Thoracic surgery Mediastinoscopy

Mediastinoscopy

Objective

In cases of suspected malignancy:

•   Endoscopic visualization of the mediastinum (tracheobron­cheal junction, bronchi, aortic arch and regional lymph nodes) 

•   Biopsy if required.

Position

Supine.

Anesthesia

General.

Procedure

1.  Transverse incision over the suprasternal notch and extended down to the pretracheal fascia. 

2.  Blunt dissection the superior mediastinum is entered.

3.  Scope is passed.

4.  Avoid injury to nearby blood vessels.

5.  Lymph node tissue biopsied.

6.  Hemostasis is achieved.

7.  Scope is removed.

8.  Wound is closed.

Instrument

•   Mediastinoscope (Fig. 19.11)

•   Electrosurgical unit 

•   Suction

•   Fiberoptic light source 

•   Basin set 

•   Blade (1) No. 15 

•   Telfa dressing pads and 22 gauge needle

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Thoracic surgery bronchoscopy

THORACIC OPERATION

Bronchoscopy

Objective

In cases of suspected bronchial lesions:

•   Endoscopy

•   For visualization of the trachea, main bronchi and their openings and the segmental bronchi 

•   Obtaining material for histopathologic and bacteriologic examination if required 

•   Foreign body removal.

Position

Supine.

Anesthesia

General.

Procedure

1.  The head is lowered.

2.  Well-lubricated scope is inserted into the mouth.

3.  The epiglottis is elevated with the tip of the bronchoscope and the scope is passed into the trachea.

4.  The scope is advanced into the bronchi.

5.  Bronchial washings, biopsy, may be obtained.

6.  The bronchial passages are well suctioned, and the scope is removed slowly.

Instruments

Rigid bronchoscopy

•   Rigid fiberoptic bronchoscope (Fig 19.8)

•   Endotracheal adaptor 

•   Fiberoptic telescope 

•   Fiberoptic light cords (2) 

•   Suction cannula (Fig. 19.9) 

•   Suction tubing 

•   Specimen collectors 

•   Biopsy forceps 

•   Sponge carriers (2) (Fig. 19.10)

•   Grasping forceps 

•   Lubricant

•   Bronchoscopy sponges 

•   Small basin with sterile saline and syringe 

•   Telfa dressing pads and 25 gauge needle 

•   Laser may be employed.

Flexible bronchoscopy

•   Flexible fiberoptic bronchoscope 

•   Endotracheal adaptor 

•   Fiberoptic light cord 

•   Biopsy forceps 

•   Brush

•   Culture jar for biopsy specimen 

•   Small basin with sterile saline and syringe 

•   Suction tubing 

•   Specimen collector 

•   Lubricant

•   Telfa dressing pads and 25 gauge needle.

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Plastic Surgery Reimplantation hand fingers

Replantation-Hand or Fingers

Objective

Replantation of amputated parts—hand or fingers—by micro­surgery.

Position

Supine with arm resting on a hand table.

Anesthesia

General + brachial.

Procedure

1.  Prepare amputated part and the stump and dissect its vessels, nerves, tendons and bone.

2.  Fixation of the amputated part with K wires.

3.  Repair tendons.

4.  Anastomosis of arteries, veins and nerves.

5.  Hemostasis.

6.  Closure dressing and splinting.

Instruments

•   Plastic surgery set

•   Microsurgery set

•   Hand surgery set consisting of:

     a.  Tourniquet (pneumatic)

     b.  Hand table

     c.  Rubber bands

     d.  K wires of different sizes

     e.  Wire driver with Jacob chuck and key

     f.   Fine periosteum elevation

     g.  Bone cutter

     h.  Wire cutting pliers

     i.   Esmarch’s bandage.

Sutures

•   Prolene 6 ‘0’ on curved round body needle (for tagging of vessels)

•   Prolene 4 ‘0’ on curved round body needle (for tendon repair)

•   Nylon 10 ‘0’ on 4 mm curved round body needle

•   Nylon 11 ‘0’ on 3.75 mm curved round body needle (for distal finger amputations)

•   Nylon 9 ‘0’ on 6 mm curved round body needle (for proximal and hand amputations)

•   Nylon 5 ‘0’ on curved cutting needle for skin

•   Dressing paraffin gauze

•   Gamjee pads

•   Velroc or Gypsona for splinting.

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Plastic Surgery microsurgical free graft

Microsurgical Free Flap Transfers

Objectives

•   Reconstruction of defects 

•   By transfer of a flap from a distant area wherein the artery and vein supplying the flap is anastomosed to an artery and vein in the recipient area 

•   Under magnification with an operating microscope

•   Operation may be done by two teams simultaneously.

Position

Depending upon the site of recipient and donor areas.

Anesthesia

General.

Procedure

1.  Clean and drape recipient and donor areas.

2.  Prepare recipient area.

3.  Dissect and prepare recipient artery and vein.

4.  Plan and flap.

5.  Raise and prepare the flap and dissect its artery and veins.

6.  Divide flap vessels, transfer flap to the recipient area.

7.  Anastomose the vessels/Close recipient area by direct closure or skin grafting.

Instruments

•   Plastic surgery set 

•   Skin grafting set 

•   Microsurgery set consisting of: 

     a.  Jewellers forceps No. 2                   2   

     b.  Jewellers forceps No. 5                   2

     c.  Vessel dilator                                  1 

     d.  Curved blunt tipped dissecting    1
microscissors 

     e.  Straight sharp microscissors          1

     f.   Microneedle holder straight          1
or curved 

     g.  Microvessel clamps                         4 

     h.  Microvessel approximator clamps   2 

     i.   Visibility background                     1

     j.   Fine suction tip                              1

     k.  Irrigation syringe with                    1
22 G venflon 

     l.   Operating microscope                    1

     m. Sterile knobs for microscope (set) 1

     n.  Microsurgical cellulose swabs

     o.  Heparin saline solution (N saline 50 mls + heparin 5000 units + xylocaine 2% 5 mls). 

Sutures

•   As for general plastic surgery 

•   10 ‘0’ Nylon on 6 mm curved round body needle or 9 ‘0’ nylon on 6 mm curved round body needle.

Any questions be sent to drmmkapur@gmail.com

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