Thoracic Surgery

Robert E. Merritt MD¹

Walter B. Cannon MD¹

Vivek Kulkarni MD²

Jay B. Brodsky MD²

¹SURGEONS

²ANESTHESIOLOGISTS

INTRODUCTION—SURGEON’S PERSPECTIVE

AIRWAY AND LUNG ACCESS CONFLICTS

As in Chapter 3, induction and maintenance of anesthesia for thoracic surgery requires interdisciplinary cooperation. Perioperative communication between the surgeon and anesthesiologist is required for a satisfactory outcome. For example, during periods of OLV, significant hypoxia and hypotension may occur. Surgery may need to be stopped temporarily while the hypoxia is corrected by reinflation of the unventilated lung. Hypotension in the absence of bleeding can be corrected by less vigorous retraction of the lung and heart by the surgeon. Quick and timely communication between the anesthesiologist and the surgeon can be lifesaving. Occasionally, during critical parts of the dissection, cessation of all respiration for short periods of time can make the surgeon’s job much easier. Testing the changes is an option.

TUBES AND TUBE SIZES

Although the size of the ETTs may not be particularly critical for most types of surgery, thoracic surgical procedures are often different. Fiberoptic bronchoscopy (FOB) through the ETT is a common event. The standard FOB just fits through an 8.0 ETT. The fiberoptic laryngoscope (FOL) used for difficult intubations will fit smaller ETTs and DLTs. Proper lubrication of the bronchoscope with a polyethylene glycol-based ointment (e.g., Carbowax rather than an aqueous jelly, which will dry out quickly) makes manipulation quite easy. The FOL can be used for correct positioning of the DLT. If the bronchial portion of the DLT cannot be advanced into the left main bronchus, the bronchoscope can be advanced through the bronchial side of the DLT into the left main bronchus. Then, through use of the bronchoscope as a stent, the DLT can be advanced over the bronchoscope into the left bronchus. The depth of the tube can be determined by bronchoscopic observation of the right main bronchus through the tracheal side of the DLT. If a laser is to be involved, have a laser-compatible ETT available, keep FiO₂ to < 0.3 and do not use N₂O.

PATIENT POSITIONING AND SURGICAL INCISIONS

Patient positioning for these procedures is dictated by the type of incision used. The incisions used most often by thoracic surgeons are the posterolateral thoracotomy (and its variations; Fig. 5-1A), the median sternotomy (Fig. 5-1B), and the anterior thoracotomy (often bilateral; Fig. 5-1C). For procedures where excellent exposure of both lungs is mandatory (e.g., bipulmonary lung transplantation), the “clamshell” incision (Fig. 5-2) has become popular. Generally, patients are in the supine position for anterior incisions (sternotomy, cervical, and anterior thoracotomy) and in the lateral position for lateral and posterolateral thoracotomies. Thoracoscopic procedures (VATS) typically are performed in the lateral position. (Note: A review of a recent CXR in the OR will help ensure that the thoracotomy is performed on the correct side.)

Figure 5-1. Primary incisions for thoracic surgery. A: Posterolateral thoracotomy, in lateral position. The incision curves in an S shape, passing under the tip of the scapula over in the fifth interspace anteriorly. B: Median sternotomy, in supine position, arms at side: the incision is made from the suprasternal notch to a point between the xiphoid process and umbilicus. C: Anterior thoracotomy in supine position. (Reproduced with permission from Fry WA: Thoracic incisions. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

Figure 5-2. The “clamshell” incision, in classic supine position, affords excellent exposure, especially for bilateral lung procedures. (Reproduced with permission from Fry WA: Thoracic incisions. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

Patients undergoing surgery in the lateral position are initially placed on a bean bag. When GA is induced, the patient is rolled onto his/her side with the kidney rest being positioned at the level of the lower ribs. An axillary roll is placed to prevent axillary compression, and the table is flexed to assist in spreading the ribs. The head and neck must be aligned in a neutral position to avoid brachial plexus injuries. The lower arm can be either extended on an arm board or flexed and placed next to the patient’s head (Fig. 5-3A). The upper arm is
then extended and held in position with either an airplane holder or an arm board with several pillows (Fig. 5-3B). The lower leg should be flexed, and the upper leg should be left extended and supported by pillows. The back is kept in a vertical position while the beanbag is evacuated of air (blanket bolsters may be placed next to the patient). Wide adhesive tape is placed across the hips to further secure the patient. A lower-body warming blanket (e.g., Bair Hugger) should be used to avoid hypothermia. To facilitate closure, the table can be returned to the flat position. Ideally, this is accompanied by inflation, and subsequent deflation, of the beanbag. The anesthesiologist may be asked to exert downward pressure on the patient’s shoulder to diminish tension on the latissimus dorsi closure.

Figure 5-3. Lateral positioning for thoracic lateral and posterolateral procedures. A: Patient on his side, with kidney rest, axillary roll, pillows between knees, and padding under elbows. Wide adhesive tape secures the position. B: Upper arm abducted 90% on arm board. (Reproduced with permission from Fry WA: Thoracic incisions. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

Figure 5-4. Segmental anatomy of the lungs. (Reproduced with permission from Clemente CD: Gray’s Anatomy, 30th American edition. Williams & Wilkins, Philadelphia: 1985.)

Although the standard posterolateral thoracotomy involves division of the latissimus dorsi and serratus anterior muscles, muscle-sparing incisions—either transverse or vertical—are gaining in popularity because they are
perceived to decrease pain and provide a more rapid recovery. Variations on the posterolateral thoracotomy all have position requirements similar to those of the standard posterolateral incision.

For an anterior incision, the patient is placed supine. A small roll placed under the shoulder blades will serve to extend the neck and facilitate access to the upper mediastinum. This is particularly important for an operation on the upper trachea and improves visualization for cervical mediastinoscopy. In general, the arms should be tucked at the patient’s sides. Having an arm extended during a sternotomy can place undue stretch on the brachial plexus → injury.

The probability of DVT in general thoracic cases is controversial, whereas the risks of prophylaxis are minimal. Given that patients undergoing thoracotomy often have protracted periods of immobility, both during and after surgery, and often have a Dx of a malignant disease (hypercoagulability), use of DVT prophylaxis is good practice. We use SCDs for all patients, except those undergoing short video-assisted procedures and reserve subcutaneous heparin for those at higher than normal risk (e.g., with prolonged postop immobility).

POSTOPERATIVE ISSUES

The most common postop issues relevant to anesthesiologists are

The need for postop mechanical ventilation;
Airway management;
Hemodynamic instability; and
Pain control.

The majority of patients undergoing thoracotomy can be extubated immediately postop. The most common exceptions are patients requiring preop mechanical ventilation, lung transplant patients, and those with “difficult” airways. Patients undergoing prolonged surgery may require postop mechanical ventilation. With shorter procedures, and those performed using minimally invasive techniques, even patients undergoing lung-volume-reduction surgery for severe emphysema generally can be extubated at the conclusion of the procedure.

Because DLTs are larger than standard ETTs, there is greater potential for laryngeal trauma and airway edema → loss of airway following extubation. By exchanging the DLT for a single-lumen ETT over a tube changer, this potentially catastrophic complication can be avoided.

Hemodynamic instability following surgery may be 2° several causes, the most important being ongoing blood loss (or inadequate intraop fluid replacement) and cardiac dysfunction. Use of epidural anesthesia may accentuate ↓ BP both intraop and postop.

With the use of epidural anesthesia and systemic analgesics (e.g., ketorolac) postop pain can be managed effectively. It is important for the anesthesiologist to communicate to the surgeon (and postop care team) which agents have been used, how the patient responded to them, and what types of hemodynamic, pulmonary, and neurological effects can be expected in the postop period.

LOBECTOMY, PNEUMONECTOMY

SURGICAL CONSIDERATIONS

Description: Surgery remains the most appropriate form of treatment for early-stage lung cancer. Other less common indications include infection (particularly mycobacterial disease and bronchiectasis), developmental abnormalities such as sequestrations, and trauma. Patients with Stage I or II non-small-cell lung cancer (disease confined to the lung or those with intrapulmonary node involvement only) generally are offered surgery, unless their pulmonary function is prohibitively poor or their comorbidities pose an unacceptable risk. Patients with Stage IIIA disease often receive preop chemotherapy and/or radiation; and those with Stage IIIB or IV disease are rarely offered an operation.

Table 5-1. Spirometric Criteria for Pulmonary Resection

Spirometry		Operable	Further Study Suggested
Forced vital capacity (FVC)		> 60% predicted	< 60% predicted
Forced expired volume in 1 see (FEV₁)		> 60% predicted	< 60% predicted
FEV₁ FVC ratio		> 50%	< 50%
Maximum voluntary ventilation		> 50% predicted	< 50% predicted
Gas exchange
	Diffusing capacity for carbon monoxide	> 60% predicted	< 60% predicted
	Arterial carbon dioxide tension	< 45 mm Hg	> 45 mm Hg
Used with permission from Olson GN: Pulmonary physiologic assessment of operative risk. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2003.

Regardless of the underlying disease, the preoperative evaluation should include an assessment of pulmonary function (Table 5-1). Spirometry is adequate for most patients with little or no functional impairment, but more elaborate tests—such as measurement of diffusion capacity, quantitative ventilation/perfusion scans, or formal exercise testing (Fig. 5-5)—are appropriate for others.

Following induction of general anesthesia, many surgeons perform a preoperative bronchoscopy. In patients with tumors in the trachea or mainstem bronchi, this step may be important in determining whether the patient should undergo a lobectomy, sleeve lobectomy, or pneumonectomy. Most patients undergoing lobectomy or pneumonectomy are placed in the lateral decubitus position. This approach permits a lateral or posterolateral thoracotomy (Fig. 5-1A)—the incision that provides optimal exposure of the pulmonary hilum. A more limited, muscle-sparing incision may be used; however, the exposure may be somewhat limited. Occasionally, a median sternotomy approach (Fig. 5-1B) is used-particularly when there is significant involvement of the anterior mediastinum by the tumor.

Over the past several years, video-assisted thoracoscopic lobectomy (VATS-lobectomy) has become more widely available. Although the anesthetic and surgical details of VATS techniques are described later in the chapter, early experiences with this procedure have demonstrated similar outcomes to those associated with the more traditional open techniques. Although a limited “access” thoracotomy is necessary to remove the mobilized lobe from the chest cavity, the technique has the advantages of minimizing soft tissue trauma and the pain associated with spreading the ribs.

Following entry into the chest, the lung on the operative side is allowed to deflate. If the lung remains inflated, a flexible bronchoscope should be used to verify correct positioning of the DLT (Fig. 5-6). Alternatively, the surgeon may be able to feel the tip of the DLT and guide it into the correct position. After stable OLV has been obtained, the lung is mobilized and the bronchovascular structures are identified. Generally, the vascular structures are divided first although, when exposure is limited, it may be best to divide the bronchus first. Hypotension and arrhythmias may occur when the hilar structures or pericardium are retracted vigorously. Such aberrations generally resolve quickly on restoration of normal anatomic relationships. Inadvertent entry into a branch of the pulmonary artery during dissection can result in rapid blood loss. Because these vessels are usually under low pressure, bleeding generally can be controlled with direct pressure on the bleeding site, while the anesthesiologist resuscitates the patient and the surgeon obtains more definitive vascular control. During a lobectomy, the surgeon will ask the anesthesiologist to reinflate the lung while the bronchus leading to the lobe that will be removed is occluded. This will ensure that the remaining lobes inflate appropriately. Thorough suctioning immediately before the lobectomy eliminates secretions as a cause of continued atelectasis. Once the lung or lobe has been resected, positive pressure is applied to the bronchial stump (and lobe) to check that there is no significant postop air leak. Large air leaks are best addressed at the time of surgery, rather than waiting for them to resolve postop.

Chest drainage is standard following lobectomy and involves placement of one or two 28-36 Fr chest tubes attached to underwater seal or suction. Placing the tubes to suction typically increases observed air leak, whereas extubating the patient in the supine position typically decreases the leak. Following pneumonectomy, chest drainage is not uniformly carried out; however, if a chest tube is to be placed, a balanced drainage system must be used or the
mediastinum will shift to the operative side, thus creating adverse hemodynamic consequences. An alternative to drainage (after the patient is placed supine) is to aspirate air from the operative pleural space until a slight negative pressure is obtained.

Figure 5-5. Physiologic assessment of patients with compromised lung function. (Reproduced with permission from Olson GN: Pulmonary physiologic assessment of operative risk. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

Usual preop diagnosis: Carcinoma of the lung; infection; developmental abnormalities; trauma

Figure 5-6. Use of a fiberoptic bronchoscope to ensure correct positioning of a leftside DLT. (Reproduced with permission from Fry WA: Thoracic incisions. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

▪ SUMMARY OF PROCEDURES

	Lobectomy	Pneumonectomy
Position	Lateral/supine	⇚
Incision	Posterolateral/median sternotomy/VATS	⇚
Special instrumentation	DLT; SCD or TED hose	⇚
Antibiotics	Cefazolin 1 g	⇚
Surgical time	2-3 h	⇚
EBL	< 500 mL (more in redo or inflammatory cases)	⇚
Postop care	PACU ± ICU; careful attention to pulmonary toilet; chest tube output	⇚ + Special balanced drainage tube
Mortality	± 1%	± 5%
Morbidity	Dysrhythmias: 10-20%	30-40%
	DVT: 5-20%	⇚
	ARDS	⇚
	PE	⇚
	MI	⇚
	Bronchopleural fistula	⇚
	Chylothorax	⇚
	Subcutaneous emphysema	⇚
	Phrenic nerve injury	⇚
	Recurrent laryngeal nerve injury	⇚
Pain score	7-8	7-8

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

The main indication for lung resection is neoplasm. Other indications include infection, hemorrhage, or air-leak. The majority of patients have a Hx of cigarette smoking with associated emphysema and/or chronic bronchitis. As most patients are older, other comorbidities are common (CAD, DM). Morbidity and mortality following thoracotomy is increased with preexisting pulmonary, cardiovascular, and neurologic disease. Lung resections are increasingly being performed via thoracoscopy, which decreases patient morbidity. Lung isolation (DLT or BB) and OLV are mandatory for surgical exposure.

Respiratory	Question patient about exercise tolerance, dyspnea, productive cough and cigarette smoking. Examine patient for cyanosis, clubbing, RR, and pattern. Listen to chest for wheezes, rhonchi, rales. Timely cessation of smoking (> 8 wk), adequate management of bronchospasm with bronchodilator treatment ± steroids, and prompt treatment of preexisting lung infections are important to reduce postop pulmonary complications. Tests: PFT (see below and Table 5-2); CXR; chest CT (if available), always examine chest imaging re: ease of lung isolation; ABG (only if indicated from H&P).
Pulmonary function	Nonsmoker with normal lungs may not require any studies for simple lobectomy. Any pre-existing respiratory disease (or possibility of pneumonectomy) should trigger lung function studies. Whole-lung tests (ABG, spirometry) are sufficient in most cases. Splitfunction lung tests (V/Q scan) should be considered if the patient has heterogeneous disease, or a planned pneumonectomy or borderline lung resection is planned. Many variables have been shown to correlate with poor outcome. The most important are FEV₁, D_LCO, and VO₂ max, which focus on different aspects (mechanics, parenchymal function, and cardio-pulmonary reserve, respectively). Postoperative predictive values of FEV₁ < 40%, D_LCO < 40%, or baseline VO₂max < 15 mL/kg/min predict ↑ risk for postop complications following pulmonary resection. Preop hypercapnia or PHTN/ RV dysfunction are relative contraindications to lung resection, except for specific circumstances (e.g., combined with LVRS in severe emphysema). Trial pneumonectomy with PA balloon occlusion is frequently discussed, but not used in clinical practice. Preop optimization of respiratory function with bronchodilator therapy should be routine.
Cardiovascular	RV dysfunction is a relative contraindication to lung resection (particularly pneumonectomy). Prophylactic digoxin or amiodarone to ↓ risk of postop atrial fibrillation have limited efficacy. Tests: ECG—look for evidence of RV hypertrophy, conduction problems, ischemia, and prior MI. ECHO to evaluate ventricular function; others as indicated from H&P.
Neurological	[check mark] Hx of previous back surgery, peripheral neuropathy. Examine thoracolumbar area for skin lesions, infection, deformities.
Musculoskeletal	Patients with lung cancer may have myasthenic (Eaton-Lambert) syndrome with resistance to depolarizing muscle relaxants and ↑ sensitivity to NDMRs. Monitor relaxation with peripheral nerve stimulator.

Table 5-2. Assessment of Risk of Postop Pulmonary Complications Following Thoracic and Abdominal Procedures

Category		Point
I.	Expiratory Spirogram
	a. Normal (%FVC + %FEV₁/FVC > 150)	0
	b. %FVC + %FEV1/FVC = 100-150	1
	c. %FVC + %FEV1/FVC < 100	2
	d. Preop FVC < 20 mL/kg	3
	e. Post-bronchodilator FEV1/FVC < 50%	3
II.	Cardiovascular System
	a. Normal	0
	b. Controlled HTN, Ml sequelae for more than 2 yr	0
	c. Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, dependent edema. CHF, angina	1
III.	ABGs
	a. Acceptable	0
	b. PaCO2 >50 mm Hg or PaO2 < 60 mm Hg on room air	1
	c. Metabolic pH abnormality > 7.50 or < 7.30	1
IV.	Nervous System
	a. Normal	0
	b. Confusion, obtundation, agitation, spasticity, discoordination, bulbar malfunction	1
	c. Significant muscular weakness	1
V.	Postop Ambulation
	a. Expected ambulation (minimum, sitting at bedside) within 36 h	0
	b. Expected complete bed confinement for at least 36 h	1
	0 Points = Low Risk; 1-2 Points = Moderate Risk; 3 Points = High Risk
With permission, Shapira BA, Harrison RA, Kacmarek RM, Cane RD: Clinical Application of Respiratory Care, 3rd edition. Year Book Medical Publish ers, Chicago: 1985.

Hematologic

Adequate O₂-carrying capacity is important. Optimize Hb preoperatively if possible (iron, EPO), consider transfusion with Hb < 7 g/dL (<10 g/dL with CAD), depending on vital signs. Although rare, bleeding can be profuse, so blood should be immediately available. Coagulopathy may preclude neuraxial anesthesia.

Tests: Hct; PT; PTT (if epidural anesthesia planned)

Laboratory

Other tests as indicated from H&P

Premedication

Midazolam 0.5-2 mg iv if patient anxious (unless respiratory compromise). When epidural opioids are planned, avoid additional systemic opioid or sedative premedication that can potentiate postop respiratory effects of neuraxial opioids.

INTRAOPERATIVE

Anesthetic technique: Combined GA with continuous regional technique (epidural or paravertebral). Anesthesia for lobectomy/pneumonectomy relies on OLV techniques to improve surgical exposure and minimize damage to the operative lung in the case of lobectomy or bi-lobectomy. The challenges to the anesthesiologist include maintaining adequate oxygenation in patients with poor pulmonary reserve and ensuring that the patient is comfortable, warm, and awake at the end of surgery.

Preinduction	Placement of a regional analgesia catheter is important for postop pain control. Continuous epidural (lumbar or thoracic) and paravertebral blocks have been shown to be effective. Epidural catheters should be placed in the awake patient, whereas paravertebral catheters can be sited asleep or intraop under direct vision. The catheter tip should be as close as possible to the level of incision to minimize the sympathectomy. Intraop use of regional analgesia reduces the amount of systemic anesthetics/analgesics required and, therefore, facilitates rapid emergence. An adequate block can be established with lidocaine or bupivacaine; however, higher concentrations will be required for intraop anesthesia than postop analgesia.
Induction	Standard induction (p. B-2). If flexible bronchoscopy is planned prior to lung resection, intubate with an ETT (≥8 mm), which will be replaced with DLT after bronchoscopy (see below). Otherwise, proceed to intubation with an appropriate sized DLT (check imaging, rough guideline: adult male, 39-41 Fr; adult female, 35-37 Fr) after induction.
Maintenance	Air/O₂ and isoflurane/desflurane/sevoflurane (around 0.5-0.7 MAC if neuraxial block established). Avoid N₂O. Use high FiO₂ = 0.8-1.0 at onset of OLV; titrate to lowest possible after HPV well established and operative lung collapsed. A local anesthetic (e.g., 2% lidocaine or 0.25-0.5% bupivacaine) can be infused or injected hourly into a thoracic (1-3 mL) or lumbar (5-10 mL) epidural catheter. Continuous infusion of local anesthetic generally provides better hemodynamic stability than hourly bolus injection. To enhance the effect of epidural analgesia, a loading dose of epidural opiate (e.g., hydromorphone 200-500 mcg [thoracic] or 1-1.5 mg [lumbar]) can be administered prior to incision. Epidural hydromorphone has a superior side-effect profile over morphine at equipotent doses. IV (compared to inhalational) anesthetics have a clinically insignificant benefit on OLV oxygenation (particularly if volatile agents are limited to < 1 MAC) and are, therefore, not necessary in the majority of cases.
Emergence	Before chest closure, lungs are inflated gradually to 20-30 cmH₂O pressure to reinflate atelectatic areas and to [check mark] for significant air leaks. Surgeon inserts chest tubes to drain pleural cavity and aid lung reexpansion. Patient is extubated in OR. If postop ventilation is required (rare), DLT exchanged for single-lumen ETT. Patient transferred in head-elevated position to PACU or ICU, breathing mask O₂. If hemodynamically unstable, monitor ECG, pulse oximetry, and arterial pressure during transfer.
Blood and fluid requirements	IV: 18 ga × 1 + 14 or 16 ga × 1 Maintain stable hypovolemia, Limit fluid to 10-15 mL/kg if possible Blood: available, but rarely required; use vasopressor (ephedrine 5-10 mg iv bolus or phenylephrine 50-100 mcg iv bolus) if hypotensive.	Postop, PVR is increased in proportion to the amount of lung tissue removed. An overhydrated patient is at risk of RV failure and pulmonary edema. Replace blood loss with colloid (1:1) to minimize volume load. Third-space loss is negligible and need not be replaced. Use of epidural local anesthetics can cause ↓ BP in a volume-restricted patient; vasopressor may be needed.
Monitoring	Standard monitors (p. B-1) Arterial line Urinary catheter ± CVP line ± PA line or TEE (rare)	It is mandatory to follow oxygenation continuously during OLV. Typically, this can be done with pulse oximetry, although continuous intraarterial PO2 monitoring is now commercially available. CVP and/or PA line optional for pneumonectomy and for patients with coexisting cardiac disease. CVP monitoring may be inaccurate intraop and is mostly placed for postop care. PA lines are rarely necessary and may interfere with PA stapling or endanger the PA stump. TEE may be of benefit in the borderline pneumonectomy to check for RV tolerance of PA cross-clamp.
Positioning	Axillary roll, “airplane” for upper arm Avoid hyperextending arms [check mark] and pad pressure points [check mark] eyes, ears, genitals	[check mark] radial pulses to ensure correct placement of axillary roll (if misplaced, will compromise distal pulses). Placing the oximeter probe on the down arm may assist in monitoring arm perfusion.
Fiberoptic bronchoscopy	FOB performed immediately before thoracotomy to evaluate resectability of lesion. Patient intubated with large ETT (≥ 8 mm), replaced with DLT or BB following bronchoscopy (see Bronchoscopy, p. 320).	Use the largest DLT that atraumatically passes through the glottis (typically, 39-41 Fr for men, 35-37 Fr for women). DLT can be placed accurately by careful auscultation ±confirmation by FOB. For a DLT, fiberoptic confirmation is done both through the tracheal lumen to confirm that the blue bronchial cuff is not hemiating above the carina, and through the bronchial lumen to confirm that the end of the tube is not abutting the secondary carina (L-DLT), or through the bronchial lumen to confirm the end of the tube is in the bronchus intermedius and the opening in the blue bronchial cuff is facing the (R)UL orifice (R-DLT). For small children, the balloon of a Fogarty embolectomy catheter is used as a BB; for adults, either a BB or a Univent tube may be used if the proper size DLT cannot be placed. BB not ideal as FOB always needed to confirm placement, lung collapse delayed, suction and CPAP not effective and repeated inflation and collapse may be difficult.
Lung isolation	Separate lungs to prevent contralateral contamination (infection, pus, blood, tumor), allow selective ventilation and facilitate operation.
OLV	Two lung vent: Vt = 8-10 mL/kg, normocapnia, PEEP 3-5 cm H₂O OLV: Vt = 4-8 mL/kg, permissive hypercapnia (PaCO₂ 50-70 mm Hg), PEEP 3-8 cm H₂O (unless BPF), FiO₂: 0.6-1.0, PIP < 35 cm H2O and plateau pressures < 25 cm H₂O, consider PCV.	Issues during OLV are oxygenation, ventilation, and lung injury. Oxygenation is rarely an issue if the DLT is adequately placed and derecruitment is avoided in the nonoperative lung. Ventilation is impaired by the smaller lumen of the DLT and the fact that only one lung is ventilated, resulting in higher ventilatory pressures. However, permissive hypoventilation allows for limiting the ventilatory stress. Acute lung injury may result in postpneumonectomy pulmonary edema, which may occur even after lesser resections. Limiting Vt, peak and plateau pressures, FiO₂, duration of OLV and atelectasis formation help to minimize the risk.
Complications	Hypoxemia	Hypoxemia is now relatively infrequent due to better lung isolation techniques and anesthetic agents with less suppression of HPV. If hypoxemia occurs, tube position should immediately be confirmed and FiO₂ increased toward 1.0. Suctioning of secretions and lung recruitment maneuvers are often all that is required. If derecruitment has occurred, higher levels of PEEP should be employed; however, this may potentially worsen oxygenation. CPAP to the (recruited) operative lung is always helpful, as is clamping of the PA to exclude shunt flow. Return to two-lung ventilation (if possible) will always improve oxygenation (even if used intermittently only) and should be considered with refractory hypoxemia.
	Hypercarbia	Mild hypercarbia is well tolerated except in the setting of severe PHTN. CO₂ levels above 70 mm Hg may be associated with tachycardia, dysrhythmias, and cardiac depression. Treat with higher minute ventilation.
	Arrhythmia	[check mark] for mechanical compression of heart or great vessels.
	Hypotension	[check mark] volume status (but always hypovolemic) and cardiac function. Consider neosynephrine for BP support if ↓ BP is 2° epidural.
	Airway rupture	[check mark] integrity of intubated bronchus after reexpanding lung.
	DVT	Preventive measures: TED hose or SCD.
	Airway trauma from intubation, tracheobronchial rupture	Force should NEVER be used during insertion of a DLT, as it may result in catastrophic airway disruptions. Do not overdistend bronchial balloon or DLT cuffs. DLT bronchial cuff usually requires < 2 mL air for airtight seal, if an appropriate (large) DLT is used.

POSTOPERATIVE

Complications	Injuries related to lateral positioning	Pressure damage to ear, eye, nose, deltoid muscle, iliac crest, brachial plexus, and radial, ulnar, common peroneal, and sciatic nerves have all been reported.
	Structural injuries related to thoracotomy	Neurologic (phrenic and recurrent laryngeal nerves), thoracic duct, spinal cord; bronchopleural fistula, tracheobronchial disruption
	Surgical complications	Cardiac herniation, tension pneumothorax, bleeding, torsion of residual lobe, acute lung injury/ARDS
	Cardiopulmonary complications	Supraventricular dysrhythmias, SVT, acute RV failure, atelectasis, BPF, pneumonia, PE. For SVT, treat underlying cause and correct electrolyte abnormalities. Most postop SVTs are 2° atrial fibrillation or 2° catecholamine surge and may resolve spontaneously. Hemodynamically unstable patients will require cardioversion. Betablockers, amiodarone, Ca⁺⁺ channel blockers, and over-drive cardiac pacing are effective in patients with unstable AF.
Pain management	Neuraxial opioids—epidural or intrathecal Parenteral opioids (iv, im, continuous iv, PCA [p. C-3]) Intercostal blocks Interpleural analgesia Epidural local anesthetics Cryoanalgesia NSAID (ketorolac)	Effective analgesia via epidural or paravertebral route is essential for patient to cough, deep breathe, and ambulate early. Epidural infusions consist of a local anesthetic + opioid mixture (smaller volume and higher concentration with thoracic placement). Paravertebral infusions are local anesthetic only, thereby avoiding opioid side effects. Paravertebral analgesia interferes less with postop lung function than epidural analgesia. Ketorolac (10-15 mg) is helpful as adjunct analgesic, particularly with referred shoulder pain.
Pain management	Tests	Hct, CXR, ABG, and others as indicated.

Suggested Readings

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10. McKenna RJ Jr, Houck W, Fuller CB: Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81(2):421-5; discussion 425-6.

11. Slinger P: Update on anesthetic management for pneumonectomy. Curr Opin Anaesthesiol 2009; 22(1):31-7.

12. Slinger PD: Postpneumonectomy pulmonary edema: good news, bad news. Anesthesiology 2006; 105(1):2-5.

WEDGE RESECTION OF LUNG LESION

SURGICAL CONSIDERATIONS

Description: Wedge resection (removal of a mass in a manner that does not remove an entire anatomical pulmonary segment) may be carried out for a number of reasons. A known or suspected cancer may be removed by this limited resection. There is general agreement that this is an appropriate operation for patients with peripheral nonsmall-cell tumors and who have pulmonary reserve limited to the point that they are unable to tolerate lobectomy. Wedge resection also is used for resection of single- or multiple-metastatic lesions from various primary neoplasms. A single metastasis may be removed through a limited thoracotomy incision. At the other extreme, a median sternotomy may be used to remove bilateral lesions. Wedge resection also is indicated for diagnostic and therapeutic purposes in lesions that defy diagnosis by less-invasive techniques. Incisions vary with location, number of lesions, and technique used. Limited thoracotomy, standard thoracotomy, or median sternotomy may be used under different circumstances. Stapling (Fig. 5-7), clamp and suture technique, or excision and suture technique may be
used for lesions in different locations. Wedge resection is best performed in the lateral position and with OLV. Small nodules on the edge of the lung and diagnostic biopsies for interstitial lung disease often can be performed with the thoracoscope, thereby avoiding a thoracotomy. In patients who cannot tolerate OLV (e.g., with ARDS), it may be necessary to keep the patient supine and ventilate both lungs. The wedge resection itself generally is carried out with a surgical stapling device (Fig. 5-7) that simultaneously staples the lung parenchyma and cuts between staple lines. Alternatively, the lung tissue can be clamped and oversewn—a technique applicable to particularly indurated lung tissue that is too thick for a stapler. A final option is to perform a pneumonotomy, enucleate the nodule, and suture the lung closed. A single chest tube usually is placed for postop chest drainage.

Figure 5-7. Stapler used to perform wedge incision. (Reproduced with permission from Scott-Conner CEH, Dawson DL: Operative Anatomy. Lippincott Williams & Wilkins, Philadelphia: 2003.)

Variant approach: Video-assisted thoracoscopy surgery (VATS; see p. 326).

Usual preop diagnosis: Metastatic tumor to the lungs; primary lung cancer (typically, lobectomy); unknown pulmonary lesion

▪ SUMMARY OF PROCEDURE

Position	Lateral or supine
Incision	Limited and related to location of solitary lesion; sternotomy for bilateral lesions
Special instrumentation	DLT
Antibiotics	Cefazolin 1 g (or other antibiotic as indicated from culture and sensitivity)
Surgical time	< 1-3 h, depending on number of lesions
EBL	< 500 mL
Postop care	PACU ± ICU; careful attention to pulmonary toilet, chest tube output
Mortality	Minimal
Morbidity	Air leaks Cardiac dysrhythmias
Pain score	2-6

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

The anesthetic considerations for this procedure are very similar to those for lobectomy/pneumonectomy, although most wedge resections are easily accomplished via thoracoscopy. Wedge resection of the lung may be performed for diagnosis of interstitial process/lesion or for resection of neoplasm in patients with poor pulmonary reserve, who may not tolerate an anatomic resection.

Respiratory	PFTs similar to major thoracotomy. Further evaluation directed toward an underlying disease (immunocompromised patient for open-lung biopsy, patient with metastatic lesions). Tests: PFTs (see Lobectomy, Pneumonectomy, p. 281); CXR; chest CT (if available), always examine chest imaging for airway problems that might interfare with lung isolation, airway compression/obstruction; ABG (only if indicated from H&P).
Cardiovascular	Tests: ECG—look for evidence of RV hypertrophy, conduction problems, ischemia, and previous MI.
Neurological	Hx of previous back surgery or peripheral neuropathy. Examine thoracolumbar area for skin lesions, infection, deformities. The placement of an epidural catheter in patients with neurologic problems is controversial.
Musculoskeletal	Patients with lung cancer may have myasthenic (Eaton-Lambert) syndrome with resistance to depolarizing muscle relaxants and ↑ sensitivity to NMRs. Monitor relaxation with a peripheral nerve stimulator.
Hematologic	Patients are often anemic from primary disease. Consider preop blood transfusion or erythropoietin therapy. Tests: Hct
Laboratory	Other tests as indicated from H&P
Premedication	Midazolam 0.5-2 mg iv if patient anxious. When epidural opioids are planned, avoid additional systemic opioid or sedative premedication, which can potentiate postop respiratory effects of central neuraxial opioids.

INTRAOPERATIVE

Anesthetic technique: GETA with one lung ventilation using a DLT or BB. This is often combined with an epidural or paravertebral block. Sometimes intercostal nerve blocks are performed when the approach is thoracoscopic or when other regional techniques are contraindicated.

Induction	Standard induction. Short-acting paralytic (succinylcholine 1-1.5 mg/kg or vecuronium 0.1 mg/kg or rocuronium 0.3-0.6 mg/kg for tracheal intubation)
Maintenance	Balanced technique: Air-O₂, isoflurane, and iv opioids (usually fentanyl). No N₂O. Pain is highly variable after thoracoscopic procedures, dependent on degree of lung dissection. If a regional catheter is used, management should be similar to pneumonectomy/lobectomy (consider lower dose of opioid). If parenteral analgesia is insufficient, useful adjuncts include intercostal block, paravertebral block and/or intrapleural local anesthetic (given through the chest tube after the lung is inflated [maximum 0.5 mL/kg of bupivacaine 0.25% with epinephrine]).
Emergence	Ensure complete recruitment of operative lung. Extubate in OR, transfer in head-up position to PACU or ICU, breathing O₂ by mask.
Blood and fluid requirements	IV: 16-14 ga × 1 NS/LR @ 2 mL/kg/h (maintenance fluid)	Replace blood loss with colloid (1:1). Third-space loss is negligible and does not need to be replaced.
Monitoring	Standard monitors (p. B-1) ± Arterial line	Depending on comorbidities.
Positioning	Lateral decubitus or supine, with wedge under back on operated side. [check mark] and pad pressure points [check mark] eyes, ears, genitals
Ventilation	Lung isolation (DLT or BB) usually required, except for easily accessible/peripheral lesions. DLT superior in regard to rapidity of lung collapse.	For OLV technique, see Anesthetic Considerations for Lobectomy/Pneumonectomy, p. 285.
Complications during OLV	See OLV under Intraop Anesthetic Considerations for Lobectomy/Pneumonectomy, p. 286.

POSTOPERATIVE

Complications	Same as for lobectomy, pneumonectomy Pain	See Postop Complications for Lobectomy, Pneumonectomy, p. 289. Pain may at times be poorly controlled with parenteral agents alone. May require neuraxial technique for rescue. More common with extensive resections than simple wedge
Complications during OLV	See OLV under Intraop Anesthetic Considerations for Lobectomy/Pneumonectomy, p. 288.
Pain management	Parenteral opioids (iv, im, continuous iv, PCA [p. C-3]). Epidural Intercostal blocks Interpleural analgesia NSAID (ketorolac 10-15 mg)	See Pain Management for Lobectomy, Pneumonectomy, p. 298.

Suggested Readings

1. McKenna RJ Jr, Mahtabifard A, Pickens A, et al: Fast-tracking after video-assisted thoracoscopic surgery lobectomy, segmentectomy, and pneumonectomy. Ann Thorac Surg 2007; 84(5):1663-7.

2. Shah JS, Bready LL: Anesthesia for thoracoscopy. Anesthesiol Clin North Am 2001; 19(1):153-71.

3. See Pneumonectomy/ Lobectomy Suggested Readings p. 289-290.

CHEST-WALL RESECTION

SURGICAL CONSIDERATIONS

Description: Removal of portions of the thoracic cage may be required under several circumstances with the two most common indications being (a) lung cancer that has invaded the chest wall and (b) primary chest-wall tumors (the notable exceptions being Ewing’s sarcoma and rhabdomyosarcoma). Although preoperative chemotherapy is not standard treatment for chest-wall sarcomas, some patients may have received Adriamycin, which is associated with cardiotoxicity at high doses. If the tumor process involves the skin, an appropriate area of skin—typically, 4 cm around the tumor—must be resected along with the specimen. Underlying subcutaneous tissue and muscle should always be resected in continuity; however, the tumor itself must not be exposed. Wide skin flaps are frequently necessary as well. Limited resection (1-5 cm segments of one or two ribs) generally requires no specific reconstructive measures, but resection of larger areas of the chest wall may require extensive reconstruction including the use
of plastic mesh replacement with or without methylmethacrylate, rib grafts and muscle, or myocutaneous flaps. Removal of anterolateral or anterior portions of the chest wall, particularly resections that include the sternum, are associated with greater postoperative instability than are resections of posterior portions of the chest wall, which are protected by the back muscles and scapula. Larger defects can be tolerated posteriorly without reconstruction, as the scapula provides chest-wall stabilization and prevents lung herniation. If a prosthesis is required, it must be covered by viable muscle to avoid erosion through the skin. Extensive reconstruction of the chest wall is often carried out in conjunction with plastic surgeons.

Usual preop diagnosis: Lung cancer with a chest-wall attachment; primary tumor of the chest wall (bone, cartilage, or soft tissue); radiation necrosis

▪ SUMMARY OF PROCEDURE

Position	Supine or lateral
Incision	Over mass to be resected
Special instrumentation	Bone instruments; Marlex (or other) mesh; methylmethacrylate
Antibiotics	Cefazolin 1 g (or as indicated by culture and sensitivity)
Surgical time	1-8 h
Closing considerations	May require help of plastic surgeon in extensive cases.
EBL	100-2000 mL
Postop care	PACU or ICU; some patients require temporary ventilatory support.
Mortality	< 5%
Morbidity	Paradoxical chest-wall motion (less in posterior resections) Pneumothorax Wound complications
Pain score	3-8

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Repair of Pectus Excavatum or Carinatum, p. 297.

Suggested Readings

1. Sellke FW, Swanson S, del Nido P: Sabiston & Spencer: Surgery of the Chest. Section I: Chest Wall, 7th edition. Elsevier Saunders, Philadelphia: 2004.

REPAIR OF PECTUS EXCAVATUM OR CARINATUM

SURGICAL CONSIDERATIONS

Description: Standard bony and cartilaginous repair of a pectus excavatum (funnel chest) or carinatum (pigeon breast) deformities is usually elective surgery with the aim of improving contour and body image. Evidence that these repairs have any positive effect on cardiopulmonary function is controversial, although some surgeons feel that it can be more than a cosmetic procedure—particularly in patients with prominent deformities. Recent evidence suggests that, although resting cardiopulmonary function tests do not improve after pectus repairs, maximal exercise capacity may improve.

To repair pectus excavatum, enough pairs of costal cartilages—usually four to six—must be removed to be able to mobilize and elevate the sternum. Depending on the severity of the defect and patient’s age, fixation of the sternum in the corrected position may be necessary. Repair of pectus carinatum is somewhat more complicated because the defects are more varied—often with a rotational component as well as anteroposterior displacement; however, removal of cartilages and correction of the position of the sternum are still the mainstays of treatment.

A midline incision provides the most satisfactory access to the cartilages and sternum. For cosmetic reasons, however, it may be important to use a curvilinear transverse incision, particularly in females. This incision requires extensive mobilization of subcutaneous and muscle flaps. The wound complication rate is somewhat greater after transverse incisions. The costal cartilages are moved by subperichondrial dissection. This may be tedious and time consuming, especially because four or five, or even more, pairs of cartilages need to be removed. The elevation of the sternum is usually fairly straightforward and usually is accompanied by a transverse sternal osteotomy (Fig. 5-8). Intercostal muscle bundles may be left attached to the sternum or may be detached and reattached for better positioning of the sternum. Sternal support normally is not used in infants, but may be used in older children.

Figure 5-8. Correction of a pectus excavatum defect in a child. After subperichondrial resection of the involved costal cartilages, a wedge osteotomy permits anterior mobilization of the lower portion of the sternum. (Reproduced with permission from Shamberger RC: Chest wall deformities. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery. 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

One common method of support is the use of a temporary transverse metal strut resting on the ribs, but beneath the sternum. The final position of the sternum is easier to predict following repair of the pectus carinatum than following repair of pectus excavatum. Because of the negative intrathoracic pressure, it is easier to hold the sternum down than up. Ideally, patients for repair of pectus excavatum are just under school age. Satisfactory repair, however, may be carried out at almost any time during childhood. As full growth is attained, results tend to be less favorable. Pectus carinatum generally has its onset during adolescence, and it is well to let the patient complete his or her growth spurt prior to undertaking repair. (Also see Repair of Pectus Excavatum/Carinatum in Pediatric General Surgery, p. 1301.)

Variant procedure or approaches: In certain circumstances, particularly in teenage girls and patients who do not engage in strenuous sports, subcutaneous, custom-made implants may be placed to improve body contour without necessitating major bony and cartilaginous repairs. These are usually carried out by plastic surgeons.

Usual preop diagnosis: Pectus excavatum or carinatum

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Transverse or vertical
Special instrumentation	Bone instruments; sometimes metal struts or wires for reconstruction
Antibiotics	Cefazolin 1 g iv q 8 h × 36-48 h
Surgical time	2-3 h
Closing considerations	Pleural and wound drainage common
EBL	100-500 mL
Postop care	ICU
Mortality	Minimal
Morbidity	Pneumothorax: 5-10% Wound infection Sternum necrosis Immigration of strut Paradoxical chest-wall motion → hypoventilation/atelectasis
Pain score	4-5

ANESTHETIC CONSIDERATIONS

(Procedures covered: chest-wall resection; repair of pectus excavatum/carinatum)

PREOPERATIVE

Patients for chest-wall resection often have extensive cancer and may be weak and debilitated. A very large resection may create a “flail chest” situation, compromising postop ventilation.

Respiratory	Mild pectus seldom interferes with ventilation; no special studies indicated. Severe pectus deformity can be associated with restrictive lung defects. Tests: CXR; PFT, ABG, if indicated from H&P
Cardiovascular	With severe pectus, the heart is displaced to the left and compressed; arrhythmias and RVOTO can occur 2° impaired filling, especially during exercise or in upright position. ECG may show right axis deviation, atrial and ventricular arrhythmias. A functional murmur may be detected. ECHO may reveal ↓ SV with MVP. Tests: ECG; cardiac catheterization if indicated. Echocardiogram if symptoms or signs suggest MVP or RVOTO.
Hematologic	Tests: Hct
Musculoskeletal	Chest-wall resection performed for invasive or metastatic cancer; patient may be markedly debilitated: pectus repair of chest-wall deformity for cosmetic, orthopedic, or cardiopulmonary indications: pectus deformity usually asymptomatic.
Laboratory	Other tests as indicated from H&P
Premedication	Consider anxiolysis with short-acting benzodiazepine. When epidural opioids are planned, minimize systemic opioid or sedative premedication to avoid potentiating postoperative respiratory depression from central neuroaxial opioids.

INTRAOPERATIVE

Anesthetic technique: GETA, occasionally combined with epidural for minimal chest-wall resection; however, epidural anesthesia is an excellent adjunct for extensive chest-wall resections or repair of pectus deformities.

Induction	Standard induction (see p. B-2). In the setting of RVOTO avoid myocardial depressants, hypovolemia and a short diastolic filling time (e.g., tachycardia). Lung isolation (DLT or BB) usually required for chest wall resections. Sequential OLV can often be accomplished with a single lumen ETT and a Rusch® EZ-Blocker^TM.
Maintenance	Standard maintenance (see p. B-3) or high-dose opioid technique (fentanyl 10-25 mcg/kg) for patient with severe RVOTO. Patients with MVP will require prophylactic antibiotics for bacterial endocarditis. OLV, if necessary, as outlined for lobectomy/pneumonectomy.
Emergence	Extubate in OR; if high-dose opioid → ICU for later extubation.
Blood and fluid requirements	IV: 18-16 ga × 1 NS/LR @ 1-2 mL/kg/h	Usually minimal blood loss. Fluid restriction unnecessary as this is extrapulmonary operation.
Monitoring	Standard monitors (p. B-1) ± Arterial line	Close monitoring with arterial and central venous catheters may be required in patients with significant cardiopulmonary compromise.
Positioning	[check mark] and pad pressure points [check mark] eyes
Complications	Pneumothorax	Unintentional pleural tear can cause pneumo-thorax. Intraop deterioration characterized by ↑ ventilatory pressure, hypotension, and hypoxemia suggests pneumothorax. Increase FiO2; D/C N2O. Ensure pleural space is decompressed appropriately with needle or tube thoracostomy.
Complications	Cardiac perforation	Rare, catastrophic event reported with aberrant bar placement during minimally invasive approach. Heralded by signs of hemorrhagic or obstructive shock. Supporting bar may interfere with external cardiac compressions.

POSTOPERATIVE

Complications

Hypoventilation

Flail chest

Atelectasis/pneumonia

Pericarditis

Bar displacement

Although most patients do not require postop ventilatory support, with extensive chest-wall resection, patient may hypoventilate. Respiratory stimulants, such as doxapram, should be avoided as they may → deep inspirations that can → severe sternal retractions. Paradoxical chest-wall movement may occur during spontaneous ventilation with flail chest; postop atelectasis 20 splinting. Obtain postop CXR. Similar to post-pericardiotomy syndrome; usually responsive to NSAIDs though occasionally corticosteroids or percutaneous drainage required. Following minimally invasive repair (Nuss) the bar may become displaced and require repositioning. Inadequate analgesia and absence of a stabilizing bar often cited as contributing factors.

Pain management

Depends on site and extent of chest wall resected. Parenteral or epidural opioids with local anesthetic.

Epidural opioids and local anesthetics are particularly useful if flail chest is present—reduces need for ventilatory support.

Suggested Readings

1. Frantz FW: Indications and guidelines for pectus excavatum repair. Curr Opin Pediatr 2011; 23(4):486-91.

2. Ghory MJ, James FW, Mays W: Cardiac performance in children with pectus excavatum. J Pediatr Surg 1989; 24(8):751-5.

3. Gips H, Konstantin Z, Hiss J: Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature. Pediatr Surg Int 2007.

4. Iida H: Surgical repair of pectus excavatum. Gen Thorac Cardiovasc Surg 2010; 58(2):55-61.

5. Jacobs JP, Quintessenza JA, Morell VO, et al: Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg 2002; 21(5): 869-73.

6. Mansour KA, Thourani VH, Odessey EA, et al: Thirty-year experience with repair of pectus deformities in adults. Ann Thorac Surg 2003; 76(2):391-5; discussion 395.

7. Nuss D, Croitoru DP, Kelly RE, et al: Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002; 12(4):230-4.

8. Robicsek SA, Lobato EB: Repair of pectus excavatum. Anesthesia considerations. Chest Surg Clin North Am 2000; 10(2): 253-9.

THORACOPLASTY

SURGICAL CONSIDERATIONS

Description: The objective of a thoracoplasty (removal of several ribs) is to permanently obliterate an existing pleural space or to collapse a portion of the lung. Formerly, this operation was used in the treatment of tuberculosis (TB); however, because of better drug therapy, appropriate pulmonary resection and the decrease in incidence of TB, thoracoplasty is now rare. The procedure also was used for obliterating empyema spaces and helping to close bronchopleural fistulas (BPFs). The use of pedicled muscle flaps (serratus anterior, pectoralis major, and latissimus dorsi are the most common) or an omental transposition have largely replaced thoracoplasty for filling empyema spaces and encouraging closing of BPFs. These operations are less deforming and better tolerated physiologically because they do not result in paradoxical motion of the chest wall.

For patients whose lungs will never expand to fill the space—such as those who have had a pneumonectomy or who have a permanently noncompliant lung—resection of multiple overlying ribs may be necessary (Fig. 5-9). Thoracoplasty is accomplished by removing several ribs in a subperiosteal fashion, allowing the underlying chest wall to collapse. This collapse is aided by the normally negative intrapleural pressure. Because the periosteum is left intact, the ribs will regenerate, resulting in a permanent, bony collapse of the chest wall. If the objective of the thoracoplasty is to obliterate a relatively small space (meaning that segments of only two to three ribs need be removed), the procedure may be done in a single stage, with little postop physiologic impairment of respiration. If extensive thoracoplasty is necessary, however, the procedure may be done in stages to minimize postop chest-wall instability and resultant respiratory problems.

Usual preop diagnosis: Pulmonary TB; BPF; empyema

Figure 5-9. Extrathoracic muscle flaps that may be used to obliterate a postpneumonectomy empyema cavity. (Reproduced with permission from Miller JI Jr: Postsurgical empyema. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery. 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

ANESTHETIC CONSIDERATIONS