Francis C. Wells Aman S. Coonar Thoracic Surgical Techniques Second Edition 123 Thoracic Surgical Techniques Francis C. Wells • Aman S. Coonar Thoracic Surgical Techniques Second Edition Francis C. Wells Aman S. Coonar Cardiothoracic surgery Cardiothoracic surgery Royal Papworth Hospital Royal Papworth Hospital Cambridge University Health Partners Cambridge University Health Partners Cambridge Cambridge United Kingdom United Kingdom Originally published BY Bailliere Tindall, London, 1990 (0-7020-1239-4) ISBN 978-3-319-66268-8 ISBN 978-3-319-66270-1 (eBook) https://doi.org/10.1007/978-3-319-66270-1 Library of Congress Control Number: 2018950400 © Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by Springer Nature, under the registered company Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland My gratitude and loving thanks to my children Joanna, Nicholas and Olivia for their forbearance through many years of hard work allowing me to produce this and other volumes. “filii nostra omnia” Francis C. Wells Preface In the 28 years since the last edition there has been a renaissance in thoracic surgery, which has come about due to a combination of new technology and the development of thoracic surgery as a distinct subspecialty. Built on the principles and foundations of good surgery, including anatomical understand- ing, exposure and gentle tissue handling modern thoracic surgery includes both open and vid- eoscopic techniques. Miniaturization, surgical telescopes, high-definition monitors, and many new devices allow superb illumination, magnification, and tremor reduction which helps minimum access sur- gery to take place. Coupled with an equally important focus on enhanced recovery, there has been a major reduction in length of stay, morbidity, and also the ability to offer surgery to frailer patients. This edition remains true to the previous in being based on simplicity and clarity for the practicing surgeon. It is mostly about the open techniques on which the minimally invasive approaches have been built. There is liberal reference as to how the minimal access techniques differ and build upon the open. The majority of the original excellent hand drawings by Gillian Lees and Kevin Marks have been retained. Cambridge, UK A. S. Coonar Cambridge, UK F. C. Wells 2018 vii Acknowledgments Ms Helen Weaver MRCS formerly clinical fellow in thoracic surgery, Royal Papworth Hospital for help in reviewing the draft manuscript We are most grateful to Gillian Lees and Kevin Marks for allowing us to reproduce once again their wonderful illustrations for this text. The clear nature of the illustrations is the foun- dation of this work The editors for patience and perseverance From Mr Aman Singh Coonar My parents for their love, wisdom and guidance for otherwise I would not have had the chance to be a doctor; my family for their support, jokes and endurance; and, my wife for everything From Francis Wells, my never ending gratitude to my parents without whom none of my meagre achievments would have been possible and to my three wonderful children, Joanna, Nicholas and Olivia for their love and forebearance throughout my frenetic career ix Contents 1 Principles of Thoracic Surgery and Enhanced Recovery ................... 1 1.1 Introduction .................................................... 1 1.2 Patient Engagement and Expectations ................................ 1 1.3 Enhanced Recovery .............................................. 1 1.4 Anaesthetic Considerations ........................................ 2 2 Fundamentals of Thoracic Surgical Techniques .......................... 3 2.1 Open Surgery ................................................... 3 2.2 VATS ........................................................ 3 2.3 Technology for Minimally Invasive Surgery ........................... 4 2.4 Surgical Telescopes .............................................. 5 2.5 Instruments for Dissection ......................................... 5 2.6 Energy Devices ................................................. 5 2.7 Stapling Devices ................................................ 5 2.8 Reinforcement of Staple Lines ...................................... 5 2.9 Steps in VATS Surgery ............................................ 5 2.9.1 Preparation ............................................... 5 2.9.2 Position ................................................. 5 2.9.3 Telescope Holders ......................................... 5 2.9.4 Ports .................................................... 6 2.9.5 Common Steps ............................................ 6 2.10 Tissue Sealants for VATS Surgery ................................... 6 2.11 General Approach to VATS Anatomical Lung Resection ................. 6 2.12 Lymph Node Dissection ........................................... 7 2.13 Protection of the Phrenic Nerve ..................................... 7 2.14 Awareness of the Anatomy Particularly Variations in Venous Anatomy ...... 7 2.15 Ensuring the Target is in the Volume to Be Removed and with a Margin ..... 7 2.16 Checking the Patency of Remaining Structures Before Stapling and the Approach to an Incomplete Fissure ........................... 7 2.17 The Incomplete Fissure ........................................... 7 3 Bronchoscopy ...................................................... 9 3.1 The Instruments ................................................. 9 3.1.1 Rigid Bronchoscope ........................................ 9 3.1.2 Fibre-Optic Bronchoscope ................................... 10 3.1.3 Rigid Bronchoscopy ........................................ 10 3.1.4 Collection of Specimens and Biopsies .......................... 12 3.1.5 Removal of Foreign Bodies .................................. 13 3.1.6 Dilation ................................................. 15 3.1.7 Fibre-Optic Bronchoscopy ................................... 15 3.1.8 Endoscopic Ultrasound (Endobronchial EBUS and  Endooesophageal EUS) ..................................... 16 xi xii Contents 3.1.9 Navigational Bronchoscopy .................................. 16 3.1.10 Deployment of Large-Airway Stents ........................... 16 4 Simple Thoracoscopy ................................................ 19 4.1 Common Indications ............................................. 19 4.2 Relative Contraindications ......................................... 19 4.3 Procedure ...................................................... 19 4.4 Drainage ....................................................... 20 5 Percutaneous Mini-Tracheostomy ...................................... 21 5.1 Procedure ...................................................... 21 6 Insertion of a Chest Drain ............................................ 23 6.1 Indications ..................................................... 23 6.2 Procedure ...................................................... 23 6.3 Removal ....................................................... 25 7 Surgical Anatomy of the Chest Wall .................................... 27 7.1 Intercostal Spaces ................................................ 27 7.2 The Diaphragm ................................................. 27 7.3 Thoracic Outlet ................................................. 29 8 Posterolateral Thoracotomy ........................................... 31 8.1 Postoperative Pleural Drainage ..................................... 34 8.2 Insertion of Drainage Tubes and Would Closure ........................ 35 9 Anterolateral Thoracotomy ........................................... 37 9.1 Indications ..................................................... 37 9.2 Procedure ...................................................... 37 10 Anterior Thoracotomy ............................................... 41 11 Median Sternotomy ................................................. 43 11.1 Procedure ..................................................... 43 11.2 Closure ....................................................... 43 12 Axillary Thoracotomy ................................................ 45 12.1 Procedure ..................................................... 45 13 Modified Ravitch Operation for Pectus Excavatum ....................... 47 13.1 Procedure ..................................................... 48 13.2 Elevation of the Sternum ......................................... 49 13.3 Sternal Osteotomy .............................................. 49 13.4 Stabilisation ................................................... 50 13.4.1 Insertion of Abrams’ Bar .................................. 50 13.4.2 Stabilisation with Plate and Screws or Plates and  Crimped Bone Clips ...................................... 50 13.5 Closure ....................................................... 50 13.6 Postoperative Management ....................................... 52 14 Nuss Procedure for Pectus Excavatum .................................. 53 14.1 Technique ..................................................... 54 14.2 Variations ..................................................... 55 14.3 Technique of Bar Removal ....................................... 55 15 Pectus Carinatum ................................................... 57 15.1 Procedure ..................................................... 57 15.2 Removal of Chondrosternal Projection .............................. 58 Contents xiii 15.3 Dissection of Costal Cartilages .................................... 58 15.4 Correction of Sternal Deformities .................................. 58 15.5 Correction of Rib Deformity ...................................... 60 15.6 Closure ....................................................... 60 15.7 Postoperative Management ....................................... 60 16 Resection of Chest Wall Tumours and Methods of Reconstruction ........... 61 16.1 Resection of Tumours that Do Not Infiltrate the Overlying Skin .......... 61 16.2 Reconstruction of the Chest Wall .................................. 61 16.3 Repair with Prosthetic Material .................................... 63 16.4 Sternal Resections .............................................. 65 16.5 Resection of Tumours that Have Invaded the Overlying Structures ........ 66 16.6 Reconstruction of the Chest Wall .................................. 66 17 Excision of First Rib for Thoracic Outlet Syndrome ....................... 69 17.1 Diagnosis ..................................................... 69 17.2 Anatomy ..................................................... 69 17.3 Variants ...................................................... 69 17.4 Transaxillary Approach .......................................... 70 17.5 Procedure ..................................................... 70 17.6 Closure ....................................................... 72 18 Thoracoplasty ...................................................... 73 18.1 Procedure ..................................................... 73 18.2 Extrafascial Apicolysis .......................................... 75 18.3 Subsequent Operations .......................................... 77 18.4 Thoracoplasty for Obliteration of an Empyema Cavity Associated with a Bronchopleural Fistula ..................................... 77 18.5 Procedure ..................................................... 77 18.6 Closure ....................................................... 77 19 Rib Resection for Empyema ........................................... 79 19.1 Indications .................................................... 79 19.2 Procedure ..................................................... 79 19.3 Postoperative Management ....................................... 81 19.4 Treatment of Empyema by Cyclical Irrigation ........................ 82 19.5 Procedure ..................................................... 82 20 Cervicothoracic Sympathectomy ....................................... 83 20.1 Indications .................................................... 83 20.2 Procedure ..................................................... 83 21 Surgical Anatomy of the Trachea ...................................... 85 22 Tracheostomy ...................................................... 87 22.1 Stoma Creation ................................................ 88 22.1.1 Percutaneous Tracheostomy ................................ 89 22.1.2 Stoma Creation in a Child .................................. 89 22.1.3 Postoperative Care ....................................... 89 22.2 Complications ................................................. 90 22.2.1 Dislodgement of the Tube .................................. 90 22.2.2 Sepsis ................................................. 90 22.2.3 Obstruction of the Tube ................................... 90 22.2.4 Tracheal Stenosis ........................................ 90 22.2.5 Extubation .............................................. 90