11 Thorax and heart surgery 11

11 Thorax and heart surgery

11.1 Median thoracotomy (sternotomy) – 134 11.1.1 Supine position – 134

11.2 Bilateral thoracotomy – 36 11.2.1 Supine position – 136

11.3 Lateral thoracotomy – 138 11.3.1 Lateral position – 138

11.3.2 Modified lateral position – 140

11.4 Anterolateral thoracotomy – 142 11.4.1 Supine position – 142

11.5 Others – 144

11.5.1 Modified supine position – 144

11.5.2 Supine position – 146

11

11.1 Median thoracotomy

11.1.1 Supine position

. Figs. 11.1–11.4

.

Indications

Sternotomy for coronary surgery (ACVB, OBCAP), valve surgery (mitral/

aortic valve replacement), HTX and type A dissection.

Preparations

4

Arm positioning devices

Padded arm protection Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms at the body with arm protection, forearm slings, clips or other positioning aids

4 Radial artery removal:

position the arm in supination position with 90°

abduction on the arm positioning device. An arm protection can be adapted on this side to make it easier to move the arm back to the body again later on

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

. Fig. 11.1. Supine position for sternotomy with arms positioned at the body

. Fig. 11.2. Arms positioned at the body with arm protection and padding

. Fig. 11.3. Optimum positioning comfort from the elbow to the hand

. Fig. 11.4. Legs uncovered for free move- ment

11.1 · Median thoracotomy

11.2 Bilateral thoracotomy

11.2.1 Supine position

. Figs. 11.5–11.7

.

Indications

Bilateral access for double lung transplantation (DLuTX).

Preparations

4

Arm positioning devices

Padded arm protection

Padded cushions Positioning

4

Standard operating table position 1, position 2 or universal operating table

Anaesthetic preparation and induction in supine position with 2 adapted

arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Place a padded cushion under the thoracic vertebrae along the body axis (to raise the thorax)

4

Position both arms at the body with arm protection, forearm slings, clips or other positioning aids

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

. Fig. 11.5. Supine position for bilateral access

. Fig. 11.6. Raised thorax and lowered posi- tioning of the arms

11.2 · Bilateral thoracotomy

. Fig. 11.7. Arm protection 1002.25A0

11

11.3 Lateral thoracotomy

11.3.1 Lateral position

. Figs. 11.8–11.10

.

Indications

Lateral access for lung transplantation (LuTX), lung segment resection and lobectomy.

Thoracoscopy for lung biopsy, pleural biopsy, pleural effusion, pericardial effusion, partial pleurectomy, resection of peripheral pulmonary nodules and tangential parenchyma resection.

Preparations

4

Arm positioning devices

4

Gel ring, gel cushion, Goepel leg holder, body support, radial adjusting clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4

Standard operating table position 1 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the rail of the head plate, position the Goepel leg holder and place a gel padded mat on the operating table

Spread out the arm on the side not being operated in max. 90° abduction

Move the patient onto the healthy side, with the back near the edge of the

operating table

4

Open the operating table step by step by lowering the pelvic and back plate (operating table in roof position)

4

Raise the head plate and position the head on a padded cushion with gel ring to leave the ear free

4

Position and fix the arms

4

Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4

Fit the body supports to the side rails and support the body at the level of the sacrum and symphysis

4 1st possibility:

position the legs with the padded cushions (normal and flat) and possibly wedge cushions

4

Fix the lower leg and the positioning aids with the body belts

position the legs with the tunnel cushion

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

. Fig. 11.8. Lateral position for lateral thora- cotomy

. Fig. 11.9. Operation table in flex position and maximum longitudinal displacement toward the head

. Fig. 11.10. Cervical spine in middle posi- tion, tip of the scapula is free with a dorsal thorax support

11.3 · Lateral thoracotomy

11

11.3.2 Modified lateral position

. Figs. 11.11–11.13

.

Indications

Lateral access for descending aorta replacement and thoracoabdominal aorta replacement.

Preparations

4

Arm positioning devices

4

Gel ring, gel cushion, Goepel leg holder, body support, radial adjusting clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4

Standard operating table position 1 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the side rail of the head plate, position the Goepel leg holder and place a gel padded mat on the operating table

Spread out the arm on the side not being operated in max. 90° abduction

Move the patient onto the healthy side, with the back near the edge of the

operating table

plate (operating table in roof position)

4

Raise the head plate and position the head on a padded cushion with gel ring to leave the ear free

4

Position and fix the arms

4

Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4

Thorax 90° position, pelvis 45° position

4

Fit the body supports to the side rails and support the body at the level of the sacrum and symphysis

4

Fit the body support to the rail of the head plate (at the back of the patient) and support on the upper scapula so that the point of the scapula is free

position the legs with the padded cushions (normal and

flat) and possibly wedge cushions

4

Fix the lower leg and the positioning aids with the body belts

position the legs with the tunnel cushion

Position the upper leg in external rotation

4

Apply the neutral electrode and connection to the HF surgery device

Arrange absorbent drapes or self-adhesive covers for preoperative skin

disinfection

4

Position the operating lights

4

O pen the operating table step by step by lowering the pelvic and back

. Fig. 11.11. Modified lateral position for thoracoabdominal access

. Fig. 11.12. Support for the shoulder and for the pelvis tilted approx. 30–40° backwards

. Fig. 11.13. Positioning with freely moving leg

11.3 · Modified lateral position

11

11.4 Anterolateral thoracotomy

11.4.1 Supine position

. Figs. 11.14, 11.15

. Indications

Preparations

4

Arm positioning devices

Padded arm protection

Small wedge cushion Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4 Minimally invasive ASD:

position the wedge cushion under the

shoulder/thorax

4 ^MIDCAB:

position the wedge cushion under the

shoulder/thorax

Position both arms at the body with arm protection, forearm slings, clips

or other positioning aids

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Anterolateral access for MIDCAB and minimally invasive ASD.

. Fig. 11.14. Supine position with wedge cushion under the right shoulder/thoracic side

. Fig. 11.15. Supine position with wedge cushion under the left shoulder/thoracic side 11.4 · Anterolateral thoracotomy

11

11.5 Others

11.5.1 Modified supine position

. Figs. 11.16, 11.17.

Indications Mediastinoscopy.

Preparations

4

Arm positioning devices

Padded arm protection

4

Gel ring, possibly flat padded cushion Positioning

4

Standard operating table position 1, position 2 or universal operating table top

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Crosswise positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Possibly pad the shoulders with a flat padded cushion

4

Tilt the operating table in the Trendelenburg position, raise the back plate by 20–30°, lower the leg plates and the head section

4

Position the head on a gel ring, possibly slightly turned to the left and reclined

4

Position the left infusion arm on the anaesthetist’s side on the arm posi- tioning device

4

Position the right arm at the body with arm protection, forearm slings, clips or other positioning aids

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

. Fig. 11.17. The head is reclined and held in a stable position with a gel ring

. Fig. 11.16. Supine position with raised back plate and lowered head plate 11.5 · Others

11.5.2 Supine position

. Figs. 11.18–11.20.

Indications

Preparations

4

Arm positioning devices

Padded arm protection

Positioning

protection

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms at the body with arm protection, forearm slings, clips or other positioning aids

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

4

C-arm and monitor trolley, X -ray protection AIC D (defibrillator) and pacemaker.

4

Standard operating table position 1 or universal operating table with X -ray

. Fig. 11.18. Positioning for implantation of a pacemaker

. Fig. 11.20. The head can also be reclined and held in a stable position with a gel ring 11.5 · Others

. Fig. 11.19. Stable positioning of the head with a gel cushion