Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана

28. An angled 28 Fr. straight chest tube is tunneled, placed in the chest cavity, and loosely secured in place with a #0-

silk pursestring suture. The chest tube is placed to water seal (AND NEVER TO SUCTION).

with a running #4-0 subcuticular suture. A sterile dressing is applied

30. The patient is rolled to the supine position. The authors prefer removing the chest tube at this point. With a breath

given by the anesthesiologist and held at 40 mm Hg pressure, the chest tube is removed in the usual fashion, the #0-

silk pursestring suture tied and a sterile dressing applied.

31. Chest x-ray obtained to assess the contralateral lung and pleural space and confirm appropriate midline positioning

of the mediastinal structures.

32. Patient is taken to the recovery room and extubated when appropriate.

Potential Complications and Pitfalls

1. The authors do not routinely perform laparoscopy unless there are concerns raised on the preoperative imaging in

2. The position of the operating table will change during various phases of the operation from steep Trendelenburg

4. Place an NG tube to facilitate identification of the esophagus during the dissection

8. For right EPPs, take care to avoid injuring the IVC and retrohepatic veins during the extrapleural dissection and

diaphragmatic reconstruction.

9. Avoid injury to the internal mammary artery and vein.

10. For patients who have had prior CABG with an ipsilateral IMA graft, special care must be taken to avoid injuring the

graft.

11. Avoid ligation of intercostal arteries

12. Avoid injury to the recurrent laryngeal nerves, which can lead to aspiration or other pulmonary complications.

14. Argon beam coagulation to the endothoracic fascia is helpful both for tumorlysis and for hemostasis.

16. Bronchoscopy is used liberally to clear secretions

17. In the absence of bleeding, hemodynamic instability in the OR may be due to an overly constrictive pericardial patch

or undue constriction on the IVC (for right-sided diaphragmatic reconstructions)

Template Dictation

Postoperative Diagnosis: Same

biopsy proven malignant [EPITHELIO ID, SARCOMATOID OR BIPHASIC TYPE] mesothelioma. Workup included:

[BLANK] was deemed an appropriate surgical candidate.[He/She] are now brought to the operating room in satisfactory

condition for planned surgical resection.

Description of Procedure:

After a team surgical briefing, the patient was brought to the operating room in satisfactory condition. Under general

endotracheal anesthesia with a double-lumen endotracheal tube in place, the patient was placed in the right lateral decubitus

th

enter to pleural space. We began the extrapleural dissection, separating the pleura from the endothoracic fascia. We

immediately encountered marked thickening of the parietal pleura. Dissection was carried posteriorly and superiorly and then

ultimately separate the subclavian artery from the apex of the lung. The dissection was then carried inferiorly. The aortic arch

was identified. The vagus nerve was identified and care taken to protect the recurrent laryngeal nerve. Using a combination

of blunt and sharp dissection to separate the pleura from the aorta, we continued the dissection caudally along the descending

thoracic aorta down to the costophrenic recess. The extrapleural dissection continued along the diaphragm and then along the

mediastinum. Pericardium was entered anteromedially. The pericardial space was palpated. There was no evidence of tumor

tumor involvement of the pleura. However, most of the disease burden was on the diaphragm and the pleura overlying

the lower lobe.]

The pulmonary artery isolated extrapericardially. The PA was clamped with a TA-30 vascular load stapler. There was no

significant increase in the PA pressure. The stapler was fired, and the PA was divided. The superior pulmonary vein and

inferior pulmonary veins were divided intrapericardially using separate firings of a TA-30 vascular load stapler. The

with a 40 mm Hg breath hold, indicating that the bronchial stump was completely intact.

numerous #1 Polypropylene sutures. The pericardium was then rebuilt also with fenestrated piece of 1-mm thick PTFE

and left the operating room in satisfactory condition.

3. Incision / access

8. Heparinization

13. Aortic crossclamp

25. Division of remaining mediastinal posterior attachments

26. Lung block removal and packaging

Note that the above steps presume that the heart is being removed for either recipient implantation or for research purposes. If

the heart is not to be used at all, minor adjustments apply, which are addressed below.

1. Standard midline sternotomies are aesthetically displeasing and limit options for open-casket funerals. Y-shaped

2. The practice of sequentially eviscerating the lungs from the pleural cavity to perform recruitment of the atelectatic

tip of the cannula is pointed backward toward the pulmonary valve. This prevents the preferential perfusion of one

lung that may otherwise occur. If the heart is not being used for implantation in a live recipient, the pulmoplegia

pulmonary artery bifurcation. When placed more proximally, the tip of the pulmoplegia cannula is directed toward the

bifurcation of the main pulmonary artery

5. It is not necessary to dissect the fascial attachments between the trachea and esophagus during the initial organ

6. Venting through the left atrium adjacent to the right superior pulmonary vein in Waterston’s groove will provide

7. It is important to carry out the organ preservation procedure in the correct order. Left ventricular distention invariably

8. The adequacy of cardioplegic solution delivery must be assured by a rapid cessation of cardiac contractile and

10. During the retrograde pulmoplegia flush, the return of clear solution into the ipsilateral pulmonary artery assures that

flushed from the pulmonary artery, which should be noted, but is, of yet, of unclear clinical significance.

11. If the heart is not being used for a live recipient, there is no need to preserve a left atrial cuff for cardiac

Template Dictation

Preoperative Diagnosis: [INDICATION—e.g. brain death secondary to trauma, etc.]

Postoperative Diagnosis: Same

Procedure(s) Performed: Bilateral donor pneumonectomy (+/- CARDIECTOMY)

Attending Surgeon: [BLANK]

Secondary Surgeon: [BLANK]

Donor hemodynamics, inotrope/pressor infusions, telemetry monitoring, echocardiogram, and chest CT, and latest arterial

blood gas were reviewed. The patient was positioned supine. Both arms were tucked. Bronchoscopy was performed and the

FINDINGS—e.g. normal, healthy airways; thick/thin secretions which cleared easily/recurred after clearance, minor

performed in standard fashion.

Bilateral pleural spaces were entered, and the lungs were palpated and visually inspected. Findings including [FINDINGS—

anticipated cross-clamp time.

pressure. A pericardial well was created, and the heart and great vessels were examined for anatomic abnormalities and

followed by taking down of the attachments of the right pulmonary artery to the superior vena cava. The superior vena cava

transplantation is anticipated). The azygos vein was ligated near its juncture with the superior vena cava. A heavy silk suture

was passed around the superior vena cava above the level of the azygos vein.

Attention was turned toward careful sharp dissection of Waterston’s inter-atrial groove in order to allow easier subsequent

A horizontal mattress #4-0 Prolene stitch was placed in the anterior midportion of the ascending aorta to later secure the

pulmonary artery. The posterior pericardium overlying the trachea (between the superior vena cava and ascending aorta) was

Careful communication occurred between our team and [THE ABDOMINAL TRANSPLANT TEAM AND ALL] receiving

team[S] in order to assure appropriate timing of heparinization and cross-clamp. 30,000 units of heparin [OR OTHER DOSE

IF APPROPRIATE] were administered via central venous access. After 3 minutes, the cardioplegia and pulmoplegia

the pulmoplegia, and a standard cardioplegia cannula for the heart preservation. The lung was reexamined for significant

syringe of prostaglandin E1 was injected into the main pulmonary artery immediately adjacent to the pulmoplegia cannula. The

COMING DOWN O N THE RIMMEL TOURNIQUETTE]. The left atrium was vented by [ATRIAL VENTING

the atrioventricular groove and the left inferior pulmonary vein, or ideally (see pitfalls above) making the initial portal of the

left atrial incision adjacent to the right superior pulmonary vein in the previously dissected Waterston inter-atrial groove]. The

being used for transplantation).

the pulmoplegia was initiated through the high-flow cannula at gravity pressure. Tidal volume was reduced by half to allow a

large volume of saline slush to be placed into both pleural spaces and the pericardial well. 5.6 liters of pulmoplegia were

infused in an antegrade fashion, with cardioplegia infused until the pulmoplegia was done [WITH A TOTAL OF BLANK

completed. The left atrial incision was extended from the vent site in Waterston’s groove. Extension of this initial left atrial

incision was carried out under the inferior edge of the inferior vena cava. The incision was further extended on the

undersurface of the left atrium parallel to the AV groove, halfway between the inferior pulmonary veins and the AV groove. It

was extended to the base of the left atrial appendage. The left atrial incision was then completed from inside the left atrium,

allowing visualization of the orifices of all 4 pulmonary veins. The right and left innominate veins were transected along with

PLASTIC TRANSPORT BAG FILLED WITH ICE].

pulmonary veins, with care taken to examine for pulmonary emboli coming up through retrograde flushing. [PE’S NOTED—no

inferior pulmonary ligaments were mobilized and divided sharply. The lower esophagus was divided with a second firing of

the GIA 45 mm stapler. The descending aorta was sharply transected. All remaining lower mediastinal tissue was then

were taken sharply against the spine, moving cephalad, until the double-lung block was free.

was amputated. Both hila were then fully prepared, mobilizing the pulmonary artery to the first upper lobe branch, and dividing

Excessive pericardium on both sides was then resected.]

The double-lung block [vs EACH SING LE LUNG SEPARATELY] was placed in a sterile plastic transport bag filled with

cold perfusate solution, while the lungs were examined for any unexpected pathology or surgical damage. The sterile plastic

transport bag was sealed and placed into a second bag, with added ice slush. This bag was then placed into a third sealed

Our team then left the donor operating room with the lungs [vs HEART AND LUNGS] [WHILE THE ABDOMINAL

TEAM CONTINUED TO WORK]. The cooler was expeditiously taken from the facility accompanied by Dr. [NAME].

3. +/- Preoperative bronchoscopy

7. Back-table donor lung preparation

12. +/- CPB weaning and decannulation

Potential Complications and Pitfalls

2. For patients with emphysema, it is important to avoid hyperinflation of the native lungs. If hypotension occurs prior to

3. For any patients whose indication is septic lung disease, preoperative bronchoscopy using an adult bronchoscope

through a single-lumen tube is a critical step. All attempts should be made to thoroughly clear the airways of purulent

secretions, which helps reduce the need for cardiopulmonary bypass. If preoperative bronchoscopy is not warranted,

the patient may be intubated with a standard left-sided double lumen tube upon induction.

4. During incision and entry into thoracic cavity, avoid internal mammary artery injury. Care should also be taken to

avoid injury to recipient lungs.

5. For bilateral lung transplants, the decision as to which lung should be done first is based on the quantitative V/Q

This strategy aids in avoidance of cardiopulmonary bypass. Further, if there were to be an event that would mandate

after implantation, appropriate wedge resections can be performed, targeting the lingula and right middle lobe using

stapling devices.

9. Perioperative hemorrhage: may be related to large raw surface area created after explantation of septic lungs or those

Leaving the chest open (and covered with a temporary dressing) followed by delayed chest closure 24 to 48 hours

10. Technically unsatisfactory bronchial anastomosis: easily identified in the OR at postimplantation bronchoscopy.

Immediate revision should be performed for inaccurate alignment and inadequate caliber.

11. PA or PV anastomotic problems: may be identified via persistent pulmonary hypertension, unexplained hypoxemia,

Template Dictation

Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [INDICATION]. A suitable donor

was identified. The harvest was conducted by our team and the organs were separated into separate lung grafts upon arrival at

[HOSPITAL].

LUMEN ENDOTRACHEAL TUBE WAS INITIALLY PLACED IN ORDER TO ALLO W THOROUGH SECRETIO N

LEFT-SIDED DOUBLE LUMEN TUBE] or [THE PATIENT WAS INTUBATED WITH A LEFT-SIDED DOUBLE

LUMEN ENDO TRACHEAL TUBE] to allow lung-isolation. Standard monitoring lines were inserted, including [LINE

TYPES] in the [LATERALITY] [VESSEL]. The patient received [DOSE] of [ANTIBIOTICS] at the time of anesthetic

The patient was positioned supine with the arms tucked into the sides. All bony prominences were appropriately padded.

EXCLUDE CARDIOPULMONARY BYPASS… Consider pulmonary pressures, oxygenation, echo findings, etc.].

[Entry onto cardiopulmonary bypass, if used: The pericardium was opened in a hockey stick-shaped incision, extending down

the ascending aorta and angling over toward the right atrial appendage. The patient was fully heparinized. Two non-pledgeted

2-0 Prolene pursestring sutures were placed in the ascending aorta, and it was cannulated without difficulty. The cannula was

secured at the sternum with silk suture to prevent dislodgement of the cannula during the transplant procedure. In a similar

fashion, a 2-0 Prolene non-pledgeted pursestring suture was placed in the right atrial appendage and it was was secured to the

sternum to prevent dislodgement during the transplant procedure. The patient was then placed on cardiopulmonary bypass

Excessive pericardium on both sides was then resected. The lungs were kept cold until the appropriate time for implantation.]

Based on the quantitative V/Q scan, the [RIGHT vs LEFT] lung was resected first [+/-AFTER THE PATIENT WAS

SAFELY PLACED O N CARDIOPULMONARY BYPASS]. Pulmonary vein branches were divided between silk ligatures.

vascular staple line. Bronchial tissue was divided with cautery. The bronchus was divided well up in the mediastinum at a

site suitable for anastomosis. The pericardium was opened circumferentially. Hemostasis was achieved. Attention was then

directed to the [LEFT vs RIGHT] side where an identical extraction of the other lung was performed. [IF NOT ON

CARDIOPULMONARY BYPASS, THE FIRST LUNG IS ISOLATED, EXPLANTED, AND DO NOR LUNG

IMPLANTED; NOTE APPROPRIATE MODIFICATIONS IF NO CARDIOPULMONARY BYPASS.]

The donor [LEFT VS RIGHT] lung was brought up into the field. It was kept cold using topical application of crushed ice. The

donor and recipient bronchi were approximated with a running suture of 4-0 PDS. A central Satinsky clamp was placed. The

tissue between the vein stumps was divided to create an atriotomy suitable for the venous anastomosis. A left atrial

anastomosis was then performed using a running suture of 4-0 Prolene with sutures placed in such a manner as to evert all

muscle from the lumen. The suture line was left open on its anterior aspect while the pulmonary artery clamp was released and

the lung de-aired antegrade.

of ventilation and perfusion of both lungs, gas exchange was [EXCELLENT, MODERATE, POOR?], hemodynamics were

[DESCRIBE USE OF INOTRO PES, PRESSO RS, AND CORRESPO NDING HEMODYNAMIC/ECHO FINDINGS.]

With this, [HE/SHE] was weaned from cardiopulmonary bypass and maintained stable hemodynamics with a s

ystemicpressure of [NUMBER], and a pulmonary artery systolic pressure in the [NUMBER]. The saturations initially were in

The patient was then extubated and re-intubated using a single-lumen tube. Flexible bronchoscopy was performed. The

airways were examined. Both bronchial anastomoses were widely patent. The donor airways were viable. Blood and

secretions were aspirated. The patient was then transferred directly to the Cardiothoracic Intensive Care Unit in stable