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Thoracotomy - Anastassiou
last updated May 2007
Patient Preparation:
CT scan + any other imaging in room
Key Equipment and Instruments:
Setup
patient on beanbag+jelly, Foley, kefzol IV, 2 lumen ET tube, bronchoscopy to confirm placement,
look at bronchi. confirm 2 lung independent ventilation, art line, sometime central line. lateral
decubitus position, axillary roll, beanbag up, trapeze. bottom leg bent, top leg straight, pillows in
between. shave axilla. mark incision. duraprep. square off with towels ioband. drape.
Procedure:
incise along thoracotomy incision.
LL: 5th intercostal space
UL: 4th intercostal space anteriorly
divide subcutaneous tissues, divide lattissumus dorsi.
retract serratus anteriorly to preserve. posteriorly, divide trapezius if seen, preserve rhomboids.
place scapular retractor, count 5th interspace (inferior to 5th rib)
enter rib space with bovie. open space.
divide 5th rib by lifting periosteum, bone cutter, then box cutter
retract with rib spreader
dissect hilum. use davol or ring forceps to retract lung away
dissect and take vein first with GIA blue 3.5mm stapler (use inferior counterincision if needed)
take branches of artery with 0-silk + clips
lympphatics with cautery
lung with GIA 45mm green (4.8mm)
bronchus with GIA 45mm green (4.8mm)
air leak test with under irrigant to 40cm pressure
tisseal if needed for pleural tears
2 chest tubes: 28F apical anterior, 28F angled posterior. anchor #0 silk horizontal mattress with
single throw to tie off upon pulling tube.
closure:
ribs: 1 loop PDS x2 simple inturrupted
muscle: 2-0 dexon in 2 layers
skin: 4-0 monocryl
dressing: dermabond or indermil
Bronchopulmonary segments of right lung
superior lobe
anterior
apical
posterior
middle lobe
lateral
medial
inferior lobe
anterior basal
lateral basal
medial basal
posterior basal
superior
Bronchopulmonary segments of left lung
superior lobe - other
anterior
apicoposterior (merger of "apical" and "posterior")
superior lobe - lingula
inferior lingular
superior lingular
inferior lobe
anteriormedial basal (merger of "anterior basal" and "medial basal")
lateral basal
posterior basal
superior
Postoperative Care:
minimize IVFs (keep Ivs TKO)
pull chest tubes out together at same time