1. Thoracic Surgery By Mike Poullis

2. Overview • What is it ? • What do you need to know as a nurse on the ward ?

3. What do you need to know as a nurse on the ward ? • Different pathologies • Different operations • Chest drains • Post operative care

4. Different pathologies • Lung cancer • Pneumothorax • Pleural effusions • Lung biopsies • Trauma • Oddities

5. Different operations • Bronchoscopy (oesophagoscopy) • Mediasteinoscopy • Mediasteinotomy / Chamberlains • Thoracoscopy VATS • Mini thoracotomy • Full thoracotomy • Pneumonectomy / Lobectomy / Wedge

6. Anatomy • Trachea • 2 bronchi • 2 Lungs • 2 lobes on left • 3 lobes on right

7. The Right Lung

8. The Left Lung

9. Bronchial system

10. Compartments of the chest

11. Lung cancer • Small cell • Non small cell • Squamous • Adeno • Large cell • Undifferentiated

12. Lung cancer • Except for small cell carcinoma of the lung it is generally accepted that surgery is the most effective therapy for lung carcinoma

13. Small Cell Lung Cancer

14. Assessment of Patient • Fitness for surgery • Operability of the tumour - Staging

15. Staging • TNM • T size and position of tumour • N lymph node status • M metastasis

16. 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)

18. Survival

19. Fitness for Surgery • Age • Pulmonary function • Cardiovascular function • Medical conditions • Nutritional Status • Performance status

20. Assessment of Operability • CT scan • Bone scan • PET scan • Mediastinoscopy • Anterior Mediastinotomy • VATS

21. Pleural effusions • Fluid in chest • Due to underlying cause • Usually malignant, but what ? • Drain for • Symptoms • Diagnosis

23. Pneumothorax • What is a pneumothorax ? • How do you treat them ? • Who requires surgery ? • What does surgery entail ? • Thoracotomy • Sternotomy • Mini thoracotomy • VATS

25. Lung biopsies • Need tissue to diagnose “Interstitial lung disease”

26. Bronchoscopy

27. oesophagoscopy

28. Mediastinoscopy

29. Mediastinoscopy

30. Mediastinotomy /Chamberlains

31. Mediastinotomy

32. Thoracoscopy

33. Video Assisted Thoracic Surgery

34. Thoracotomy Posterolateral Lateral Anterolateral Mini thoracotomy

35. Thoracotomy - Posterolateral

36. Thoracotomy - Anterolateral

37. Mini thoracotomy • Small incision thoracotomy

38. Lung Resection • Pneumonectomy • Lobectomy • Wedge

39. Lung Resection – Pneumonectomy Intrapericardial Extrapericardial No reserve Sputum pO2 Fluid balance Infiltrates Temperature AF

40. Lung Resection – Lobectomy 3 Lobes on RT RUL RML RLL (not RUL & RLL) 2 lobes on LT LUL LLL

41. Wedge resection

42. Chest drains • What are they ? • Why use them ? • Suction and its role • What drain do you take out MARK IT

44. 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

45. 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

46. Chest Drain

47. Suction • What does it do? • Makes the external pressure negative • Air or blood drains more easily out of chest Dangers • 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

48. 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

49. Drain Removaland Timing of Drain Removal

50. 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