IN THE NAME OF GOD Incisions in cardiothoracic

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IN THE NAME OF GOD Incisions in cardiothoracic surgery Dr. mehdi hadadzadeh Assistant professore

IN THE NAME OF GOD Incisions in cardiothoracic surgery Dr. mehdi hadadzadeh Assistant professore of cardiovascular surgery

�A surgical incision opens an aperture into the thorax to permit the work of

�A surgical incision opens an aperture into the thorax to permit the work of the planned operation to proceed

�If an operation is difficult, you are not doing it properly, " applies directly

�If an operation is difficult, you are not doing it properly, " applies directly to the incision used

The choice of incision: � underlying pathology � the site (e. g. lung, chest

The choice of incision: � underlying pathology � the site (e. g. lung, chest wall, oesophagus) �experience of the surgeon

Types of incisions �Median Sternotomy �Posterolateral thoracotomy �Anterolateral thoracotomy �Lateral thoracotomy �Bilateral thoracosternotomy �Subxiphoid(pericardial

Types of incisions �Median Sternotomy �Posterolateral thoracotomy �Anterolateral thoracotomy �Lateral thoracotomy �Bilateral thoracosternotomy �Subxiphoid(pericardial window)

Posterolateral thoracotomy �gold standard of thoracic incisions � excellent exposure for most general thoracic

Posterolateral thoracotomy �gold standard of thoracic incisions � excellent exposure for most general thoracic procedures including the lung, heart, aorta, the lower esophagus, and diaphragm �This approach is also used for spinal operations

Preoperative preparation �Assessment of pulmonary function �given a dose of antibiotics preoperatively �preoperative education

Preoperative preparation �Assessment of pulmonary function �given a dose of antibiotics preoperatively �preoperative education and incentive spirometry training as to the importance of adequate inspiration postoperatively to prevent atelectasis (lung collapse

Position �complete lateral decubitus position �use of sandbags, rolled sheets front and back or

Position �complete lateral decubitus position �use of sandbags, rolled sheets front and back or bean bags supporting the back and the abdomen

�The lower leg is flexed at the knee and hip while the upper leg

�The lower leg is flexed at the knee and hip while the upper leg lies straight on the top of the pillow

�to avoid post operative complications ; � cutaneous necrosis, � venous thrombosis � or

�to avoid post operative complications ; � cutaneous necrosis, � venous thrombosis � or nerve compression.

�arm placed on an angle pad �free from any fixation.

�arm placed on an angle pad �free from any fixation.

Incision �The position of the vertebral spines and the nipple is notified. � The

Incision �The position of the vertebral spines and the nipple is notified. � The standard incision follows between scapula and mid-spinal line to the anterior axillary line � passing 3 cm below the tip of the scapula.

�The skin incision : No. 10 scalpel � latissimus dorsi and serratus anterior muscles

�The skin incision : No. 10 scalpel � latissimus dorsi and serratus anterior muscles : No. 10 scalpel or cautery �Posteriorly, the muscle layers of the rhomboid and trapezius are incised �The pleural space : incising the musculature between the ribs or via an osteotomy �transect the muscles on the superior border of the ribs to avoid injuring the neurovascular bundle. �ribs may be transected or resected

�at the level of the 5 th rib for exposure of the upper thoracic

�at the level of the 5 th rib for exposure of the upper thoracic area : COA �level of the 6 th or 7 th rib for lower thoracic area (e. g. , lower esophageal or diaphragmatic surgery)

�After operation drainage tubes must be placed �The rib approximator is closed and No.

�After operation drainage tubes must be placed �The rib approximator is closed and No. 1 chromic or No. 1 vicryl sutures are placed to encircle the bone along the length of the incision. � Silk sutures are to be avoided as it increases postoperative pain �The cut ends of the trapezius and latissimus dorsi muscles are then approximated and sutured �subcutaneous tissue is closed using an interrupted 3 -0 absorbable sutures. �The skin is closed using surgical clips or a running 4 -0 subcuticular stitch such as Monocryl.

disadvantages of this incision �increased potential for blood loss and moderate time requirement for

disadvantages of this incision �increased potential for blood loss and moderate time requirement for opening and closing the incision �prolonged ipsilateral shoulder and arm dysfunctions �compromised pulmonary function and chronic post thoracotomy pain syndromes �scolioses have been described in children

Median sternotomy �Most common thoracic incision �Indications: cardiac operations-anterior mediastinal lesions-bilateral lung procedures �Speed

Median sternotomy �Most common thoracic incision �Indications: cardiac operations-anterior mediastinal lesions-bilateral lung procedures �Speed in opening and closing �Supine position and arms in patient, s side

Incision �Incision from below the suprasternal notch toa point between the xyphoid and umblicus

Incision �Incision from below the suprasternal notch toa point between the xyphoid and umblicus �An electric saw with a vertical blade is used �An oscillating saw is used for repeated sternotpmy

�Bone wax is a useful tool to control bleeding from sternum �sterile mixture of

�Bone wax is a useful tool to control bleeding from sternum �sterile mixture of beeswax and isopropyl palmitate

�Sternal retractor is used in lower thired of the sternum and gradually opened

�Sternal retractor is used in lower thired of the sternum and gradually opened

�Stainless steel wire is at present the standard suture in median sternotomy

�Stainless steel wire is at present the standard suture in median sternotomy

Disadvantage of this incision �Scar formation �Brachial plexus injury �Chronic chest pain

Disadvantage of this incision �Scar formation �Brachial plexus injury �Chronic chest pain

Axillary(lateral)thoracotomy �Advantages: muscle sparing-ease and speed-good cosmetic �Disadvantages: limited exposure �Choice in majority of

Axillary(lateral)thoracotomy �Advantages: muscle sparing-ease and speed-good cosmetic �Disadvantages: limited exposure �Choice in majority of pulmonary resections , PDA ligation, PA banding and…. �Lateral decubitus position homolateral arm is abducted at 90° at the shoulder level, flexed at the elbow �Incision Between posterior border of pectoralis major and anterior border of latisimus dorsi �through the 4 th or 5 th intercostal space;

Bilateral thoracosternotomy(clamshell) �Previously choice for bilateral lung transplant �Incision along the inframammary creases and

Bilateral thoracosternotomy(clamshell) �Previously choice for bilateral lung transplant �Incision along the inframammary creases and across the sternum � 4 or 5 th intercostal space �Poor healing of wound

Anterolateral thoracotomy �Useful in variety of operation on heart, pulmonary resection and esophagus �Supine

Anterolateral thoracotomy �Useful in variety of operation on heart, pulmonary resection and esophagus �Supine and operation site elevated 30 degree

�Incision from lateral border of sternum to midaxillary at 4 or 5 interspace �Pectoralis

�Incision from lateral border of sternum to midaxillary at 4 or 5 interspace �Pectoralis major and seratus anterior is divided

Subxiphoid incision(pericardial window) �Indications: pericardial effusion, pericardial biopsy, epicardial pacemaker �Supine posision, midline incision

Subxiphoid incision(pericardial window) �Indications: pericardial effusion, pericardial biopsy, epicardial pacemaker �Supine posision, midline incision over the xiphoid

Intrapleural(chest) tubes �Whenever thoracotomy has been done �exit of fluids and air and monitors

Intrapleural(chest) tubes �Whenever thoracotomy has been done �exit of fluids and air and monitors of bloodloss �Separate incision