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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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244 Decortication of the lung
c
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An empyema classically progresses
1a, b, c
1 Exudative
2 Fibropurulent with loculations
3 Organizing with a thick fibrin wall
An exudative empyema is watery with a leucocyte count of
less than 6 400 per mL. At this stage it can be conveniently
drained by a wide-bore needle, an image-guided catheter
placed under radiographic or ultrasonographic control, or an
intercostal catheter.
through three phases:
a
b
If the effusion is not completely drained, it then evolves
into a multi-loculated fibropurulent lesion, which requires a
more formal approach for management. Often the empyema
is sterile after treatment by appropriate antibiotics, and the
patient is no longer toxic; but if the lesion is left, the underlying lung becomes entrapped, which leads to the ongoing danger of recrudescence of local infection.
At this stage, the insertion of an intercostal catheter, even
with the adjunctive use of streptokinase, is ineffective, and the
treatment choice is between a muscle-sparing minithoracotomy or a video-assisted thoracoscopic clean-out of the space
and removal of peel from the underlying lung.
PREOPERATIVE ASSESSMENT AND
PREPARATION
A video-assisted thoracic surgery (VATS) approach results in
a shorter hospital stay and less postoperative morbidity and is
the procedure of choice. The exact stage at which an
1a
1b
1c
empyema becomes mature and the peel can no longer be handled by a VATS approach is often blurred, and the surgeon
should not hesitate to open the chest and proceed with a formal decortication if necessary. In my hands the conversion
rate has been 30%, but the rate inevitably varies depending on
the enthusiasm with which the VATS approach is used.
OPERATION
e
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Video-assisted thoracoscopic approach
Operation 245
The best studies for detecting and localizing a
2a, b
tomographic scan and percutaneous ultrasonography. Figure
fibropurulent empyema are the computed
2a
2a is a computed tomographic scan that shows a loculated
empyema treated by decortication using VATS. Figure 2b is
an ultrasonogram of a basal right loculated collection.
2b
Modified
sponge
holder
3
Telescope
Wide-bor
sucker
The operation is carried out under an anesthetic using a
3
double-lumen tube, which allows protection of the
dependent lung. The patient is placed in the full lateral position with the scapula pulled well forward. A three-point triangular approach is used, and modified sponge holders and
large-bore suction devices are used to evacuate the pleural
space of debris. Usually only one port for the telescope is
required as the other instruments are easily introduced
through short incisions. The port for the telescope is moved
along with the instrument for better lateral views.
If the peel over the parietal pleura is soft, it can be safely
worked off the underlying structures with the modified
sponge holders. The space is then irrigated with an antibiotic
saline solution, and two or more drainage tubes are left in situ
via the port sites. Care should be taken to check that the
underlying lung re-expands to fill this space. Gentle suction is
applied postoperatively.
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Decortication
Mature empyemas with a thick rind require a formal decortication via a thoracotomy unless the patient is too frail or has
significant comorbidity that rules out a major procedure in
which case a rib resection and drainage is preferable. It used
to be advised that it was necessary to wait six weeks for the
peel to mature and strip more easily, but modern imperatives
mandate proceeding with treatment expeditiously.
The peel over the parietal pleura splints the chest wall
4
and causes the ribs to become contracted as it matures.
The peel over the lung entraps it and prevents it from reexpanding. If the ribs are contracted, then a full rib resection
during the approach is helpful and aids in starting to strip the
parietal pleura from the chest wall before inserting a rib
spreader.
4
5
The peel should be stripped from the lung with care
6
using a peanut on a long artery forceps for blunt dissection to avoid air leaks as far as possible.
The aim of the procedure is to perform a total empyec-
5
tomy. This goal is often not feasible because of difficulties at the apex and over the diaphragm, and frequently the
cavity must be opened and the visceral pleura approached
directly.
6
The fissures should be cleared and, in extreme cases in
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7
which the peel is adherent to the lung without an apparent plane, it can be cut in a crosshatched manner and the
anesthetist asked to vigorously reinflate the lung.
Obtaining full reinflation of the lung is important, as any
residual space will lead to a further empyema, and this goal
can usually be accomplished with persistence. On rare occasions a small space will remain despite the surgeon’s best
efforts, in which case it can be filled with a muscle flap. Small
superficial air leaks can be ignored as they will stop when the
lung abuts the chest wall, but any tears in the lung should be
sutured with an absorbable suture or treated with tissue glue.
Oozing from the raw chest surface can be a problem and must
receive attention. Two or more intercostal catheters are left in
situ and placed on gentle suction, and physiotherapy is
started as soon as the patient is awake. Antibiotics should be
continued to cover at least the early postoperative period.
POSTOPERATIVE CARE
Postpneumonic empyemas are generally easier to treat than
specific empyemas such as those due to tuberculosis, but the
principles are the same. Similarly, although children have
remarkable powers of healing compared with adults, they
should not be left with thickened pleura and splinted chest
walls, and an aggressive approach using a VATS technique in
early cases and open decortication in later cases is justifiable.
Postoperative care 247
7
A small number of patients exist with trapped lung and
8
malignant effusions when the peel is infiltrated with
tumor which prevents easy dissection yet where decortication
is useful. These include patients with stable carcinoma of the
breast who have neglected malignant effusions and patients
with localized malignant mesothelioma who are having
debulking of the tumor before adjunct phototherapy. In these
cases the tumor cells grow directly into the lung, which prevents simple removal of the rind and requires careful excision
with a scalpel.
This procedure results in superficial air leaks; but if the
lung can fully re-expand, these leaks generally cease within a
few days. The lung should be tested by re-expansion under
saline, and any large leaks should be managed by direct
suture, superficial diathermy, or tissue glue. Two or more
drain tubes are then introduced and gentle suction is applied.
8
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OUTCOMES
The earlier an empyema is treated, the better the outcome, as
there is less likelihood of ending up with residual pleural
thickening leading to splinting of the chest with impaired
pulmonary function.
The best results can be expected in younger patients and
those without significant co-morbidities. In older patients,
and particularly when there are associated problems, a balance has to be struck between the desire to end up with a good
functional result and the dangers of major operative procedures.
FURTHER READING
Angelillo-Mackinlay T. Empyema and haemothorax. In: Yim APC, Izzat
MB, Landreneau RJ, Mack MJ, Naunheim KS eds. Minimal access
cardiothoracic surgery. Philadelphia: WBSaunders, 2000: 48–57.
Maskell NA, Davies CW, Nunn AJ, et al. First Multicentre Intrapleural
Sepsis Trial (MIST) Group. UK Controlled Trial of intrapleural
streptokinase for pleural infection. New England Journal of Medicine
2005; 352: 865–74.
Shields TW. Decortication of the lung. In: Shields TW ed. General
thoracic surgery. Baltimore: Williams & Wilkins, 1994: 710–13.
Striffeler H, Gugger M, Im Hof V, Cerny A, Furrer M, Ris HB. Video-
assisted thoracoscopic surgery for fibrinopurulent pleural empyema
in 67 patients. Annals of Thoracic Surgery 1998; 65: 319–23.
Thurer RJ. Decortication in thoracic empyema. Chest Surgery Clinics of
North America 1996; 6(3): 461–90.
Thoracic incisions
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M. BLAIR MARSHALL MD
Chief, Division of Thoracic Surgery, Georgetown University Medical Center, Washington DC, USA
23
PRINCIPLES AND JUSTIFICATION
In approaching the chest, numerous options are available to
choose from as a means of entry into the thorax. These
approaches can be modified to fit special circumstances. The
art of thoracic surgery starts with the decision-making for
each approach with or without modifications to suit each
particular situation.
OPERATION
Posterolateral thoracotomy
The posterolateral thoracotomy has been the incision of
choice for many thoracic procedures and continues to be
the most frequently used incision. The incision gives full
exposure of the entire thoracic cavity and has stood the
test of time. When made through the fifth intercostal
space, the hilum can be readily accessed for exposure and
control of the pulmonary artery, veins, the distal trachea,
and bronchi.
A sandbag is placed on the operating table prior to putting
the patient on the table. The patient is induced with general
anesthesia after placement of a thoracic epidural catheter. A
Foley catheter and pneumatic compression stockings are
placed. The endotracheal tube is positioned, and bronchoscopy is performed evaluating the trachea, right and left
bronchi down to the subsegmental level. We then change the
endotracheal tube to a double-lumen tube, and the patient is
placed in the full lateral decubitus position. The patient’s
superior posterior iliac spine is positioned at the level of the
break in the table. The free arm is brought up, flexed at the
elbow, and supported with a padded armrest. The bottom leg
is flexed at the knee, and pillows are placed between the legs.
Frequently, the bottom foot will need additional padding.
The bed is maximally flexed to stretch the intercostal space.
The axilla is usually adequately protected by the beanbag,
although in some cases additional protection is required. The
chest is prepped and draped.
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The standard skin incision follows an arc between
1a
inferior border of the scapula and the second being the midpoint between the thoracic spine and the medial margin of
the scapula. From this arc, the lateral extension of the incision
continues across horizontally as needed. The posterior extent
of this incision may be continued up to the base of the neck
paralleling the spine for a posterior approach to superior sulcus tumors and other chest wall resections. The length of the
incision is determined by the extent of the procedure being
performed.
two anatomical points, the first being 2 cm below the
1a
Once the skin and subcutaneous tissues have been divided,
the latissimus dorsi is divided. Small vessels are cauterized. In
the case of a limited incision, we try to spare the serratus anterior. The areolar tissue along the posterior edge of the serratus is divided obliquely extending inferiorly toward the
anterior margin of the latissimus. The incision is continued
between the latissimus and serratus allowing for further
mobilization. When a more extensive posterior incision is
required, as for first rib resections, it may be necessary to
divide the inferior border of the trapezius and the rhomboids
to lift the scapula away from the chest wall.
Next, the thoracotomy is made by dividing the intercostal muscles along the top border of the sixth rib through
the fifth intercostal space (ICS). The fifth ICS is identified
by counting the ribs beneath the scapulae. We use the
insertion of the posterior scalene onto the second rib as the
starting point for counting. Relying on palpation of the first
rib may be misleading. We do not routinely resect a posterior margin of rib although this maneuver may be helpful
in reoperative surgery. One must keep the mammary vessels in mind to avoid their inadvertent injury during the
anterior division of the intercostal muscles. Posteriorly, the
intercostals can be divided to the angle of the rib. We try to
elevate the thoracicus iliacus and sacrospinalis off the posterior ribs and spine rather than dividing them when the thoracotomy extends posteriorly. This maneuver is particularly
useful in the elderly patient with osteoporotic fragile ribs
who is at greater risk for rib fractures. The Finnichietto
retractor is inserted and slowly opened. Gradual opening of
this retractor during the dissection helps to prevent rib
fractures that contribute to postoperative pain and subsequent morbidity.
1b
After performing the procedure, we place a single
1b
modified by cutting additional drainage holes. By placing the
tube in this fashion, the chest tube courses along the sulcus
between the diaphragm and chest wall, then curves posteriorly with the tip resting at the apex. This position allows for
complete drainage of the thoracic cavity with a single tube.
chest tube through a lateral tunnel. This chest tube is
Operation 251
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After unflexing the table, the ribs are reap-
1c,d
do not overapproximate the ribs but bring them to their
normal anatomical position. The muscle layers are closed
meticulously, especially posteriorly where the trapezius and
proximated with a large absorbable suture. We
rhomboids may have been divided. If a rib has been
removed, we approximate the intercostal muscles with an
absorbable suture. The various layers are irrigated as they
are closed. The fascia is reapproximated, and the skin is
closed.
1c
Muscle-sparing thoracotomy
VERTICAL AXILLARY INCISION
The posterolateral thoracotomy is the incision of choice for
many thoracic surgeons; however, we frequently reserve this
incision for extensive resections and more commonly use a
1d
vertical axillary muscle-sparing thoracotomy. For an uncomplicated lobectomy or other intrathoracic procedures, this
incision has the advantage that none of the muscles are
divided, it ensures excellent exposure, less postoperative pain,
and improved cosmesis. Also, because only the intercostal
muscles are divided and because it is much shorter, this incision can be closed more rapidly.
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The patient is positioned as for a posterolateral thoraco-
2
tomy except the axilla is opened slightly by rotating the
shoulder slightly posteriorly to expose the axilla. In women
we usually place the incision along the lateral breast crease.
Care should be taken not to make the incision too far posteriorly because injury to the long thoracic nerve may occur.
2
The subcutaneous tissues are divided exposing the serratus
anterior and the lateral margin of the pectoralis major.
Usually, one cannot count the ribs posteriorly as in a posterolateral thoracotomy so they must be counted anteriorly. The
best landmark for doing this is the tubercle of the first rib.
The surgeon’s hand is placed up through the axillary space in
order to palpate this tubercle. When proceeding with this
aspect of the incision, it is best to elevate the insertion of the
serratus from the ribs initially; this maneuver defines the
plane between the intercostal muscles and the serratus.
Proceeding in this fashion will allow for easier exposure of
this plane. Once the serratus has been mobilized from the
third to the fifth rib, enough laxity of this muscle exists to
proceed with the thoracotomy. The intercostal muscles are
divided along the superior aspect of the fifth rib in the fourth
intercostal space. Using an army/navy retractor to elevate the
serratus exposes the intercostal muscle for division. A small
rib spreader is used to separate the ribs, and then a Balfour
retractor is placed perpendicular to this to hold the serratus
and other soft tissues out of the field.
MUSCLE-SPARING POSTEROLATERAL THORACOTOMY
The patient is positioned as for a regular posterolateral thoracotomy. The skin incision is made along the standard skin
incision for a posterolateral thoracotomy, centered on the
posterior axillary line. The subcutaneous tissue is divided,
and the lateral margin of the latissimus is mobilized initially.
The anterior margin of the serratus is mobilized by dividing
the areolar tissue as in the posterolateral thoracotomy. Once
this step is done, the thoracotomy is made through the fifth
intercostal space as in the standard posterolateral thoracotomy.
Thoracoabdominal incision
This incision is most commonly used for thoracoabdominal
aortic operations, gastroesophageal junction tumors, or other
procedures where combined access to the chest and abdomen
is necessary. The incision may vary according to the intent of
the operation, i.e. whether it is necessary to come midline on
the abdomen or how high to make the thoracotomy for exposure of the distal arch.
The patient is placed on a beanbag in a right lateral decubitus position with the left hip rotated to provide exposure of
the abdomen and groin. The thoracic incision extends from
the posterior axillary line, across the costal margin, and continues on the abdomen in either a paramedian or median
fashion. The thoracotomy is made through the sixth to the
ninth interspace depending on how high in the chest exposure is required. The incision comes across the costal arch and
then is extended onto the abdomen. The diaphragm is
divided circumferentially leaving enough muscle along the
chest wall to hold sutures. While dividing the diaphragm, we
place sutures of alternating color on either side of the cut
diaphragm to facilitate reapproximation at the end of the
procedure.
Following the procedure, the diaphragm is reapproximated, and chest tubes are placed. We usually resect a margin
of cartilage at the costochondral junction. Because the junction usually heals poorly, resecting a margin prevents postoperative pain from a nonunion. We place the paracostal
sutures but do not tie them. The abdominal fascia is closed,
and then the paracostal sutures are tied.
Median sternotomy
This incision may be used to access the mediastinum and
both pleural spaces. Thoracic surgeons have found this particular incision useful for bilateral metastectomy, volume
reduction surgery, and resection of anterior mediastinal
tumors. Anatomical resections may be performed through
this incision but can be a more challenging operation than
that performed through a thoracotomy. The position of the
heart makes a left lower lobectomy particularly difficult.
Operation 253
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The patient is placed in the supine position. A rolled
3a
prepped from the neck to abdomen. The skin incision is
made just below the sternal notch down to the xyphoid. The
fascia is divided, and the ligament at the sternal notch is
divided with electrocautery.
3b
usually mark this point with electrocautery to use as a guide
for the sternal saw. This step is to avoid an uneven cut
through the sternum.
sheet is placed behind the shoulders. The patient is
The midline is determined by palpating the intercostal spaces on either side of the sternum. We
3a
3b
3c
The reciprocating sternal saw is placed with the
3c
num, and the sternotomy is made. Once this step is done,
each half of the sternum is elevated, and periosteal bleeders
are identified and cauterized. If continued bleeding ensues
from the sternal marrow, bone wax may be used to stop this.
However, we do not use bone wax routinely. A sternal or
hemisternal retractor is positioned and slowly opened. A
brachial plexus injury can occur if the sternum is opened too
widely. For pulmonary parenchymal procedures, the hemisternal retractor is useful. Also, when working posteriorly,
placing laparotomy packs can aid in bringing the lung up
toward the operative field.
bottom blade hugging the deep border of the ster-
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