1. Cardiac
1.1. Includes procedures of the heart and associated great vessels performed to treat acquired or congenital.
1.1.1. New vocabulary
1.2. Surgical Anatomy
1.2.1. Heart - a muscular organ that consists of four hollow spaces, or chambers
1.2.2. Heart Valves - maintain unidirectional blood flow
1.2.3. Cardiac Cycle - the pumping action of the heart from one beat to the next
1.2.4. Conduction System - contains a network of specialized cells, which generate electrical activity along conduction pathways
1.3. Diagnostic Procedures
1.3.1. Cardiac Catheterization - an interventional radiology procedure that involves insert
1.4. Case Planning
1.4.1. Positioning
1.4.1.1. Median sternotomy (supine) - a artial or full midline incision is made through the sternum
1.4.1.2. Paramedium (supine) - the incision is made to right or left of the sternum; used for minimally invasive procedures and lymph node biopsy
1.4.1.3. Anterolateral, posterolateral - a modification of the lateral position in which the patient is supine with soft adding under the hip and shoulder of the affected side.
1.4.2. Instruments and Equiment
1.4.2.1. General set augmented with cardiac instruments, general thoracic instruments, stapling devices, and lung instruments
1.4.2.2. Rumel tourniquet - a short length of synthetic tubing either commercially prepared or cut from a straight (Robinson) urinary catheter; threaded over cannulation sutures to help hold them in place; used when large vessels are occluded or isolated with a vessel loop or umbilical tape
1.4.2.3. Coronary Artery Instruments - extremely delicate; scissors, forces, needle holders; similar to vascular instruments; angled at the tips; longer instruments with precision tips
1.4.2.4. Valve Instruments - include special retractors to expose the valve, suture holders, and accessories for the valve prosthesis; sizers and holders
1.4.2.5. Aneurysm Instruments - dissecting instruments and vascular clamps
1.4.2.6. Endoscopic Instruments - used during video-assisted thoracoscopy (VATS)
1.4.2.7. Vessel and Patch Grafts
1.4.2.7.1. Prosthetic grafts - used to replaced abnormal, diseased, or injured segments of an artery or vein
1.4.2.7.2. Available in assorted sizes
1.4.2.7.3. Two most common grafts
1.4.2.7.4. Preclotting - method of preparing a graft to prevent leakage; the graft is flushed with blood, which provides a seal between the fibers of the graft; seldom required, because woven and knitted grafts are impregnated with collagen.
1.4.2.7.5. Available as straight or bifurcated tubes made of Teflon, Dacron, or polytetrafluoroethylene (PTFE)
1.4.2.7.6. Patch grafts - made of Teflon (PTFE); used to strengthen a suture line or to close a defect (an abnormal opening in the tissue).
1.4.2.8. Prosthetic Valves - extremely expensive; should be handled as little as possible
1.4.2.8.1. St. Jude Medical (mechanical) valve
1.4.2.8.2. Hancock porcine (biological ) valve - stored in a glutaraldehyde solution, which must be removed by rinsing the valve in three separate basins of normal saline for 2 minutes in each basin (for a total of 6 minutes)
1.4.2.9. Pacemaker - a device that produces electrical impulses tha tstimulate the heart muscle
1.4.2.10. Defibrillator - required to convert fibrillation) ineffectual quivering of the ventricles) into a functional rhythm
1.4.2.11. Fibrillator - causes the heart to quiver, during repair of a leaking anastomosis
1.4.2.12. Cardiopulmonary Bypass
1.4.2.12.1. Heart-lung machine - takes the place of the heart and lungs by pumping and perfusing blood, which has been shunted outside the body
1.4.2.12.2. Heart-lung pump - collects the blood, removes excess carbon dioxide, oxygenates the blood, and returns it to the body
1.4.2.12.3. Sterile cannulas - shunt the blood away from the heart
1.4.3. Drugs
1.4.3.1. Heparin - an anticoagulant that prevents the conversion of fibrinogen to fibrin; does not dissolve blood clots, but prevents them from forming; administered through a large vein or the right atrium before cannulation for cardiopulmonary bypass or before a blood vessel is occluded; prevents blood clot formation in the bypass circuit; dosage is calculated according to body weight; also distributed to the surg tech for local use on field
1.4.3.2. Protamine Sulfate - administered to reverse the anticoagulant effects of hearin; IV protamine administered after bypass has been completed and the cannulas have been removed
1.4.3.3. Lidocaine - (Xylocaine) 1% commonly used in the treatment of ventricular arrhythmia; controls particular rhythmic patterns including premature ventricular contractions and ventricular tachycardia
1.4.3.4. Epinephrine - has many actions, including cardiac stimulation; it cannot start a heart that has stopped beating, but it can stimulate the adrenergic receptors in the heart
1.4.3.5. Cardioplegic Solution - the intentional interruption of the heart's pumping action;
1.5. Surgical Procedures
1.5.1. Median Sternotomy - a midline incision used for surgical procedures of the heart and great vessels in the thoracic cavity
1.5.2. Cardiopulmonary Bypass - diverts blood away from the heart and lungs so that surgery can be performed
1.5.3. Sump Catheterization - a sump catheter is inserted into the left ventricle soon after cardiopulmonary bypass has been established to suction blood and air and maintain cardiac decompression; reduces the risk of air embolism in the systemic circulation
1.5.4. Infusion of a Cardioplegic Solution - used to stop the heart; reduces the energy required by the cardiac muscle by eliminating the energy requirements of contraction
1.5.5. Coronary Artery Bypass Grafting - coronary artery bypass (CAB) of a narrow segment of one or more coronary arteries is performed to improve circulation to the heart; procedure is commonly known by its acronym, CABG, for coronary artery bypass grafting
1.5.6. Transmyocardial Revascularization - (TMR) a series of small-bore transmural channels creating with the carbon dioxide or holium-yttrium-aluminum-garnet laser to perfuse the myocardium; goal is to increase blood flow to the heart in patients in whom bypass surgery or medical management is not feasible; may be used in conjunction with standard CAB
1.5.7. Resection of a Left Ventricular Aneurysm - resection of a left ventricular aneurysm reduces the risk of rupture and embolism
1.5.8. Aortic Valve Replacement - involves the replacement of a diseased valve
1.5.9. Mitral Valve Repair and Replacement - a diseased mitral valve is replaced to open a constricted valve (stenosis) or to prevent blood from regurgitation into the left atrium;
1.5.10. Resection of an Aneurysm of the Ascending Aorta - the repair of an aneurysm and restore function to the valve
1.5.11. Resection of an Aneurysm of the Aortic Arch - the repair of an aneurysm and restore adequate blood flow to the aorta and its branches
1.5.12. Resection of an Aneurysm of the Descending Thoracic Aorta - the repair of an aneurysm of the descending thoracic aorta to prevent rupture and life-threatening hemorrhage
1.5.13. Insertion of an Artificial Cardiac Pacemaker - pacemaker implanted in the body to correct cardiac arrhythmia caused by a disease of the conduction system
1.5.14. Replacement of a Pacemaker Battery - a malfunctioning pacemaker generator is replaced to prouce contnous pacing
1.5.15. Implantable Cardioverter-Defibrillator - an electronic cardiac defibrillating and monitoring device used in patients susceptible to ventricular fibrillation or ventricular tachycardia
1.5.16. Surgery for Atrial Fibrillation (Cardiac Ablation) - the selective destruction of diseased conductive tissue to correct atrial fibrillation
1.5.17. Pericardial Window - removal of accumulated blood or fluid in the pericardium, through the creation of a pericardial window, improves cardiac function
1.5.18. Pericardiectomy - removal of the adherent scar tissue improves cardiac function
1.5.19. Insertion and Removal of an Intraaortic Balloon Catheter - reduces the workload of the heart after myocardial infarction or in patients who cannot be taken off bypass
1.5.20. Ventricular Assist Device - used to wean patients from cardiopulmonary bypass when other means are ineffective
1.5.21. Heart Transplantation - the goal of heart transplantation is to replace a diseased heart with a healthy donor heart
2. Thoracic and Pulmonary
2.1. Definition - Thoracic and Pulmonary surgery includes procedures of the respiratory and thoracic cavity, excluding those that involve the heart and cardiac vessels.
2.2. Anatomy
2.2.1. Pharynx - lies behind the oral cavity and communicates with the nasal cavities.
2.2.2. Larynx - connects the trachea with the oopharynx
2.2.3. Trachea - begins at the larynx and branches into the two main airways the right and left primary bronchi and bronchial tree
2.2.4. Bronchi - Right bronchus is straighter than the left
2.2.4.1. Bronchioles - smaller branches of the bronchi
2.2.5. Lungs - Right lung has three lobes; Left lung has two lobes
2.2.5.1. Bronchopulmonary segments - smaller segments of the lungs
2.3. Respiratory Function
2.3.1. Ventilation - the breathing process; involves contraction of the diaphragm and accessory muscles and expansion of the ribs to pull air into the lungs
2.3.2. Diffusion (oxygen) - the transfer of oxygen from the alveoli in the lungs to the bloodstream
2.3.3. Perfusion (oxygen) - the movement and absorption of oxygen molecules into body tissues; oxygenation
2.4. Diagnostic Tests
2.4.1. Pulmonary Function
2.4.1.1. Tidal Volume - the amount of air exhaled during normal respiration
2.4.1.2. Minute volume - the amount of air exhaled per minute
2.4.1.3. Vital capacity - the total volume of air exhaled after maximum inspiration
2.4.1.4. Functional residual capacity - the volume of air remaining in the lungs after exhalation
2.4.1.5. Total lung capacity - the total amount of air in the lungs when fully inflated
2.4.1.6. Forced vital capacity - the amount of air expelled in the first, second, and third seconds after exhalation
2.4.1.7. Peak expiratory flow rate - the maximum amount of air expelled in forced expiration
2.4.2. Laboratory Tests
2.4.2.1. Complete blood count (CBC) - a basic screening tool for surgical patients
2.4.2.2. Arterial Blood Gases (ABGs) - arterial blood is assessed for oxygen and carbon dioxide levels and pH (acid-base balance)
2.4.3. Imaging Studies
2.4.3.1. Radiographs - used to screen for tuberculosis and other fibrotic diseases
2.4.3.2. Magnetic Resonance Imaging (MRI)
2.4.3.3. Ultrasound scans
2.4.3.4. Computed tomography (CT)
2.4.3.5. Pulmonary angiography - performed when CT scans are inconclusive for diagnosis of pulmonary embolism; blood vessels are injected with a contrast medium
2.4.3.6. Endoscopic procedures - performed to obtain biopsy specimens of cells, fluid, and tissue
2.5. Case Planning
2.5.1. Prepping and Draping
2.5.1.1. Incisions - posterolateral and anterolateral
2.5.1.2. Lateral position
2.5.1.3. Skin prep - extend from the neck to the iliac crest
2.5.1.4. Draping - body sheet, towels for squaring the incision, incise drape, and fenestrated thoracotomy drape
2.5.2. Instruments
2.5.2.1. General surgery
2.5.2.2. Chest wall
2.5.2.3. Lung
2.5.2.4. Bronchus clamps
2.5.2.5. Surgical stapling
2.5.2.6. Vascular clamps
2.5.3. Drugs and Solutions
2.5.3.1. Hemostatic Agents - to control bleeding from the lung surface and for coagulation at the site of anastomosis of the large vessels
2.5.3.2. Gelfoam soaked in thrombin
2.5.3.3. Absorbable collagen
2.5.3.4. Bone sealant (Ostene) - seals the cut edges of a rib or sternum
2.5.3.5. Fibrin sealant - to prevent he escape of air from a lung or bronchial anastomosis
2.5.4. Closed Chest Drainage
2.6. Surgical Procedures
2.6.1. Insertion of Chest Tubes - to provide closed chest drainage
2.6.1.1. Made of heavy Silastic or polyvinyl chloride
2.6.1.2. Inserted through a stab incision away from the surgical incision
2.6.1.3. Sutured to the chest wall with heavy, nonabsorbable sutures and dressed with petroleum gauze, fluffed, and flat gauze
2.6.2. Bronchoscopy - endoscopic examination of the trachea and bronchi
2.6.2.1. Goal is to assess the respiratory structures, remove specimens for biopsy, or perform a minor surgical procedure
2.6.2.2. Flexible Bronchoscopy
2.6.2.3. Rigid Bronchoscopy
2.6.3. Mediastinoscopy - endoscopic examination of the mediastinum through an incision
2.7. Thoracoscopy (Video-Assisted Thorcoscopic Surgery) - minimally invasive surgery of the thoracic cavity
2.7.1. Case Planning
2.7.1.1. Patient Preparation
2.7.1.1.1. Lateral Position with Operative side Up
2.7.1.1.2. General anesthetic
2.7.1.1.3. Prepped from the neck to the iliac crest and from bediside to bedside
2.7.1.2. Trocar and Cannulas
2.7.1.2.1. Three or Four Ports
2.7.1.3. Instruments
2.7.1.3.1. 10-mm lenses in sizes 0 and 30 degrees
2.7.1.3.2. Scope, camera, and light source
2.7.1.3.3. Thoracoscopy instruments
2.7.2. Thoracoscopy: Lung Biopsy - a small portion of lung tissue is removd for pathological assessment
2.7.3. Lung Volume Reduction Surgery - portions of the lung severely affected by chronic pulmonary emphysema are removed to improve pulmonary function
2.7.4. Scalene Node Biopsy - performed on patients with palpable nodes in the area of the scalene fat pads; performed to establish cancer staging or to confirm a diagnosis
2.7.5. Thoracotomy - the general term for open surgery of the thoracic cavity; procedure for opening and closing the chest
2.7.6. Lobectomy - a lobe of the lung is removed to prevent the spread of cancer or to treat a benign tumor
2.7.7. Pneumonectomy - the removal of the entire lung
2.7.8. Rib Resection for Thoracic Outlet Syndrome - performed to release the compression of the neurovascular tissue and restore function to the affected upper extremity, neck, or shoulder.
2.7.9. Decortication of the Lung - surgical removal of a portion of the parietal pleura
2.7.10. Lung Translplantation - one or both lungs is performed to remove a diseased lung and replace it with a donor lung
2.7.10.1. Single-Lung Transplantation (Recipient)
2.7.10.2. Bilateral Lung Transplantation (Recipient)