Procedures

Intermediate Format:

Cervical Rib Resection

Objectives• Assess the related terminology and

pathophysiology of the lungs.

• Analyze the diagnostic interventions for a patient undergoing a cervical rib resection

• Plan the intraoperative course for a patient undergoing_____________.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position

• Identify the incision used for the procedure

• Analyze the procedural steps for cervical rib resection.

• Describe the care of the specimen

Terms and Definitions

• Thoracic outlet: formed by the first ribs, spine, and sternum

Definition/Purpose of Procedure

• Decompression of the thoracic outlet through partial or entire removal of the rib

• Surgical Goal: release compression of the neurovascular tissue and restore neurovascular function to the affected upper extremity, neck, or shoulder

Pathophysiology

• Thoracic Outlet Syndrome– Compression of the subclavian vessels and the

brachial plexus at the apex of the thorax. – Other names: cervical rib syndrome, first

thoracic rib syndrome, costoclavicular syndrome, hyperabduction syndrome

– Classifications• Arterial thoracic (result compression of subclavian

artery and results in severe ischemia of arm)

• Neurological

• Venous thoracic

Surgical Intervention:Special Considerations

• Patient Factors– Will be in pain; assist with transfer, etc.

• Room Set-up

• Anesthesia: General ; may add cervical-thoracic-paravertebral regional block for postop pain management

Surgical Intervention: Positioning

• Position during procedure– Lateral decubitus (may be semilateral for axillary or

anterolateral approach)

• Supplies and equipment– Pillows, 3 in tape, foam padding,

• Special considerations: high risk areas– Proper padding of bony prominences at hips, knees,

ankles, upper body, axillary or chest rolls

Surgical Intervention: Special Considerations/Incision

• Special considerations

• State/Describe incision– Transaxillary incision between the pectoralis

muscle and the latissimus dorsi muscle on the affected side

Surgical Intervention: Supplies

• General

• Specific– Suture & Blades– Bone wax– Medications on field (name & purpose)– Catheters & Drains—a drain will be placed

Surgical Intervention: Instruments

• General: soft tissue and bone instrumentation (Chest set)

• Specific: soft-tissue dissection instruments as well as rib cutters, elevators, and rongeurs are added to the set

Thoracic Instrumentation

Thoracic Instruments

Surgical Intervention: Equipment

• General: ESU

• Specific

Surgical Intervention: Procedure Steps

• The skin and subcutaneous tissue are incised with scalpel and electrodissection.

• Soft-tissue dissection continues, to identify neurovascular bundle.

• Dissection is carried out to the level of the cervical rib (if present) or the first rib. If the first rib, it is meticulously dissected subperiosteally using the periosteal elevator. – STSR has available: rib elevator, stripper, and rib raspatories.

Note: too much traction in the brachial plexus and damage to the subclavian artery or vein are avoided during dissection.

Surgical Intervention: Procedure Steps

• A wedge is taken from the midportion, or the rib is removed entirely using rib shears.

• A drain is placed, incision closed, and dressing applied.

Counts

• Initial: sharps, sponges, instruments

• First closing

• Final closing– Sponges– Sharps– Instruments

Specimen & Care

• Identified as portion of rib

• Handled: routine (formalin)

Resources

• Alexanders pp. 1053, 1074-1075

• STST Ch 22, p. 877

• Fullers (New 4th ed) Ch 29; 3rd ed Ch 24

• http://tellmeabouttos.com/surgery1.htm

• www.vesalius.com

• MAVCC Unit 12

For visualization of the pleurae, lower and middle mediastinum, and pericardium, the surgeon would need a:

a. Thorascope

b. Mediastinoscope

c. Bronchoscope

d. Laryngoscope

As the STSR, with which of the following procedures would you anticipate the use of chest tubes and a water-seal drainage system?

a. Lobectomy

b. Scalene Node Biopsy

c. Percutaneous Transluminal Coronary Angioplasty

d. Cardiac Pacemaker Insertion

Which of the following retractors would be most useful in a posteriolateral Thoracotomy?

A. Balfour

B. O’Sullivan-O’Connor

C. Davidson scapula

D. Weitlaner

With which of the following procedures would you expect the greatest amount of bleeding?

A. Wedge Resection of the Lung

B. Decortication of the Lung

C. Open Thoracotomy fro Closure of a Ruptured Bulla

D. Closure of a Patent Ductus Arteriosus

The removal of a lung is referred to as a/an:

a. Pneumonectomy

b. Endarterectomy

c. Blalock-Hanlon operation

d. Cryoablation

Cervical Rib Resection is performed to relieve:

A. Thoracic Inlet Syndrome

B. Thoracic Outlet Syndrome

C. Adult Respiratory Distress Syndrome

D. pneumothorax

The procedure performed to remove a fibrous covering from the lung following empyema formation is:

A. Aneurysmectomy

B. Thoracostomy

C. Thymectomy

D. Pulmonary Decortication

When two chest tubes are placed into the pleural space, the uppermost tube is used to:

a. Evacuate air/re-establish negative pressure

b. Evaluate blood/re-establish positive pressure

c. Evacuate serous fluid/re-establish positive pressure

d. Evacuate pus/re-establish negative pressure

When a rib is removed, the remaining bone edges are trimmed with a:

a. Doyen raspatory

b. Bethune shear

c. Lebsche knife

d. Stille-Luer rongeur

When transporting a patient with a closed water-seal drainage:

a. The bottle should be kept at or above the height of the patient’s chest

b. The chest tube should always be clamped

c. Chest tube clamps should accompany the patient at all times

d. The patient should be placed in Trendelenburg position

Mediastinoscopy is usually performed with the patient in what position?

a. Lateral

b. Sims

c. Dorsal recumbent

d. prone

Removal of air or fluid from the pleural cavity via needle aspiration is:

a. Thoracoscopy

b. Thoracotomy

c. Hemocentesis

d. Thoracentesis