Patient Preparation
Most thoracic operations are facilitated by the placement of a double-lumen endotracheal (ET) tube or a bronchial blocker by the anesthesiologist. This allows isolation of the ipsilateral lung and greatly facilitates the conduct of the operation. Isolating the lung during minimally invasive or videoscopic thoracic surgery is almost mandatory. Often, the patient's poor pulmonary reserve does not permit single-lung ventilation and lung isolation.
Postoperative pain is best controlled with epidural analgesia. The epidural catheter is placed by the anesthesiologist, usually before the induction of general anesthesia; it can also be effectively used intraoperatively to complement general anesthesia. Pain control can also be achieved with an extrapleural, paravertebral catheter delivering a continuous infusion of fentanyl or bupivacaine (0.1%). If these options are unavailable, an intercostal nerve block with a long-acting local anesthetic (eg, 0.5% bupivacaine with epinephrine) at the time of chest closure aids the management of postoperative pain.
Preoperative antibiotic prophylaxis, usually within the hour preceding the skin incision, has been found to produce a significant reduction in wound infection rates and infectious complications. Usually, a first-generation or second-generation cephalosporin is chosen as the drug of choice, with Staphylococcus aureus (the most common pathogen) a primary target.
During positioning, the pressure points should be well padded. Foam pads for the elbows, an axillary roll for the dependent axilla to avoid injury to the brachial plexus, and pillows placed beneath pressure points on the legs are standard precautions.
An assessment of the risk of possible venous thromboembolism should be individualized for each patient. Measures to reduce this risk, which should be considered in all patients, include the following:
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Application of tight elastic hose stockings
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Use of sequential compression devices
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Perioperative use of heparin or enoxaparin
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Muscles of the chest wall (muscles that are commonly encountered during the performance of thoracotomies).
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Partial sternotomy. Combined with a transverse collar neck incision, an upper partial sternotomy gives excellent access to the trachea, thymus, thyroid, etc.
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The latissimus dorsi muscle. The latissimus dorsi muscle defines the nomenclature for standard thoracotomy incisions, with incisions through it arbitrarily defined as lateral.
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Basic thoracic incisions. Standard thoracotomy incision shown, which can be modified and minimized. Video-assisted thoracic surgery (VATS) incisions can also be incorporated into the standard incision.
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Clamshell incision (bilateral thoracosternotomy). The skin incision is in the inframammary crease, curving upwards toward the midline.
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Videothoracoscopic approach (VATS). Typical positioning of VATS instruments with the camera in the center position of the triangle.
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Anterior approach to Pancoast tumor. Neck incision along the sternocleidomastoid muscle, across the manubrium and then laterally below the clavicle.
Tables
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- Overview
- Periprocedural Care
- Technique
- Approach Considerations
- Sternotomies
- Thoracotomies
- Anterior Mediastinoscopy
- Transverse Thoracosternotomies
- Thoracoabdominal Incisions
- Extrathoracic Incisions
- Laparoscopy
- Video-Assisted Thoracoscopic Surgery
- Robotic-Assisted Thoracic Surgery
- Chest-Wall Resection and Reconstruction
- Approaches to Pancoast Tumors
- Postoperative Care
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- Media Gallery
- References
