pract. 9 - operations of the thorax (sem 2)

Layers of the Thorax

• Skin

• Subcutaneous fat

• Superficial fascia

• Deep fascia

• Extrinsic muscles

• Intrinsic muscles

• Endothoracic fascia

• Parietal pleura

• Visceral pleura

• Lung

Types of Thoracic Injuries

• Crush injuries: lung, pleura, ribs

  • external pressure

• Single rib fracture

• Multiple rib fractures

• Steering wheel injury: bilateral rib fractures, flail chest, sternal fracture

• Stove-in chest / Flail chest

  • a section of the rib cage becomes detached from the rest of the chest wall

  • due to fractures in multiple ribs

• Traumatic (open) pneumothorax

• Hemothorax / Hemopneumothorax (commonly with fractured ribs)

• Tension pneumothorax (most dangerous)

• Pericardial or cardiac rupture, bronchial rupture

• Associated injuries: liver, spleen, diaphragm, major vessels

Trauma Classification

• Penetrating: parietal pleura is breached

• Non-penetrating: parietal pleura remains intact

Thoracic Surgeries

• Lobectomy

  • Surgical removal of a lobe of the lung

• Pneumonectomy

  • Removal of an entire lung

• Segmentectomy

  • Removal of a specific segment of a lung lobe

• Wedge resection

  • Removal of a small, wedge-shaped portion of the lung that includes the lesion and a margin of healthy tissue.

• ICD insertion

  • (Intercostal Drain / Chest Tube Insertion)

  • Insertion of a tube into the pleural space to remove:

    • Air (pneumothorax)

    • Blood (hemothorax)

    • Pus (empyema)

    • Fluid (pleural effusion)

thoracic incisions

• Median sternotomy

• Posterolateral thoracotomy

• Anterolateral thoracotomy

• Clamshell incision

Median Sternotomy

• Incision:

  • Vertical cut through the sternum

  • just below the neck to below the sternum

• Access: Both lungs, heart and mediastinum

• Commonly used for:

  • Cardiac surgeries

  • (e.g., CABG, valve replacement)

  • Bilateral lung procedures

Posterolateral Thoracotomy

• Incision: From back (posterior axillary line),

  • around to the front of the chest

• Involves cutting through the latissimus dorsi and intercostal muscles

• Access: One side of the thoracic cavity (excellent view of lung, oesophagus, aorta)

• Used for:

  • Lobectomy

  • Pneumonectomy

  • Esophageal surgery

Anterolateral Thoracotomy

• Incision: Along the anterior chest wall

  • (4th–6th intercostal space)

  • more toward the front

• Access: Heart, anterior lungs, chest wall

• Used for:

  • Emergency thoracotomies (e.g., trauma)

    • relieve the pressure- cardiac tamponade

    • clamp the blood vessel (aorta)- haemorrhage

  • Some cardiac procedures

Clamshell Incision

• Incision:

  • Bilateral transverse thoracotomy

  • across the chest (under the breasts),

  • joining both sides

  • → opens chest like a clamshell

• Access: Both lungs, entire mediastinum, heart, great vessels

• Used for:

  • Bilateral lung transplantation

  • Extensive trauma

  • Mediastinal tumors

pathological effects of chest injuries

Immediate effects

• Hypoxia

• Hypercapnia

• Acidosis

• Hypovolemic Shock

  • Due to internal bleeding

• Cardiac Arrhythmias

• Bronchospasm

  • Reflex airway narrowing

  • In response to trauma or pain

  • → worsens hypoxia

Late Effects

• Empyema

  • Collection of pus in the pleural cavity

• Fibrothorax

  • Thickening and fibrosis of the pleural space

• Lung Abscess

• Mediastinitis

  • Severe infection of the mediastinum

Thorax Boundaries (According to Stef)

• Superior: suprapleural membranes

• Posterior: vertebral bodies

• Lateral: ribs & intercostal muscles

• Anterior: sternum & costal cartilages

• Inferior (floor): diaphragm

Anatomical lines

What are the 4 manipulations of the thorax? (stef question)

Puncture

Thoracocentesis

• controlled puncture of the pleural space

• using a needle or cannula.

• To remove fluid or air from the pleural cavity.

VATS (video assisted thoracoscopic surgery)

• using a thoracoscope (camera) and small incisions.

• Purpose:

  • Lung biopsy

  • Pleural biopsy

  • Lobectomy or wedge resection

  • Decortication for empyema

Thoracotomy (incision)

• A major open surgical incision into the thoracic cavity.

• Purpose: Direct access to lungs, heart, oesophagus, and major vessels.

Operations- names only

• Thoracocentesis

• Pneumothorax

• Pericardiocentesis

• Rib resection

• Pleurodesis

• Empyema

• Decortication

Thoracocentesis

(Pleural Puncture)

• Purpose: Diagnostic or therapeutic aspiration of pleural fluid.

• Position: Patient seated, leaning forward.

• Site: 8th–9th intercostal space

  • mid/posterior axillary line.

• Technique:

  • Local anesthesia (1%)

  • Needle inserted above upper border of rib below (to avoid neurovascular bundle)

  • Antibiotic instillation post-aspiration

Pneumothorax

• Definition: Entry of air into pleural cavity, collapsing lung.

• Types:

  • Spontaneous

  • Traumatic

  • Tension → Most dangerous

    • Mechanism: Air enters during inspiration but can't exit

      → pressure ↑

      → mediastinal shift

      → ↓ venous return

      → heart failure

    • Emergency: Needs needle decompression

      • 2nd ICS

      • midclavicular line

      • or chest tube

Pericardiocentesis

• Purpose: Aspiration of fluid/blood from pericardial sac

• Indication: Cardiac tamponade

• Approach: Insert needle just below xiphoid,

  • angle 45°

  • directed upwards and leftwards

• Needle: 16 or 18G

Rib Resection

Surgical removal of a rib

Purpose:

• Access to thoracic organs

• Rib tumour excision

Pleurodesis

• part of the pleural space is artificially obliterated.

• It involves the adhesion of the visceral and the costal pleura.

• stick visceral to costal pleura

  • The mediastinal pleura is spared

Empyema

• Definition: Pus in the pleural cavity

• Caused by:

  • Lung abscess rupture

  • Pneumonia complications

  • Surgery, trauma

• Phases:

  1. Exudative: Thin pus

     Fibropurulent: Thick, fibrinous

  2. Organising: Fibroblast rind forms

• Tx: Thoracocentesis + antibiotics ± surgery

Decortication

• Removal of restrictive layer of fibrous tissue over the lung

• Helps the lung tissue to re-expand

Terminology (stef question)

• Pneumothorax- presence of atmospheric air in the thorax

• Hemothorax- presence of blood in the thorax

• Pyothorax- presence of pus in the thorax

• Chylothorax- presence of lymphatic fluid in the thorax

• Hydropneumothorax- presence of liquid and air in the thorax

• Lobectomy- removal of a lung lobe

• Pneumonectomy/ pulmonectomy- removal of the whole lung

• Pneumonothorax- presence of pus and blood in the thorax