Complications of thoracic surgery may be minimized through a mastery of the 3-dimensinal anatomy of hilar and mediastinal structures
Thorough pre-operative evaluation of cardio-pulmonary reserve is imperative prior to embarking upon elective thoracic surgery
General principles of thoracic surgery for trauma include large, utility incisions (most commonly left anterolateral thoracotomy or median sternotomy), proximal and distal control of bleeding vessels, and guided blood product resuscitation.
Progress in thoracic surgery has mirrored that of general surgery, with many open procedures giving way to minimally invasive techniques. Although the realm of trauma has traditionally been immune to this phenomenon, it too has undergone refinement. Perhaps the most striking example of a shift towards minimally invasive approaches in trauma has been that of retrograde endovascular balloon occlusion of the aorta in lieu of resuscitative emergency department thoracotomy.1 Additional examples of this trend include video-assisted thoracic surgery (VATS) lobectomy for both malignant and nonmalignant pulmonary lesions, endobronchial ultrasound (EBUS) guided mediastinal lymph node biopsy, navigational bronchoscopy, and endoscopic approaches to esophageal pathology.
The emergence of minimally invasive thoracic surgical techniques has not diminished the importance of both meticulous preoperative planning and sound knowledge of surgical anatomy. Rather, when intraoperative problems do arise during these procedures, it is even more important to rapidly identify and correct them. Small incisions, alternative positioning, and personnel unfamiliar with techniques for rapid hemorrhage control within the chest converge to create potentially dangerous situations, underscoring the importance of a rapidly available, experienced thoracic surgeon.
PITFALLS AND PEARLS
✓ Successful bailout maneuvers in thoracic surgery are made possible only through a mastery of both tracheobronchial and hilar anatomy. There is no substitute for this intimate 3-dimensional understanding of the relationships of the pulmonary arteries, veins, and bronchi.
✓ The pulmonary vascular system (both arterial and venous) is generally low pressure. As such, direct occlusion of bleeding vessels with a peanut gauze or sponge stick is usually an effective temporary means of hemorrhage control. This maneuver then buys the surgeon time to plan for definitive hemorrhage control (eg, broadening the incision or obtaining proximal and distal control).
✓ General operative principles in thoracic surgery include wide exposure prior to control of bleeding, proximal and distal control of bleeding vessels, debridement and anastomosis of healthy tension-free tissue, and either muscle or pericardial coverage of tenuous anastomoses or repairs.
✓ Although several cardiopulmonary parameters have been associated with operative risk in elective thoracic surgery, the most predictive are: (1) The predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1) <30%, and (2) maximal oxygen consumption (VO2max) of 10 mL/kg/minute.
✓ Pleural effusions in hospitalized patients are common; they should be drained only for diagnostic or therapeutic purposes.
✓ Management of esophageal perforation is dictated by the physiologic status of the patient, the underlying status of the esophagus, and the duration of the perforation. Strategies include nonoperative, percutaneous, endoscopic, and open surgical techniques.
✓ The utility incision for thoracic trauma is the left anterolateral thoracotomy. This incision may be widened to a bilateral anterolateral thoracotomy (ie, “clamshell” thoracotomy) if necessary. Lateral decubitus positioning should be avoided in cases of hemorrhagic shock as it may result in cardiopulmonary embarrassment and limit exposure to bleeding structures.
✓ Regarding penetrating cardiac trauma, exposure is critical. In the trauma bay, a left anterolateral thoracotomy incision should be extended to a bilateral “clamshell” incision readily. Cardiac repair should be undertaken prior to any attempt to restore a perfusing rhythm. Coexisting holes in the back wall of the heart should be thoroughly excluded. Aortic cross clamping should be minimized or avoided altogether.
The hypothesis: A thorough cardiopulmonary workup is essential prior to undertaking pulmonary resection.
The story: A 68-year-old woman is undergoing an open right lower lobe (RLL) lobectomy for a hilar lung cancer. Preoperative medical “clearance” was obtained via the patient’s internist. Due to the location of the tumor, a left pneumonectomy is ultimately required to obtain a satisfactory oncologic resection.
The patient’s outcome: Worsening heart failure and eventual death in the surgical intensive care unit (ICU).
What went wrong? Failure to appreciate the cardiopulmonary reserve of the patient, as well as the physiologic magnitude of a pneumonectomy.
How to prevent this error in the future? Pulmonary resection has profound physiologic consequences. A detailed preoperative assessment of a patient’s cardiopulmonary reserve is essential to maximizing the success of any pulmonary operation. So-called “clearance” from referring providers should be questioned thoroughly. The American Thoracic Society, Society of Critical Care Medicine, and American College of Chest Physicians have each put forth evidence-based recommendations for physiologic evaluation prior to resectional surgery.2 These recommendations are based upon the predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1), diffusing capacity of carbon monoxide (DLCO), low technology stress test (eg, 6 minute walk test), and cardiopulmonary exercise testing with measurement of maximum oxygen consumption (VO2max). These recommendations are summarized in Figure 9.1. In addition to these guidelines, patients for whom a pneumonectomy is a possibility should undergo echocardiography and, in the case of estimated elevation of pulmonary arterial pressures, right heart catheterization with measurement of these pressures. Finally, a thorough review of the preoperative CT chest will aid in determining the presence of any congenital vascular abnormalities, such as a partial anomalous pulmonary venous return (see Figure 9.2), anomalous single pulmonary venous trunk,3 and azygous lobe (see Figure 9.3).
Figure 9.1
Guidelines for physiologic evaluation prior to pulmonary resection.
PFTs, pulmonary function tests; PPO, predicted postoperative; FEV1, forced expiratory volume in one second; DLCO, diffusing capacity for carbon monoxide; CPET, cardiopulmonary exercise testing; METS, metabolic equivalent, VO2max, maximal oxygen consumption. (Data from Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:7S-37S).
Figure 9.3
Azygous lobe.
An azygous lobe is a congenital variation of the upper lobe of the right lung. As it has no bronchi, veins, and arteries of its own, it is not a true, or even accessory, pulmonary lobe, but rather an anatomically separated part of the upper lobe. It is usually an incidental finding on chest x-ray or computed tomography (CT); as such it is not associated with any morbidity but may cause technical problems in thoracoscopic procedures.
The hypothesis: An intimate knowledge of hilar anatomy is essential to performing pulmonary resection.
The story: A 75-year-old man is undergoing a VATS right upper lobe (RUL) lobectomy for a RUL squamous cell carcinoma. During dissection around the back wall of the right superior pulmonary vein, brisk hemorrhage is encountered. Attempts to grab the area with a forceps result in worsening hemorrhage. Superior retraction of the RUL to improve exposure worsens the hemorrhage further. Ultimately, conversion to an open thoracotomy is necessary to achieve hemorrhage control.
The patient’s outcome: Prolonged recovery in the surgical ICU with ventilator-dependent respiratory failure.
What went wrong? In this case, a lack of knowledge of hilar anatomy both resulted in and exacerbated hemorrhage. The right main pulmonary artery emerges from the pericardium transversely, and splits into a superior and inferior division within 2 cm. The inferior division courses immediately posterior to the right superior pulmonary vein and as such is particularly at risk of injury during dissection of the posterior wall of this vein (see Figure 9.4). The RUL typically consists of apical, anterior, and posterior segmental arteries. The apical and anterior segmental arteries arise from the superior division of the right pulmonary artery and are thus usually taken from a superior approach (refer to Figure 9.4). However, the posterior segmental artery typically arises from the inferior division of the pulmonary artery in the interfissure plane (see Figure 9.5). Indiscriminate superior retraction of the RUL may tear this branch. Finally, hemorrhage control from pulmonary arterial bleeding can almost always be temporarily controlled by applying gentle, direct pressure with either peanut gauze or a sponge stick. This allows time to delineate the injury and achieve proximal and distal control.
Figure 9.4
The inferior division of the right pulmonary artery courses directly posterior to the right superior pulmonary vein, and is at risk for injury during dissection of the latter structure.4 (Reproduced with permission from Hood RM. Techniques in General Thoracic Surgery. Philadelphia: Saunders; 1985. Copyright © Elsevier).
Figure 9.5
The usual origin of the posterior segmental artery to the RUL is from the mid inferior division of the right pulmonary artery.4 (Reproduced with permission from Hood RM. Techniques in General Thoracic Surgery. Philadelphia: Saunders; 1985. Copyright © Elsevier).
How to prevent this error in the future? In this case, knowledge of the anatomic relationship of the posterior wall of the pulmonary vein to the anterior wall of the inferior division of the right pulmonary artery may have led to a more careful dissection. Similarly, knowledge of both the existence and location of the posterior segmental artery may have resulted in more gentle superior retraction of the RUL. When the bleeding started, gentle occlusion with a sponge stick would have most likely controlled the hemorrhage. Finally, in cases of hilar tumors, proximal control of the main pulmonary artery and the pulmonary veins intrapericardially using a Rummel tourniquet is advised.
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Surgical Safety Checklists—Pitfalls and Pearls
When Things Go Wrong in the Operating Room: Intraoperative “Rescue” Strategies
Failure to Plan is Planning to Fail: How to Prevent Intraoperative Complications in Orthopedic Surgery
Technical Errors and Bail-Out Strategies in Abdominal Surgery
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