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What are the 3 surgical approaches to thorax?
- lateral thoracotomy
- median sternotomy
- transthoracic (bilateral lateral thoracotomy across sternum)
What are 3 options for lateral thoracotomy? which is 1st choice?
- intercostal (1st choice)
- rib resection
- periosteal stripping and rib resection
For esophageal FB at base of heart, which intercostal space is approached for sx? right or left?
4th right lateral thoracotomy
For cardiopulmonary bypass, which intercostal space is approached? right or left?
- 4th intercostal space
- Right lateral thoracotomy
For cranial lung lobectomy, which intercostal space is approached? For intermediate lobectomy? Caudal lobectomy?
5th (6th for intermediate lobectomy; 7th for caudal)
To access thoracic duct in dog, which intercostal space is approached? right of left? how does this compare to the cat?
- dog: 8th right lateral thoracotomy
- cat: 8th left lateral
For PDA, PS, PRAA, or to access pericardium, which intercostal space is approached? right or left?
4th Left lateral thoracotomy
To access caudal esophagus, which intercostal space is approached? right or left?
9th Left lateral thoracotomy
Is diaphragm or intercostal muscles more important for respiratory control in small animals?
For Left lateral thoracotomy at 4th space, which muscles are manipulated before pleura is incised?
- 1-cutaneous muscle
- 2-latissiumus dorsi m. (transect then retract dorsal)
- 3-serratus ventralis & scelenus mm. (bluntly separate)
- 4-intercostal mm. (transect ventral to dorsal, avoid nerves)
- then pleura is incised to enter thorax
For thoracotomy closure, sutures are pre-placed around ribs to approximate closure; then how are muscles sutured/which muscles are NOT sutured?
- do NOT close intercostal mm.
- close cutaneous trunci w/SQ in small patients
- other muscles closed routinely (simple contin)
- stagger sutures for air sealed closure
For placement of thoracostomy tube, where is stab incision made in relation to thoracotomy incision? How is tube placed from this stab incision?
- 2-3 rib spaces dorsal and caudal to sx incision
- tunnel tube SQ for 1-2 spaces then enter pleural space
- chinese finger trap or purse string to suture to skin
The direction of the thoracostomy tube should always be from where to where?
dorsal-caudal to cranio-ventral
What are 3 options for post op analgesia?
- intercostal nerve block (caudal to rib 1-2 before/after incision)
- intrapleural bupivicaine (lateral to bathe incision site)
What are indications of median sternotomy?
- access entire lung field or exploratory sx
- subtotal pericardectomy
- aortic valve replacement
- (limited view of dorsal field)
For sternotomy, are all sternabrae detached for the procedure?
leave 1st sternabra attached for better/stable closure
What structures should be avoided when cutting near sternum?
large thoracic vessels that will bleed a lot; stay on midline
How are sternebrae closed?
- drill to place orthopedic wire in figure 8 pattern --> twist ends and bend toward bone so don't contact soft structures
- other tissues closed routinely
Where is thoracostomy tube placed with median sternotomy approach?
stab at 7-9th space --> tunnel cranially 1-2 spaces then enter pleural cavity
What are disadvantages of median sternotomy approach?
- more lengthy
- increased morbidity
- severe post op pain