Medical Surgical Thoracic

Thoracoplasty – not a common operation.

TB chest copy

This is not a common operation. I have done a few, basically where I thought an attempt to do a pneumonectomy was fraught with a huge risk. The other lung appeared good on Xray, but on the affected side there was a bronchopleural fistula, a pyothorax, and a destroyed lung. Whenever the patient lay on their healthy side they coughed up copious pus as it ran from the pyothorax through the fistula into the trachea, sometimes in sizeable volumes and was coughed up. TB was very common; this film doesn’t show a case suitable for this surgery.

Using a double lumen tube to stop pus spilling over into the other during the operation, you do a lateral thoracotomy, carefully preserving the latissimus dorsi muscle and dissect it from the distal insertion onto the iliac crest, being careful to preserve its nerve supply. Then with care the ribs from 2 to 10 are excised in as full an extent as you are able. There is major anatomy passing above the second rib requiring special care. All the pus is sucked out and the fistula closed, either directly or by raising a flap of intercostal muscle and sutured over it.

The lady in the film below was totally incapacitated. The postop film at the end of the post is her, when she was up again and doing her own housework!

cavitated lung copy

The preserved latissimus dorsi muscle is inserted through a hole in between 2 strips of intercostal muscle and placed to help fill up the pleural cavity. A drain is laid into the cavity, and the wound closed in layers. A bulky dressing is applied and the arm strapped to the side to keep pressure on the area. We usually used a thoracic epidural catheter for pain relief. The anaesthetist after I’d put in the epidural catheter and intubated the patient was usually the cleaner whom I’d taught to watch over things. Follow up on Mesfin of the ‘3 Teenagers’ Blood transfusion was not usually necessary.

opening chest copy
post thoacoplasty copy22

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