1. Thoracic
1.1. Thoracospic Approach (VATS)
1.2. Thoracotomy Approach-preoperative preparations
1.2.1. Incision into the chest wall
1.2.1.1. posterolateral incision
1.2.1.2. anteriolateral incision
1.2.1.3. median sternotomy incision
1.2.1.4. lateral incision
1.2.2. Common diagnosis
1.2.2.1. Lung cancer
1.2.3. Equipment
1.2.3.1. thermal-regulating units
1.2.3.2. headlight
1.2.4. Pharmacology
1.2.4.1. Local injection
1.2.4.2. antibiotic irrigation
1.2.5. Instruments
1.2.5.1. Basic Instrument Set
1.2.5.2. Basic Thoracic Instrumentation
1.2.5.2.1. Retractors/re-approximator
1.2.5.2.2. Periosteal elevators and Rasps
1.2.5.2.3. Rongeurs
1.2.5.2.4. ringed instruments
1.2.5.3. Retractor Set
1.2.5.4. Extra Long Instruments
1.2.5.5. Mayo set-up apply principles of work simplification through knowledge of procedure
1.2.5.6. Backtable
1.2.6. Supplies
1.2.6.1. Anesthesia Supplies
1.2.6.1.1. double-lumen endotracheal tube
1.2.6.1.2. arterial line
1.2.6.1.3. central venous line
1.2.6.1.4. Epidural catheter
1.2.6.2. Unsterile Supplies
1.2.6.2.1. Sequential compression devices
1.2.6.2.2. thermal-regulating blanket
1.2.6.2.3. ESU dispersive pad
1.2.6.2.4. Urinary catheter kit
1.2.6.3. Sterile Supplies
1.2.6.3.1. Stapling devices
1.2.6.3.2. extended bovie tip
1.2.6.3.3. silk ties
1.2.6.3.4. chest tube
1.2.6.3.5. pleur-evac
1.2.6.3.6. Clip appliers
1.2.6.3.7. additional raytec and laps
1.2.6.3.8. kittners
1.2.6.3.9. Magnetic Pad
1.2.7. Position
1.2.7.1. Lateral or semilateral
1.2.7.1.1. Positioning Devices
1.2.8. Draping
1.2.8.1. 4-6 towels and transverse laparotomy drape
1.2.9. Procedure
1.2.9.1. Incision through (Skin, SQ and Muscle) and Hemostasis (10 blade and bovie)
1.2.9.2. If rib needs to be excised, it is done so at this time. (rib shears)
1.2.9.3. periosteum are stripped from rib
1.2.9.4. Parietal Pleura incised with scalpel and scissors/debakey
1.2.9.5. Retraction: Rib Spredder is placed for retraction
1.2.9.6. Dissection
1.2.9.6.1. Sharp-long metz/ong debakey
1.2.9.6.2. Blunt
1.2.9.7. Pneumectomy
1.2.9.7.1. the following structures are identified and isolated with vessel loops or umbilical tape
1.2.9.7.2. The identified structures above are clamped, ligated and divided
1.2.9.8. Lobectomy
1.2.9.8.1. the following structures are isolated, clamped and doubly ligated and divided
1.2.9.8.2. Additional fissures are clamped, divided and sutured closed
1.2.9.9. Segmental Resection
1.2.9.9.1. the following structures are identified and isolated with vessel loops
1.2.9.9.2. the identified structuers are then clamped, ligated and divded
1.2.9.9.3. Bronchus is clamped and remaining lung is inflated to confirm boundaries
1.2.9.10. Wedge Resection
1.2.9.10.1. the lobe is grasped with duval lung clamp
1.2.9.10.2. Hemostatic clamps are applied in three rows to outline the wedge and incision is made between clamps (or stapler is used)
1.2.9.10.3. Specimen is removed
1.2.9.11. Lung Transplant
1.2.9.11.1. Pneumectomy is performed with structures being isolated as close to the lung as possible
1.2.9.11.2. Pericardium is opened around the pulmonary veins to allow room for arterial clamps
1.2.9.11.3. Three anastamoses are completed for single-lung transplant
1.2.9.12. Decortication:
1.2.9.12.1. removal of fibrinous tissue deposits, cancer or membrane "rind" on the visceral and parietal pleura that interferes with pulmonary ventilation
1.2.9.12.2. membrane is incised and separated from visceral pleura using sharp or blunt dissection
1.2.9.13. Pleural Space is checked for hemostasis and air leaks
1.2.9.14. Pleural flap is sutured of bronchial stump
1.2.9.15. Chest tube insertion
1.2.9.15.1. inserted through the incision and exteriorized through a stab wound
1.2.9.15.2. tubes secured with haevy silk suture
1.2.9.16. Rib approximation
1.2.9.16.1. Rib approximator
1.2.9.16.2. heavy suture or wires to approximate ribs and close muscle layer
1.2.9.17. Muscle, Skin
1.2.9.17.1. 2-0 vicryl, staples or 4-0 monocryl
1.3. Other Surgical Procedures
1.3.1. First Rib Resection
1.3.1.1. Decompression for Thoracic Outlet Syndrome
1.3.1.2. Incision (skin, SQ, Muscle) 10 blade and ESU
1.3.1.3. Dissection
1.3.1.3.1. Blunt
1.3.1.3.2. Sharp
1.3.1.4. wedge is taken from center of ribs or rib is removed entirely using rib shears
1.3.1.5. Drain placed
1.3.1.6. Incision closed
1.3.2. Mediastinoscopy
1.3.3. Bronchoscopy
1.4. Special Populations
1.4.1. Pediatrics
1.4.1.1. Pectus Excevatum
1.4.2. Geriatric
1.4.2.1. Concerns: (anesthetic and post-operativ)e
1.4.2.1.1. increased risk of aspiration
1.4.2.1.2. Airway clearance
2. Cardiac Surgery (Fuller)
2.1. Learning Objectives:
2.1.1. Discuss anatomy and physiology relevant to cardiac surgery.
2.1.2. Describe the pathology related to cardiac surgical procedures.
2.1.2.1. Discuss indications for cardiac surgery
2.1.3. Identify diagnostic interventions related to cardiac surgery.
2.1.4. List equipment, instruments, supplies and medications needed for cardiac surgery
2.1.5. Identify special considerations for cardiac surgery
2.2. I
2.2.1. Introduction to Cardiac Surgery
2.2.1.1. Performed to treat acquired and congenital diseases of the heart and great vessels
2.2.1.2. Cardiac-surgery techniques build on those used in thoracic, general and vascular surgical procedures using both open and minimally invasive techniques but tend to be more complex and require equipment specialized only to this area
2.2.1.3. Due to the complexity this area requires a thorough understanding of cardio-thoracic anatomy and cardiac function
2.3. II.
2.3.1. Surgical Anatomy
2.3.1.1. Heart
2.3.1.1.1. Mediastinal space
2.3.1.1.2. Pericardium
2.3.1.1.3. Cardiac Muscle (Myocardium): capable of generating electrical impulses which cause the heart to contract
2.3.1.1.4. 4 chambers of the Heart
2.3.1.2. Heart Valves: Maintains unidirectional blood flow
2.3.1.2.1. AV valves
2.3.1.2.2. Semilunar valves
2.3.1.3. Cardiac Cycle
2.3.1.3.1. Pumping action from one beat to the next.
2.3.1.3.2. Two phases of the cardiac cycle
2.3.1.4. Conduction System
2.3.1.4.1. each phase of the cardiac cycle is triggered by an electrical impulse in specific areas of the heart
2.3.1.4.2. network of specialized cells which generate electrical activity along conduction pathways. Transmit nerve signals that cause the cardiac muscle to contract
2.3.1.5. Cardiac Anatomy I
2.3.1.5.1. Cardiac Anatomy II
2.4. III.
2.4.1. Pathology
2.4.1.1. Coronary Artery Disease
2.4.1.1.1. Atherosclerosis
2.4.1.1.2. leading cause of death in industrialized world
2.4.1.1.3. risk factors
2.4.1.2. Valvular dysfunction
2.4.1.2.1. Valve regurgitation
2.4.1.2.2. Valve stenosis
2.4.1.3. Aneurysm
2.4.1.3.1. ventricle
2.4.1.3.2. ascending thoracic aorta
2.4.1.3.3. aortic arch
2.4.1.3.4. descending thoracic aorta
2.4.1.4. Congenital anomalies
2.4.1.4.1. Septal defects
2.4.1.4.2. Tetralogy of Fallot
2.4.1.4.3. transposition of great arteries
2.4.1.4.4. tricuspid atresia (congenital absence or closure)
2.4.1.5. Infection
2.4.1.6. Pericardial effusion
2.4.1.7. Trauma
2.5. IV.
2.5.1. Diagnostic Procedures
2.5.1.1. ECG (resting electrocardiogram)
2.5.1.2. Stress Test (excercise ECG)
2.5.1.3. Mediastinoscopy
2.5.1.4. Radiology Tests
2.5.1.4.1. Positron emission tomography (PET) scan with or without stress test
2.5.1.4.2. Chest radiography
2.5.1.4.3. computed tomography scan (CT)
2.5.1.4.4. Angiography
2.5.1.4.5. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA)
2.5.1.4.6. Cardiac catheterization
2.6. V.
2.6.1. Perioperative Considerations
2.6.1.1. A.
2.6.1.1.1. Special Considerations
2.6.1.2. B.
2.6.1.2.1. Positioning
2.6.1.3. C.
2.6.1.3.1. Instruments
2.6.1.4. D.
2.6.1.4.1. Equipment
2.6.1.5. E.
2.6.1.5.1. Supplies
2.6.1.6. F.
2.6.1.6.1. Pharmacology
2.7. VI.
2.7.1. Surgical Procedures
2.7.1.1. A.
2.7.1.1.1. SET UP
2.7.1.2. B.
2.7.1.2.1. Coronary Artery Bypass Grafting (CABG)
2.7.1.3. C.
2.7.1.3.1. Aortic Valve Replacement
2.7.1.4. D.
2.7.1.4.1. Aneurysm Repair
2.7.1.5. E.
2.7.1.5.1. mechanical circulatory assistance devices and pacemakers
2.7.1.6. F.
2.7.1.6.1. Cardiac Window
2.7.1.7. G.
2.7.1.7.1. Cardiac Ablation
2.7.1.8. H
2.7.1.8.1. Heart Transplant
2.7.1.9. I.
2.7.1.9.1. Congenital Heart Disease