Cardiothoracic Surgery

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Cardiothoracic Surgery
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I. Definition

• Cardiothoracic surgery is the surgery
  concerned with all structure that lie within the
  thoracic cage like , ribs , lungs , heart ,
  esophagus

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II . Types

• A. Cardiac Operation
• Closed Cardiac , as ( closed mitral valvotomy
  CMV and closure of patent ductus arteriosus PDA
  )
• Open Cardiac Using cardiopulmonary by pass
  machine as in repair of congenital heart disease
  and coronary heart by pass graft..

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• B. Non Cardiac Operation
• As lung resection (pneumonectomy ,
  lobectomy )
• and thymectomy,

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III. Incision

• Thoracotomy
• 1- Definition It is an incision into the
  thoracic cavity to gain access to lungs , bronchi
  , heart and oesophagus.

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2-Types

• Lateral Incision
• A. Antero Lateral.
• B. Postero Lateral.

• Anterior Incision
• Transverse.
• Vertical.

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Anterolateral

• - Start close to midline in front, follows along
  the line of a rib below the breast to the
  posterior axillary line.
• - Used for approaching anterior thoracic
  structures, as in closed mitral valvotomy and
  pleurectomy.
• The muscle cut are pectoralis major and minor,
  serratus anterior, internal and external
  intercostals.
• The intercostals space is entered through the
  upper border of the six or the fifth rib.

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Posterolateral

• Follow the vertebral border of the scapula and
  the line of a rib ( 5,6,7 or 8 ).
• Used in dealing with posterior structures as in
  lung operations.
• The muscle cut are trapezius, latissimus dorsi ,
  rhomboids, serratus anterior , intercostals and
  erector spinae.
• A rib may be removed , so that when other ribs
  are retracted there is sufficient space for
  access to the thorax

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Transverse.

• - Submammary and bilateral, through the fourth
  intercostal space and transversely divide the
  sternum.
• - The pectoralis major is divided together with
  internal and external intercostals.

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Vertical

• The incision passes through the meeting of the
  two pectoralis major in front of the sternum and
  opening of the linea alba (meeting of the two
  recti) then sawing of the sternum.
• Used for doing more than 95 of open heart
  surgery and in thymectomy.

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IV. Drainage System

• 1- Pleural cavity is a closed space with
  negative pressure -3 to -5 to prevent collapse of
  the lung.
• 2- Pericardial sac protect the heart.
• Any collection of fluid or air will cause
  impairment of respiration and cardiac function in
  proportional to collected amount.
• - Drainage Removal of unwanted fluid and air
  from the thorax following surgery or trauma.

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Types

• Closed
• -Simple air tight system is used to allow drain
  and prevent air entry.
• -Rubber tube introduced into the interthoracic
  space and fixed with suture.
• -The other end connected to calibrated glass
  tube which terminates under the water.
• - The oscillations of water inside the under
  water pipe represents the respiratory movement.

• B. Opened
• A tube may be inserted into a pocket of pus
  which then drain out onto a dressing.

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Causes of intra-thoracic Collection

1. After any thoracic operation.
2. Traumatic
3. Inflammatory.
4. Neoplastic.

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What will be drained

• Air Pneumo -thorax.
• Blood Haemo - thorax.
• Serous Hydro thorax
• Pus Pyo Thorax.

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Area of drain

• 1- Pleural.
• 2- Mediastinal.
• A) Pericardial.
• B) Retrosternal.

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Points to be noted

• Amount and type of drainage
• 200 ml in the first 24 hours.
• Air can be seen as a bubbles in the water.
• If bubbles stop, it may because of
• a) all air has been removed.
• b) the tube is locked.

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• 2- Swing of water
• The level of water fall in inspiration and rises
  in expiration.
• If swing stop
• a) Lung is fully expanded.
• b) tube is blocked.

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• 3-Suction
• Pull the water level in the bottle up
• Creating a negative pressure
• Pull the water in the tube down
• Creating suction effect on the air or fluid
  in the pleural cavity.

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• 4- The Tubes
• Fixed to the thoracic wall by a stitch and
  should not detached from the patient or from the
  bottle.

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• 5-Clamps
• Used when the bottle is to be changed or
  removed.

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When remove the drain

• When the drained fluid is completely clear
  and its amount is less than 300 cc per day.

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