Cardiothoracic surgery Q&A 2019

Cardiothoracic surgery Q&A 2019

• 1.
  P a ge | 1 Cardiothoracic Surgery Q&A 2019 Kareem Alnakeeb Video-assisted thoracoscopic surgery (VATS)  VATS set consists of: 1. Telescope 2. Camera head & camera source 3. Light cable & light source 4. Screen 5. Instruments: long, double joint instruments  Indications: - Biopsies from pleura, lung, mediastinum or diaphragm - Decortication - Bullectomy and blebectomy - Pulmonary resection, wedge resection or lobectomy - Thymectomy in cases of thymic tumors & myasthenia gravis. - Resection of pulmonary and mediastinal tumors. - Repair of diaphragmatic eventration and hernia - Post-traumatic exploration in only vitally stable patient  Contraindications: - Lack of well-prepared VATS set and instruments. - Untrained surgeon - Unstable patient - Inability to tolerate single lung ventilation. - Inability to do a complete job as open thoracotomy (ex, complete oncological clearance). - Extensive adhesions (in early learning curve), possible with experienced surgeon.  When to convert to open thoracotomy? - Emergent complication: Uncontrollable bleeding. - Technical problems: (Equipment or stapler malfunction - Poor visualization). - Anatomical or oncological problems: • Extensive adhesions with inability to further progress • Inability to do a complete job as open thoracotomy (ex, complete oncological clearance or if you need to palpate). • Accidentally discovered lesion which is beyond surgeon’s experience to deal with thoracoscopically.
• 2.
  P a ge | 2 Cardiothoracic Surgery Q&A 2019 Kareem Alnakeeb  Advantages: - Cosmetic wounds. - Less postoperative pain - Less postoperative hospital stay - Less incidence of wound infection - Faster return to normal life  Disadvantages: - Cost (staplers) - Difficult control in cases of emergent bleeding  you have to convert to open thoracotomy if uncontrolled - Relatively longer operative time  shortened with advanced learning curve  Philosophy of minimally invasive cardiothoracic surgeries: - Less pain - Less blood transfusion - Less Cardiopulmonary Bypass (CPB) - Cosmetic wounds  Types of pulmonary resection: - Anatomic resection: (Pneumonectomy, Bilobectomy, Lobectomy, Segmentectomy) - Non-anatomic resection: (wedge resection)  Causes of pneumothorax: 1. Primary spontaneous ▪ Due to rupture of apical subpleural bleb or cysts. ▪ Occurs most frequently in tall, thin, young males and smokers. 2. Secondary spontaneous ▪ Due to diseased lung (eg, bullae in emphysema, infections). 3. Traumatic ▪ Caused by blunt (eg, rib fracture), penetrating (eg, gunshot), or iatrogenic (eg, central line placement, lung biopsy, barotrauma due to mechanical ventilation) trauma
• 3.
  P a ge | 3 Cardiothoracic Surgery Q&A 2019 Kareem Alnakeeb  Types of pneumothorax: 1. Simple (closed) 2. Open 3. Tension: Air enters pleural space but cannot exit. May lead to  intrathoracic pressure  mediastinal displacement  kinking of IVC   venous return   cardiac output  Lines of treatment of pneumothorax - Observation (X-ray /6h) - Aspiration - Chest tube - Exploration (Surgery or VATS)  Median Sternotomy Advantages: Disadvantages (Complications): - Good exposure - Easy - Rapid - Familiar to surgeon - Dehiscence or bone fractures - Infection (superficial or deep mediastinitis) - Bleeding - Disfiguring scar or keloid - Infected sinus - Painful stainless wire  Most common Mediastinal masses: Some pathologies (eg, lymphoma, lung cancer, abscess) can occur in any compartment, but there are common associations: Anterior: Thyroid, Thymic neoplasm, Teratoma, “Terrible” lymphoma. Middle: Esophageal carcinoma, metastases, hiatal hernia, bronchogenic cysts. Posterior: Neurogenic tumor (eg, neurofibroma), multiple myeloma  Ideal prosthetic valve: - Cheap - Available - Easy to implant - Durable - Inert - Silent - Not need long-life anticoagulation
• 4.
  P a ge | 4 Cardiothoracic Surgery Q&A 2019 Kareem Alnakeeb  Modalities of surgery for Mitral Valve Disease: - Closed mitral valvotomy - Open mitral valvotomy Rarely used - Mitral valve replacement - Mitral valve repair Closed mitral valvotomy Indications Contraindications - Surface area of MV < 2 cm2 . - Diastolic pressure gradient > 5 mmHg. - Severe symptoms. - Massive uncontrolled hemoptysis (urgent).  The best valve for CMV is isolated pliable non-calcific valve with doming leaflets. - Calcific MS. - Heavily fibrotic immobile leaflets. - Incompetent valve. - Left atrial thrombus. - History of systemic embolization. - Hemiplegia or paraplegia.  Indications for open mitral valvotomy: - Isolated mitral stenosis with: o Left atrial thrombus. o History of systemic embolization. o Hemiplegia or paraplegia.  Indications for mitral valve replacement: - Calcific mitral stenosis. - Extensive fibrotic immobile stenotic valve. - Severe mitral incompetence. - Native valve endocarditis. - Prosthetic valve endocarditis. - Stuck prosthetic valve.  Indications for mitral valve repair: - Severe mitral incompetence due to: o Myxomatous degeneration of mitral valve. o Floppy mitral valve. o Ruptured chordeae. o Elongated chordeae. o Selected cases with limited valve calcification, rheumatic etiology, endocarditis.
• 5.
  P a ge | 5 Cardiothoracic Surgery Q&A 2019 Kareem Alnakeeb  Advantages of mitral valve repair: - The original valve is preserved. - No need for long-life anticoagulation. - No hazards of thromboembolic complications. - No hazards of mechanical complications of prosthetic valves. - No hazards of calcification or degeneration of biological valves.  Diaphragmatic Eventration: - Def: all or part of the diaphragmatic muscle is replaced by fibroelastic tissue. - Can be congenital or acquired - Many patients are asymptomatic - Can be seen incidentally on chest x ray & diagnosis is confirmed by fluoroscopy or US - In infants the management depends on the extent of the respiratory distress, often NO need to treatment  Congenital diaphragmatic Hernia: - due to failure of fusion of diaphragmatic components during development - Types:  Bochdalek hernia: ▪ Common (95%) ▪ Posterolateral ▪ May protrude into the posterior mediastinum  Morgagni hernia: ▪ relatively uncommon ▪ anterior retrosternal or peristernal ▪ herniation of omentum and other abdominal contents into the thorax manifest as a right cardiophrenic angle mass - Diagnosis by: GI barium study or CT. - Treatment is surgical in symptomatic cases.