Skip to Main Content

++

INTRODUCTION

++

  • Complications of thoracic surgery may be minimized through a mastery of the 3-dimensinal anatomy of hilar and mediastinal structures

  • Thorough pre-operative evaluation of cardio-pulmonary reserve is imperative prior to embarking upon elective thoracic surgery

  • General principles of thoracic surgery for trauma include large, utility incisions (most commonly left anterolateral thoracotomy or median sternotomy), proximal and distal control of bleeding vessels, and guided blood product resuscitation.

++

STATE OF THE ART

++

Progress in thoracic surgery has mirrored that of general surgery, with many open procedures giving way to minimally invasive techniques. Although the realm of trauma has traditionally been immune to this phenomenon, it too has undergone refinement. Perhaps the most striking example of a shift towards minimally invasive approaches in trauma has been that of retrograde endovascular balloon occlusion of the aorta in lieu of resuscitative emergency department thoracotomy.1 Additional examples of this trend include video-assisted thoracic surgery (VATS) lobectomy for both malignant and nonmalignant pulmonary lesions, endobronchial ultrasound (EBUS) guided mediastinal lymph node biopsy, navigational bronchoscopy, and endoscopic approaches to esophageal pathology.

++

The emergence of minimally invasive thoracic surgical techniques has not diminished the importance of both meticulous preoperative planning and sound knowledge of surgical anatomy. Rather, when intraoperative problems do arise during these procedures, it is even more important to rapidly identify and correct them. Small incisions, alternative positioning, and personnel unfamiliar with techniques for rapid hemorrhage control within the chest converge to create potentially dangerous situations, underscoring the importance of a rapidly available, experienced thoracic surgeon.

++

PITFALLS AND PEARLS

  • ✓ Successful bailout maneuvers in thoracic surgery are made possible only through a mastery of both tracheobronchial and hilar anatomy. There is no substitute for this intimate 3-dimensional understanding of the relationships of the pulmonary arteries, veins, and bronchi.

  • ✓ The pulmonary vascular system (both arterial and venous) is generally low pressure. As such, direct occlusion of bleeding vessels with a peanut gauze or sponge stick is usually an effective temporary means of hemorrhage control. This maneuver then buys the surgeon time to plan for definitive hemorrhage control (eg, broadening the incision or obtaining proximal and distal control).

  • ✓ General operative principles in thoracic surgery include wide exposure prior to control of bleeding, proximal and distal control of bleeding vessels, debridement and anastomosis of healthy tension-free tissue, and either muscle or pericardial coverage of tenuous anastomoses or repairs.

  • ✓ Although several cardiopulmonary parameters have been associated with operative risk in elective thoracic surgery, the most predictive are: (1) The predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1) <30%, and (2) maximal oxygen consumption (VO2max) of 10 mL/kg/minute.

  • ✓ Pleural effusions in hospitalized patients are common; they should be drained only for diagnostic or therapeutic purposes.

  • ✓ Management of esophageal perforation is dictated by the physiologic status of the patient, the underlying status of the esophagus, and the duration of the perforation. Strategies include nonoperative, percutaneous, endoscopic, and open surgical techniques.

    ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.