Endoscopy and thoracic trauma L2.pdfhhfyf

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1. Endoscopy in
thoracic surgery
========
thoracic trauma
Dr Saad Mukhlif
Assist. Professor and consultant surgeon

2. Objective to learn
•Endoscopes??
•Types
•Indications
•Procedure and anesthesia.
•Thoracic injuries
•Types management,

3. Endoscopic procedures
Endoscopy is procedure used to visualized the internal organs through
natural or artificial orifices. The procedure can be done under general
or local anesthesia and in addition to visualization of the lesion,
taking samples for many subsequent laboratory purposes also can
be done.

4. ENDOSCOPIC ACCESSORIES
are tools used with the procedures
to get maximum information :-
1-Brushing for cytological
examination.
2-Biopsy for histopathological
examination.
3-Endoscopic U/S.
4-LASER THERAPY ,CRYOTHERAPY.

5. ESOPHAGOSCOPY
•The first esophagoscopy procedure
is done in 1868by Kassmaul using
13 mm metallic tube ,fiber optic
esophagoscopy introduced in 1958

8. diagnostic & therapeutic indication
•1-Dysphagia &Odenophagia.
•2-reflux esophagitis.
•3-truama.
•4-Tumor staging &screening .
•5-Upper GIT bleeding.
•6-Removal of foreign body in the esophagus.
•7-Follow-up of previously found polyp,tumoror ulcer.

10. BRONCHOSCOPY
An endoscopic procedure which provides direct access to the tracheo-bronchial
tree ,and play essential role in diagnosis and treatment of chest conditions. Two
types of bronchoscope are available (flexible and rigid),the procedure can be
used for diagnostic and therapeutic purposes or both at the same section.

16. DIAGNOSTIC INDICATIONS
Persistent cough,
Hemoptysis, localized lung lesion,
Abnormal chest radiography,
suspected tumor of the lung,
follow-up of chest disease.

18. THERAPEUTIC INDICATIONS
Removal of foreign bodies of tracheo-bronchial tree.
post operative atelectasis.
trans bronchial drainage of lung abscess.
brachytherapy.
placement of endo-tracheal tubes.
opening of narrowed tracheal stenosis and localized
management of tumor with phototherapy.
laser therapy or cryotherpy.

19. NO ABSOLUTE CONTRA-INDICATIONS FOR
BRONCHOSCOPY ONLY RELATIVE CONDITIOND
•1-Bleeding disorders.
•2-Patient on ventilator.
•3-Sever tracheal obstruction .
•4-Bronchial asthma.
•5-Certain infections e.g. active TB ,HIV.

20. COMPLICATIOMS
Bronchoscopy considered as safe procedure ,most
complications are preventable :-
A-anesthetic complications :due to medications can
result in respiratory depression, hypotension and
syncopalattacks.
B-technical difficulties can cause trauma and
bleeding.
C-biopsy related complication :pneumothorax and
bleeding.

21. MEDIASTINOSCOPY
Mediastinoscopyis performed via a 3-cm incision in the
suprasternalnotch, which is carried down to the trachea in
the midline between the strap muscles.
The pretrachealfascia is incised, and blunt digital dissection
along the anterior tracheal wall to the level of the carina
then permits insertion of the mediastinoscopefor biopsy of
the mediastinal lymph nodes.
These nodes are accessed by blunt dissection (using a suction
cautery).

22. Mediastinoscopy
back through the pretrachealfascia into the mediastinal soft tissues.
A standard staging procedure for lung cancer includes biopsies of the
right and left paratrachealand the subcarinallymph nodes.

24. THORACOSCOPY
The rapid progress that occurred in the late 1980s in use of the
laparoscope for abdominal surgery stimulated thoracic surgeons to
rediscover the thoracoscope as a tool in the diagnosis and treatment
of pulmonary and mediastinal pathology.

26. •although not replacing conventional open techniques, in many circumstances
allow the surgeon to accomplish the same goals with less morbidity. Advances in
video technology and surgical stapling facilitated the application of thoracoscopy
to procedures previously not considered amenable to minimally invasive
approaches.

27. PRINCIPLES AND GENERAL TECHNIQUE
Working within the abdominal cavity requires the insufflation of gas
(carbon dioxide) to create a space in which to manipulate
instruments,
The thorax, by virtue of its rigid bone structure, provides its own
space once the lung is collapsed.
Single-lung ventilation to the contralateral side through a double-
lumen endobronchialtube allows collapse of the lung on the side
of interestonce the negative intrapleuralpressure is lost by
placement of the first intercostal incision.

30. Chest x-ray showing giant bulla causing compression of
adjacent lung parenchyma in a patient with bullous
emphysema.

31. Thoracoscopic view of a typical apical bleb in a
young patient who presented with spontaneous
pneumothorax.

32. Initial application of a linear stapler in
excision of an apical bleb.

33. COMPLICATIONS
converted to an open procedure when the intended VATS procedure
was not able to be completed successfully.
air leaks lasting longer than 7 days;
bleeding requiring blood transfusion .
superficial wound infections.
Mortality a 2%.

36. Thoracic injuries incidence
•It accounts for 25% of all injuries, during war and civil.
•May be combined with or only thoracic injuries.
• usually they life-threatening and occur due to bleeding but fortunately 80% can
be managed conservatively by proper Dx and resuscitation.
•The rest of thoracic injuries may need subsequent intervention and only 10% of
them need surgical intervention.

39. Simple rib fracture
•Due to local trauma or sever cough.
•No underlying lung or parenchymal injury.
•On Examination local tenderness.
•Treated by analgesia orally and local plaster, may needs I.C.N BLOCK.
•Elderly patient precautions……..

40. Flail rib fractures
More than two ribs at two sites or fracture of more than two ribs at on anterior
side of ribs and other same ribs which includes the sternum (steering wheel
injury).
This will makes the segment moves paradoxically and causing continuous trauma
to the lung tissue with every single respiratory cycle .
ARDS adult respiratory distress syndrome

41. Flail fracture ribs

42. Flail chest

43. Treatment
•A- immobilization by sand bag or bandaging.
•B- deep anesthesia and ventilation for 2-3 weeks which needs trachiostomy.
•C- surgical correction.

44. Fracture of sternum
•RTA especially for the driver steering wheel injury with central chest wall pain
and tenderness.
•Retro-sternal cardiac and mediastinal injuries should be excluded.
•Chest radiography on lateral view and CT scan are useful.
•Most cases treated by analgesia and few cases needs fixation and
wiring(displacement)

45. Injuries to the pleura
•Traumatic pneumo-thorax:- C.F,EX,MX.
•Tension pneumo-thorax:- C.F,EX,MX.
•Traumatic hemothorax:- source of bleeding 1,2,3.
CHEST TUBE VERSUS THORACOTOMY
Massive initial bleeding.
Continuous bleeding.
Retained clot in the pleura leads to empyema.

46. Lung parenchymal injuries
•Lung contusion.
•Intra-parenchymal hemorrhage.
•Massive tracheo-bronchial injuries.

47. Diaphragmatic injury
•Rupture diaphragm:-
History
Clinical features
Radiology
Treatment

48. Emergency thoracic trauma
conditions
•Tension pneumothorax
•Open thoracic sucking wounds.
•Flail chest rib fractures.
•Cardiac tamponade.
•Massive hemothorax.

49. Thank
you