics- anamnesis
- direct visualisation or palpation of theobstruction (pharyngeal, cervical)
- orogastric tube- X-ray (plain, contrast)- oesophagoscopy
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Esophageal ObstructionPlain esophagography
Esophageal ObstructionPlain esophagography
Esophageal ObstructionPositive contrast esophagography
Esophageal ObstructionPositive contrast esophagography
Esophageal ObstructionEsophageal Obstruction
• TherapyPharyngeal: - oral removalCervical: - push back to the pharynx
or- endoscopic removal
or- surgical exploration
pushing backor
esophagotomy
• TherapyPharyngeal: - oral removalCervical: - push back to the pharynx
or- endoscopic removal
or- surgical exploration
pushing backor
esophagotomy
Esophageal ObstructionSurgery - Esophagotomy
Esophageal ObstructionSurgery - Esophagotomy
Esophageal ObstructionSurgery - Esophagotomy
Esophageal ObstructionSurgery - Esophagotomy
Esophageal ObstructionSurgery - Esophagotomy
Esophageal ObstructionSurgery - Esophagotomy
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Surgical conditions requiring thoracic surgery
Surgical conditions requiring thoracic surgery
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
LobectomyLobectomy
surgical removal of (a) lung lobe(s) surgical removal of (a) lung lobe(s)
LobectomyLobectomy
• Indication- circumscribed neoplasia, abscess,
foreign body of a lung lobe- severely injured and collapsed
lung lobe- spontaneous pneumothorax
causing pulmonary lesion - lung lobe torsion
• Indication- circumscribed neoplasia, abscess,
foreign body of a lung lobe- severely injured and collapsed
lung lobe- spontaneous pneumothorax
causing pulmonary lesion - lung lobe torsion
LobectomyLobectomy
• Diagnosis- respiratory symptomes - laterolateral and ventrodorsal X-ray
projection- bronchoscopy
• Diagnosis- respiratory symptomes - laterolateral and ventrodorsal X-ray
projection- bronchoscopy
LobectomyPulmonary neoplasia
LobectomyPulmonary neoplasia
LobectomyLobectomy
• Surgery- right or left sided lateral thoracotomy- isolation of the affected lung lobe- partial lobectomy V-shaped
resection on the edge- lobectomy ligature of accompaning
pulmonary vessels closure with double layer
of continuous sutures- chest drainage
• Surgery- right or left sided lateral thoracotomy- isolation of the affected lung lobe- partial lobectomy V-shaped
resection on the edge- lobectomy ligature of accompaning
pulmonary vessels closure with double layer
of continuous sutures- chest drainage
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Partial lobectomyInjured lung lobe
Partial lobectomyInjured lung lobe LobectomyLobectomy
• Surgery- right or left sided lateral thoracotomy- isolation of the affected lung lobe- partial lobectomy V-shaped
resection on the edge- lobectomy ligature of accompaning
pulmonary vessels closure with double layer
of continuous sutures- chest drainage
• Surgery- right or left sided lateral thoracotomy- isolation of the affected lung lobe- partial lobectomy V-shaped
resection on the edge- lobectomy ligature of accompaning
pulmonary vessels closure with double layer
of continuous sutures- chest drainage
LobectomySurgery
LobectomySurgery
LobectomySurgery
LobectomySurgery
LobectomyLobectomy
• Postoperative care- monitoring of respiration
- postoperative analgesia
- check-up X-ray
• Postoperative care- monitoring of respiration
- postoperative analgesia
- check-up X-ray
Surgical conditions requiring thoracic surgery
Surgical conditions requiring thoracic surgery
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
• Thoracic trauma
• Esophageal Obstruction
• Patent Ductus Arteriosus (elective course)
• Persistent Right Aortic Arch (elective course)
• Lung lobectomy
• Diaphragmatic hernia
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Diaphragmatic HerniaDiaphragmatic Hernia
• Diaphragm: - a musculotendinous wall - separates the abdominal and
the thoracal cavities- contributes to respiration,
abdominal press (excretion, partus)
- develops from 6 embryonic segments
• Diaphragm: - a musculotendinous wall - separates the abdominal and
the thoracal cavities- contributes to respiration,
abdominal press (excretion, partus)
- develops from 6 embryonic segments
Diaphragmatic HerniaDiaphragmatic Hernia• Definition:
abnormal dislocation of abdominalorgan(s) into the thoracal cavity through acongenital or acquired, normal or abnormaldefect of the Diaphragm clinical consequences due to the
compression of the intrathoracal organs and themorphological as well as functional disorder ofthe affected abdominal structures
• Definition: abnormal dislocation of abdominal
organ(s) into the thoracal cavity through acongenital or acquired, normal or abnormaldefect of the Diaphragm clinical consequences due to the
compression of the intrathoracal organs and themorphological as well as functional disorder ofthe affected abdominal structures
Diaphragmatic HerniaDiaphragmatic Hernia
• Classification:a.,Congenital (abnormal development of
segments) - pleuroperitoneal diaphragmatic hernia
(hereditary)- peritoneopericardial hernia(PPDH - defect of septum transv.)
- hiatal hernia (sliding/axial orrolling/paraoesophageal)
- diaphragmatic eventrationb., Acquired, traumatic ( 90-95 %)
- left / right sided or bilateral- circular, radial or combined hernial gate
• Classification:a.,Congenital (abnormal development of
segments) - pleuroperitoneal diaphragmatic hernia
(hereditary)- peritoneopericardial hernia(PPDH - defect of septum transv.)
- hiatal hernia (sliding/axial orrolling/paraoesophageal)
- diaphragmatic eventrationb., Acquired, traumatic ( 90-95 %)
- left / right sided or bilateral- circular, radial or combined hernial gate
Peritoneopericardial Diaphragmatic Hernia(PPDH)
Peritoneopericardial Diaphragmatic Hernia(PPDH)
↓↓ ↓↓ ↓
↓↓ ↓↓
Definition- abnormal opening between the peritoneal and the pericardial
sac- dislocation of abdominal organs to the pericardium
Peritoneopericardial Diaphragmatic Hernia(PPDH)
Peritoneopericardial Diaphragmatic Hernia(PPDH)
↓
Peritoneopericardial Diaphragmatic Hernia(PPDH)
Peritoneopericardial Diaphragmatic Hernia(PPDH)
• Definition- abnormal opening between the peritoneal and the pericardial sac
- dislocation of abdominal organs to the pericardium
• Definition- abnormal opening between the peritoneal and the pericardial sac
- dislocation of abdominal organs to the pericardium
Bojrab: Current Techniques of Small Animal Surgery
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Diaphragmatic HerniaDiaphragmatic Hernia
• Classification:a.,Congenital (abnormal development of
segments) - pleuroperitoneal diaphragmatic hernia
(hereditary)- peritoneopericardial hernia(PPDH - defect of septum transv.)
- hiatal hernia (sliding/axial orrolling/paraoesophageal)
- diaphragmatic eventrationb., Acquired, traumatic ( 90-95 %)
- left / right sided or bilateral- circular, radial or combined hernial gate
• Classification:a.,Congenital (abnormal development of
segments) - pleuroperitoneal diaphragmatic hernia
(hereditary)- peritoneopericardial hernia(PPDH - defect of septum transv.)
- hiatal hernia (sliding/axial orrolling/paraoesophageal)
- diaphragmatic eventrationb., Acquired, traumatic ( 90-95 %)
- left / right sided or bilateral- circular, radial or combined hernial gate
Hiatal Hernia(HH)
Hiatal Hernia(HH)
• Definition- displacement of the abdominal esophagus, esophagogastricjunction and/or part of the stomach into the thorax
• Definition- displacement of the abdominal esophagus, esophagogastricjunction and/or part of the stomach into the thorax
Hiatal Hernia(HH)
Hiatal Hernia(HH)
Axial or sliding HHAxial or sliding HH
Hiatal Hernia(HH)
Hiatal Hernia(HH)
Axial or sliding HHAxial or sliding HH
Hiatal Hernia(HH)
Hiatal Hernia(HH)
Axial or sliding HHAxial or sliding HH
Hiatal Hernia(HH)
Hiatal Hernia(HH)
Rolling or Paraesophageal HHRolling or Paraesophageal HH
↓↓ ↓↓ ↓
↓ ↓
↓
• Definition- displacement of the abdominal esophagus, esophagogastricjunction and/or part of the stomach into the thorax
• Definition- displacement of the abdominal esophagus, esophagogastricjunction and/or part of the stomach into the thorax
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Hiatal Hernia(HH)
Hiatal Hernia(HH)
Bojrab: Current Techniques of Small Animal Surgery
Rolling or Paraesophageal HHRolling or Paraesophageal HH
Hiatal Hernia(HH)
Hiatal Hernia(HH)
Bojrab: Current Techniques of Small Animal Surgery
Rolling or Paraesophageal HHRolling or Paraesophageal HH
Diaphragmatic HerniaDiaphragmatic Hernia
• Classification:a.,Congenital (abnormal development of
segments) - pleuroperitoneal diaphragmatic hernia
(hereditary)- peritoneopericardial hernia(PPDH - defect of septum transv.)
- hiatal hernia (sliding/axial orrolling/paraoesophageal)
- diaphragmatic eventrationb., Acquired, traumatic ( 90-95 %)
- left / right sided or bilateral- circular, radial or combined hernial gate
• Classification:a.,Congenital (abnormal development of
segments) - pleuroperitoneal diaphragmatic hernia
(hereditary)- peritoneopericardial hernia(PPDH - defect of septum transv.)
- hiatal hernia (sliding/axial orrolling/paraoesophageal)
- diaphragmatic eventrationb., Acquired, traumatic ( 90-95 %)
- left / right sided or bilateral- circular, radial or combined hernial gate
Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia
• Incidence: - cat dog
• Aethiology:- car accident- falling down- penetrating wound
• Incidence: - cat dog
• Aethiology:- car accident- falling down- penetrating wound
Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia• Pathogenesis:
depens on time of anamnesis
size of hernial gate (incarceration) dislocated organs (omentum, liver etc) status of intrathoracal organs
(lungs)
systemic alteration- shock- ARD
• Pathogenesis: depens on time of anamnesis
size of hernial gate (incarceration) dislocated organs (omentum, liver etc) status of intrathoracal organs
(lungs)
systemic alteration- shock- ARD
Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia• Pathogenesis (cont.)
intrathoracal alterations- thoracic contusion
- pulmonary oedema/hemorrhage- pneumothorax, hemothorax
abdominal disorders- hepatic contusion,
congestion, rupture- splenic congestion/rupture- gastrointestinal laceration,
obstruction
• Pathogenesis (cont.) intrathoracal alterations
- thoracic contusion- pulmonary oedema/hemorrhage
- pneumothorax, hemothorax
abdominal disorders- hepatic contusion,
congestion, rupture- splenic congestion/rupture- gastrointestinal laceration,
obstruction
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Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia
• Diagnosis–general assessment–detailed examination–supplementary examination–differential diagnosis
• Diagnosis–general assessment–detailed examination–supplementary examination–differential diagnosis
Traumatic Diaphragmatic HerniaGeneral assessment
Traumatic Diaphragmatic HerniaGeneral assessment
• weakness, apathy• lying or sitting position• cyanotic, pale mucous membranes• prolonged CRT• tachypnoe, dyspnoe
• weakness, apathy• lying or sitting position• cyanotic, pale mucous membranes• prolonged CRT• tachypnoe, dyspnoe
Traumatic Diaphragmatic HerniaDetailed examination
Traumatic Diaphragmatic HerniaDetailed examination
• Circulation:- shock- tachycardia- dislocation or lack of heart sounds
• Circulation:- shock- tachycardia- dislocation or lack of heart sounds
Traumatic Diaphragmatic HerniaDetailed examination
Traumatic Diaphragmatic HerniaDetailed examination
• Thorax: Auscultation - increased respiratory sounds
(pulm. oedema)- lack of resp. sounds (liver,
spleen or PTX)- gastrointestinal sounds
(stomach, intestine)
• Thorax: Auscultation - increased respiratory sounds
(pulm. oedema)- lack of resp. sounds (liver,
spleen or PTX)- gastrointestinal sounds
(stomach, intestine)
Traumatic Diaphragmatic HerniaDetailed examination
Traumatic Diaphragmatic HerniaDetailed examination
• Thorax: Percussion- dislocated diaphragmatic
line- decreased resonance (liver,
spleen, omentum)- increased resonance
(stomach, intestine, PTX)- fluid line (hemothorax)
• Thorax: Percussion- dislocated diaphragmatic
line- decreased resonance (liver,
spleen, omentum)- increased resonance
(stomach, intestine, PTX)- fluid line (hemothorax)
Traumatic Diaphragmatic HerniaDetailed examination
Traumatic Diaphragmatic HerniaDetailed examination
• Abdomen: Palpation- abnormal, "empty" feeling
• Abdomen: Palpation- abnormal, "empty" feeling
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Traumatic Diaphragmatic HerniaSupplementary examination
Traumatic Diaphragmatic HerniaSupplementary examination
X-ray: - plain laterolateral and dorsoventral projection
- line of Diaphragm - position of intrathoracal organs- lung pattern (oedema, hemorrhage,
contusion)- free contents of thoracal cavity
(fluid, gas) - position of liver and stomach- positive contrast examination (Ba)
X-ray: - plain laterolateral and dorsoventral projection
- line of Diaphragm - position of intrathoracal organs- lung pattern (oedema, hemorrhage,
contusion)- free contents of thoracal cavity
(fluid, gas) - position of liver and stomach- positive contrast examination (Ba)
Traumatic Diaphragmatic HerniaPlain X-ray
Traumatic Diaphragmatic HerniaPlain X-ray
Traumatic Diaphragmatic HerniaPlain X-ray
Traumatic Diaphragmatic HerniaPlain X-ray
Traumatic Diaphragmatic HerniaPositive contrast study
Traumatic Diaphragmatic HerniaPositive contrast study
Traumatic Diaphragmatic HerniaSupplementary examination
Traumatic Diaphragmatic HerniaSupplementary examination
• Ultrasonography:- line of Diaphragm- position of intraabdominal organs
• Laboratory examination- blood gas analysis- complete blood-count - biochemical parameters (ALT, AP,
lipase, amylase, urea, creatinine etc)- thoracocentesis
• Ultrasonography:- line of Diaphragm- position of intraabdominal organs
• Laboratory examination- blood gas analysis- complete blood-count - biochemical parameters (ALT, AP,
lipase, amylase, urea, creatinine etc)- thoracocentesis
Hernia diaphragmatica traumatica Ultrasonography
Hernia diaphragmatica traumatica Ultrasonography
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Traumatic Diaphragmatic HerniaDifferential Diagnosis
Traumatic Diaphragmatic HerniaDifferential Diagnosis
• Pleural effusion without herniation (hydro-, hemo-, chylo-, pyothorax)
• Pulmonary oedema, hemorrhage, pneumonia
• PTX• GDV, intestinal obstruction• Cardiac disorders
• Pleural effusion without herniation (hydro-, hemo-, chylo-, pyothorax)
• Pulmonary oedema, hemorrhage, pneumonia
• PTX• GDV, intestinal obstruction• Cardiac disorders
Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia
Therapy absolute indication of surgery! Therapy absolute indication of surgery!
Traumatic Diaphragmatic HerniaTherapy
Traumatic Diaphragmatic HerniaTherapy
1., Stabilisation of circulatory and respiratory status
- oxygenisation (mask, intubation, tracheostomy)
- shock management- diuretics (furosemide)- correction of acid-base and ionic
imbalance- sedation (diazepam, acepromasine)- thoracocentesis (7-8. intercostal space)
1., Stabilisation of circulatory and respiratory status
- oxygenisation (mask, intubation, tracheostomy)
- shock management- diuretics (furosemide)- correction of acid-base and ionic
imbalance- sedation (diazepam, acepromasine)- thoracocentesis (7-8. intercostal space)
Traumatic Diaphragmatic HerniaTherapy
Traumatic Diaphragmatic HerniaTherapy
2., Surgery - objective and subjective conditions- correct (inhalation) anaesthesia- monitoring (pulsoxymetry, capnogr.) - surgical approach (laparotomy,
laparotomy combined with partial sternotomy)
- detection of type and extension of hernia, affected organs
2., Surgery - objective and subjective conditions- correct (inhalation) anaesthesia- monitoring (pulsoxymetry, capnogr.) - surgical approach (laparotomy,
laparotomy combined with partial sternotomy)
- detection of type and extension of hernia, affected organs
Traumatic Diaphragmatic HerniaTherapy
Traumatic Diaphragmatic HerniaTherapy
2., Surgery (cont.)- reposition of abdominal organs- evaluation of the vitality of organs- removal of necrotic tissues
(lobectomy, resection)- restoration of the Diaphragm (one
or two layers, interrupted or continuous, absorbable or nonabsorbable)
- chest drain placement (?)
2., Surgery (cont.)- reposition of abdominal organs- evaluation of the vitality of organs- removal of necrotic tissues
(lobectomy, resection)- restoration of the Diaphragm (one
or two layers, interrupted or continuous, absorbable or nonabsorbable)
- chest drain placement (?)
Traumatic Diaphragmatic HerniaSurgery
Traumatic Diaphragmatic HerniaSurgery
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Traumatic Diaphragmatic HerniaSurgery
Traumatic Diaphragmatic HerniaSurgery Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia
• Postoperative care- oxygenisation- intensive monitoring (blood gas
analysis)- infusion, diuresis- analgesia ( flunixin meglumine,
opiates)- mashy diet
• Postoperative care- oxygenisation- intensive monitoring (blood gas
analysis)- infusion, diuresis- analgesia ( flunixin meglumine,
opiates)- mashy diet
Traumatic Diaphragmatic HerniaTraumatic Diaphragmatic Hernia
• Assessement of Prognosis- time of anamnesis- response to stabilisation therapy- status of lungs and the liver- return of spontaneous respiration
after surgery- survival of the first 24 hours postoperatively
• Assessement of Prognosis- time of anamnesis- response to stabilisation therapy- status of lungs and the liver- return of spontaneous respiration
after surgery- survival of the first 24 hours postoperatively
Thank You for Your Attention !Thank You for Your Attention !
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