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SA Sx - Pulmonary Sx 1

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drraythe's version from 2017-10-10 13:38

Intro to Pulmonary Sx

Question Answer
When is a complete lobectomy indicated?Dz process involving entire lobe or area near hilus of lobe (Ex: lung lobe torsion, neoplasia, trauma, contamination or Infxn)
When is a Partial lobectomy indicated?When there are Focal lesions distal in lobe
Dogs & cats may tolerate removal of up to ____% of their lung mass.50%
Which side pneumonectomy is NOT recommended & why?Dogs & cats may tolerate removal of up to 50% of their lung mass. → However, Bc the right lung possesses slightly greater than 50% of the total lung mass, complete right pneumonectomy is not recommended.
It is ok to do a full Left pneumonectomy if....If the right lung is healthy
What is a pneumonectomy?Removal of a full lung
If you perform a pneumonectomy, how might the heart be affected?Mediastinum might migrate, electrical axis of heart might migrate as well if mediastinum/heart is migrating
Explain the surgical technique for a complete lobectomy? (Part one-vessels)Isolate & pack off lung lobe to be resected → Vessels & bronchus are ligated at the hilus *(1) Isolate pulmonary artery (right-angled forceps) & Place 3 ligatures (middle ligature is transfixing). Repeat process w/ pulmonary vein. Excise vessels btwn transfixing & distal ligatures (pic is rt. angle forceps)
For a complete lobectomy, which vessel (pulmonary A or V) do you ligate 1st & why? EXCEPTIONS?1ST ARTERY, THEN VEIN!
The exceptions are:
(1) Small dogs/cats, bc if you ligate the a 1st, the vein is small & will collapse & be hard to find/ligate.
(2) Vein 1st if neoplasia or abscess (don't want to irritate it & then have it seed & spread through veins)
How is the ligations of the pulmonary aa & vv kinda different from what we're used to?Do 3 ligatures, circumferential → transfixing → circumferential & transfix btwn intermediate & distal ligature
Explain the surgical technique for a complete lobectomy? (part 2 - trachea)The bronchus is transected btwn 2 crushing clamps → 1 or 2 rows of horizontal mattress sutures, interrupted or continuous are placed through bronchus → Cut margin of bronchus is over sewn w/ simple continuous sutures
*Aside from pulmonary A & V, what other vessels are you worried about w/ a complete lobectomy?Bronchial vessels are what supply the lung parenchyma. Must ligate these as well.
What would be the surgical technique for a complete lobectomy if you used a stapler? (What stapler would you use?)TA stapler may be used for complete lobectomy. The hilus of the lobe is isolated → The entire pedicle is stapled → The lobe is excised distal to the staples
What is the surgical technique for a PARTIAL lobectomy?Crushing clamps are placed across the lobe proximal to the lesion → 1 or 2 rows of continuous horizontal mattress sutures placed proximal to the clamps (3-0 or 4-0 absorbable suture, small taper needle) → cut distal to mattress sutures & prox to clamps → can run simple cont at end of excision. Use small suture.
What important thing must you consider once you've done a partial lobectomy?Make sure no leaks! (Do water test via submerging lung in some saline & give breath, look for bubbles) bc leak can lead to pneumothorax - even hypertensive (tension) pneumothorax
Can you use a stapler for a partial lobectomy?Yes! TA gives double row of staples which is usually airtight
How do you check the partial lung lobectomy for air leaks?(1) Sterile saline is dripped across the suture line while the lung is inflated
(2) In large dogs, the suture line may be placed in a bowl of fluid while the lung is inflated
If there is a leak, how do you fix it?Leaks are closed w/ interrupted sutures
Why might you think a lame animal has a lung prob?Some animals may have lameness bc the lung lobe tumor has spread to other sites or has czd swelling & bony Rxn along the toes & lower bones of the leg (“hypertrophic osteopathy”). (Inflammation of cortex of long bones)
Why should you try to limit the amt of stitches in the lung parenchyma to only what is necessary?Each hole is a potential leak
Leak in lung parenchyma leads to what kinda pneumothorax?Tension/hypertensive
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Trachea Sx

Question Answer
What is tracheal collapse?An acquired end-stage Dz of the tracheal cartilage, leading to mechanical collapse of the trachea on inspiration &/or expiration
Hx of a tracheal collapse sufferer?Chronic Hx of coughing
Chronic bronchial Dz
Coughing w/ excitement
Big CSs of tracheal collapse“Honking” cough
Cyanosis
Syncope (when they faint they relax & it actually gets better for a bit but uh, not a good long term plan)
What are the grades for tracheal collapse?GRADE 1: 25% collapse
GRADE 2: 50% collapse
GRADE 3: 75% collapse
GRADE 4: 100% collapse
What are the 2 types of tracheal collapse based on region?Cervical or thoracic
When does collapse happen if it's in the cervical trachea?Inspiration
When does collapse happen if it's in the thoracic trachea?Expiration
Why is tracheal collapse kinda like a vicious cycle?Inspire harder bc having trouble breathing, leads to more pressure, which increases flattening of trachea..etc
4 types of surgical Tx for tracheal collapse?(1) Dorsal membrane plication
(2) Ventral ring chondrotomy (not in use anymore)
(3) External tracheal splints (ring or spiral)
(4) External tracheal stents
Medical management methods for tracheal collapse?Weight loss
Cough suppressants
Bronchial dilators
Sedation
What are you doing in a dorsal membrane plication? WHEN do you want to do this procedure? What is the suture pattern you use?C-shaped cart, where there isnt cart there is a membrane - try to bring membrane close together & cart rings closer together. mattress stitches. Keep membrane together & circumference of trachea can be regained. Only when you still have good architecture of trachea (Not helpful in grade 3/4 when rings are weakened or flat)
What are you doing in the tracheal ring splint technique?Use a splint to support cart. Membrane & maintain carts open. Place around ouTside of trach, maintain w/ sutures. (Was 1st done by cutting syringe cases & drilling holes in them for the suture to go through. Now there are things you can buy)
Diagram for tracheal splint
What are the 2 major precautions you must keep in mind when doing a tracheal ring splint technique?(1) The recurrent laryngeal nn runs on dorsal aspect of trachea - DON'T damage it
(2) Trachea has SEGMENTAL blood supply - do not disrupt this
What is the "domino effect" you risk when you do a tracheal splint?If you enforce on area...the adj area might become weakened
Explain the approach you take to place the tracheal splintDorsal rectum, VM approach, displace mm like eso Sx.... delicately dissect around trach rings & try to pass splints & place sutures
Do you want to suture into the lumen when placing your tracheal splint? If you do, what do you do?Don't want to, but if you, will have to improve diameter of lumen...might elicit some more coughing, support PTx w/ meds (cough suppressants) & might need some humidifiers bc if too dry mucosa, more coughing
Disadvantages of external tracheal splints?Extensive surgical approach
Anesthetic risks
Prolonged postoperative care & pain
High cost of ANx & aftercare
Trachea adjacent to supported trachea may be at higher risk of collapse
Advantages of external tracheal splints?Most animals improve postop
Where do Internal Tracheal STENTS go? What must you do to place them?Instead of outside, these go inside. Place w/ cath-place w/ ruler (need to use fluoroscopy)
Potential advantages of internal tracheal STENTS?(5)(1) Catheter delivery - no Sx required
(2) Shorter ANx
(3) Reduced postoperative pain
(4) Reduced cost (?)
(5) Entire trachea is treated at 1 time
Potential disadvantages of internal tracheal STENTS?(2)(1) Endoscopy or fluoroscopy required
(2) Stent cannot be retrieved back into delivery catheter if error in placement or sizing is made (← questionable, depends on if it is an old or new model)
If your stent isn't long enough, should you put in two?Overlapping 2 is not the best idea. Ciliary cells - move w/ goblets cells to remove shit. If too much pressure will damage goblet cells & cilliar-muco cells
Is Sx on the trachea for tracheal collapse a cure?NO - just a Tx to improve pulmonary Fxn
Which is generally more successful - the tracheal SPLINTS or the tracheal STENTS?Stents
3 possible complications of stenting?(1) Decreased mucociliary clearance
(2) Inflammation & exuberant granulation tissue formation (still a FB - can have hypertrophy to tissues in response to the FB )
(3) Pressure necrosis
6 things you can do for post-op care after tracheal stent (can apply to splint too, im sure..)(1) Perioperative ABx
(2) Corticosteroids for 7d
(3) Sedation
(4) Cough Suppression
(5) 24hrs O2 if needed
(6) Humidification
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TracheAL TRAUMA

Question Answer
How can intubation cz trach trauma?Act of intubation itself can cz damage, rotate PTx w/o deflating cuff...
If there is severe damage to the trach, what is your rad gonna look like?AIR EVERYWHUR (SQ emphysema)
If there is a bunch of tracheal damage, what salvage procedure should you try? What if the hyoid apparatus is involved? (think: bit by dog)Tracheostomy - remainder of trachea is applied to skin as a tube - if hyoid is involved, this swallowing apparatus is also compromised, so may have to do esophagostomy or gastrostomy tube also
Tracheal Resection & Anastomosis → how many rings can you usually take away w/ this & why?Resection of 3-5 rings easily done, but up to 8-10 rings (25%) can be resected (however in class this might be too many)....Only can do LIMITED amt of rings bc the trachea DOES NOT LIKE TENSION! If more than 3-5, you will need harness to keep dogs head down to prevent stress on trach (neck flexion)
2 ways to minimize tension on the trachea after you have performed a tracheal resection & anastomosis?(1) Use tension relief sutures (bridging by going around carts so not all tension on 1° wound)
(2) Use a harness that keeps the head down to reduce tension
What are 2 ways to resect the trachea (based on where you cut) & which is probably preferred (why?)(1) Cut through the membrane btwn each ring (easier but not the best)
(2) *Resect trachea btwn rings (split cartilage) (more demanding but better & strong apposition & no membrane that might get inverted too)
Explain Sx technique for Tracheal Resection & AnastomosisResect trachea btwn rings (split cartilage) → Handle trachea w/ umbilical tape or traction sutures → Suture dorsal tracheal membrane 1st → Place sutures around rings, add tension sutures if necessary
Which part of the trach do you sew 1st in a resect/anastomosis?Suture dorsal tracheal membrane 1st
If there is a small hole/you arent so sure about your anastomoses of the trach, how can you help?Can sometimes use patching technique - if hole can use mm in vicinity (like for eso) & tracheal mucosa will rapidly cover that (*still be aware there is a weak point where there is no cart), A pleural patch may be placed over the suture line
How do you place tension sutures for your resect+anasto?Tension sutures are placed 2-3 rings from the suture line on each side
What tool might be useful to help w/ a trach resect & ana?Can use a tube (not sure if ET or bain or what) kinda acts like a stink, helps you place & guide stitches, etc.
If there is a small leak in your repair of the trach, aside from patching, what else can you do?Leave 1-2 stitches on skin not closed so allow drainage (otherwise can cz SQ emphysema)
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