Cardiothoracic and vascular surgery in sulaimani the begining

transcript

CARDIOTHORACIC AND VASCULAR

SURGERY IN SULAIMANI

THE BEGINNING

PROF. ABDULSALAM Y TAHASchool of Medicine/ University of Sulaimani/ Iraq

www.slideshare.net/salamppt www.authorstream.com

https://sulaimaniu.academia.edu/AbdulsalamTahawww.linkedin.com/pub/abdulsalam-taha/a6/844/112/

INTRODUCTIONIn October 2003, I moved from Basra, south of Iraq to Sulaimani, Region of Kurdistan following an invitation from the minister of health in Kurdistan and began to

establish a unit of cardiothoracic and vascular surgery; the first in Kurdistan, Iraq.

01/03/2004 2

BASRA SULAIMANI

Prof. Abdulsalam Y Taha/ CTV Surgery in Sulaimani, the beginning

INTRODUCTION

• No thoracic surgeon worked in this city before.

• We searched for the necessary equipments andinstruments in Sulaimani Teaching Hospital itselfas well as in other places in Sulaimani.

• We could obtain most of the necessaryequipments, although more was needed.

• This presentation was made 3 months after ourstart.

• The aim was to demonstrate some of the casesoperated upon in our unit soon following itsestablishment.

• We could arrange a bronchoscopy unit forboth flexible and rigid types.

• In the first 3 months of our work, 43patients have been examined by flexiblebronchoscopy.

• In April 2004, we have got paediatric rigidbronchoscopes; thus we took theresponsibility of doing bronchoscopy forchildren for all age groups for bothdiagnostic and therapeutic indicationsespecially the removal of aspiratedtracheobronchial foreign bodies as this isone of the most common emergencies inour specialty.

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Indications for FOB Number of Patients Comments

Bronchogenic carcinoma 24 Forty three patients (29 males and 14 females) underwent 45 fiberoptic bronchoscopies.

The first fiberoptic bronchoscopy was performed on 31st

December 2003.

Pulmonary metastases 2

Bilateral vocal cord paralysis 1

Normal bronchoscopy 3

Chest infection 5

Bronchiectasis 1

Pleural plaques 1

Bronchorrhoea 1

Interstitial lung disease 2

Bronchopulmonary toilet 1

Ruptured PHC 1

Encysted empyaema 1

Idiopathic haemoptysis 1

Total 43

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Right upper lobe bronchogenic carcinoma

Digital Photography and Flexible Bronchoscopy

• An increasing number of patients with differentthoracic lesions were bronchoscoped using aflexible bronchoscope (Olympus BF Type 20). AKodak digital zoom 6440 camera held by anassistant was brought into contact with theproximal end of the bronchoscope whenever aninteresting abnormality was seen and a stillphotograph and sometimes a video record wasobtained. The photos were saved in the computerand edited if necessary and used fordocumentation, research and teaching.

RIGHT-SIDED BRONCHOGENIC CARCINOMA

MEDIASTINAL WIDENING WITHNORMAL BRONCHOSCOPY

RUPTURED PHC IN LUL

LONG-STANDING FOREIGN BODY

ASPIRATION IN LLLRETRIEVED BY

RIGID BRONCHOSCOPY

METALIC FB IN HYPOPHARYNX

REMOVED BYRIGID

OESOPHAGOSCOPY

FB IN OESOPHAGUSREMOVED BY RIGIDOESOPHAGOSCOPY

We could arrange sets of surgical instruments specific for vascular and thoracic operations. We are in need of Fogarty embolectomy catheters. In cooperation with the administration of the Teaching Hospital, we had a theatre for elective cases together with the neurosurgical department. We had 2 operating days per week beside extra days in Shorish Hospital.

Resident doctors experienced the attractiveness of our specialty; thus many of them declared their will to join us. We had three permanent and one rotator doctors beside 4 nurses. We started to create an ICU for thoracic surgery in the Teaching Hospital, although small to start with, I am sure it will get bigger with time.

SENIOR HOUSE OFFICERS

OUR INITIAL TEAM

We aim to have a centre of Thoracic and Cardiovascular Surgery in Suliemanya in a short time capable of dealing with emergent and non-emergent conditions. We wish to have a cardiac cath.lab or at least a facility of peripheral angiography soon. We plan to contact the Iraqi scientific council of Thoracic and Cardiovascular Surgery once we complete the requirements of our centre so that students of this council

will be trained in our centre .

Endoscopic Procedures

Procedure Number of Patients

comments

FOB 45

Rigidbronchoscopy

Rigid oesophagoscopy

Diagnostic thoracoscopy

Total 63

Details of Surgical Procedures

Procedure Number of Patients

1 Posterolateral thoracotomy 13

2 Anterior mediastinotomy 1

3 Exploration & resection of a huge

AVM of the face

4 Oesophageal substitution by

5 Surgery for lower limb varicose

6 Resection of haemangioma of the

7 Resection of malignant soft tissue

mass from lower limb

8 Repair of femoral artery & vein

injury

9 Exploration and ligation of injured

femoral vessels in irreversibly

ischemic limb

10 Repair of popliteal artery injury 1

11 Exploration & repair of brachial

artery injury

12 Embolectomy 2

13 Exploration of bleeding wounds 3

14 Feeding gastrostomy 5

15 Lumbar sympathectomy 2

16 Wound debridement 3

17 Tracheostomy 1

Total 45

Details of Elective Thoracotomies

1. R posterolateral thoracotomy for resection of neurofibroma.

2. L posterolateral thoracotomy for removal of huge intact PHC from LLL.

3. L posterolateral thoracotomy for removal of ruptured PHC

4. L posterolateral thoracotomy for repair of traumatic diaphragmatic hernia.

5. Repair of left-sided diaphragmatic eventration.

6. R thoracotomy for drainage of encysted empyaema.

7. Trans-sternal thymectomy for MG.

Details of Thoracotomies

Emergency thoracotomy 2

1. Left posterolateral thoracotomy for continuing bleeding (repair of lacerated left main PA)

2. Exploratory median sternotomy for suspected cardiac tamponade ( the case proved to be traumatic asphyxia).

Semi-urgent thoracotomy 4

1. Thoracotomy for lung decortication

2. Thoracotomy for clotted haemothorax

3. Thoracotomy for congenital TOF

Total 6

It was the midnight of 18th January 2004 when I was phoned to see a young chap with life- threatening bleeding from left- sided chest tube after being shouted with a bullet. The entrance was over the manubrium sterni while the exit was from left back near left scapula. The patient was extremely pale and shocked. More than 3 liters of blood were drained via the chest tube; still the bleeding was brisk once the clamp on the tube was removed. Clinically and radiologically, there was massive haemothorax with great mediastinal shift. Emergency thoracotomy was done in minutes. Using the available surgical instruments, we could find a big laceration in left main pulmonary artery beside laceration of LUL. The lacerated LMPA was repaired by 3-0 silk suture. The patient had an uneventful recovery.

BULLET INJURY TO LEFT CHEST: LMPA InjuryPostoperative CXR

AN 8 YEAR OLD BOY WITH DRY COUGH FOR 3 MONTHS

To summarize the case:

The diagnosis of intact PHC in an endemic area is not difficult. Plain radiographic appearance of (full moon against the dark sky) is characteristic. The main concern is the surgical removal of the cyst and its contents safely, without spilling the scolices-rich fluid into the surgical field and thus avoiding recurrence and surgical closure of the bronchial fistulae to achieve early and full lung expansion postoperatively. Safe removal requires protection of the airways from fluid spillage and drowning during surgery. This is the combined responsibility of the surgeon and anaesthesiologist. No double-lumen endotracheal tubes are designed for children due to their small airways.

Careful entry into the pleural space, avoidance of sudden rupture of the cyst, walling off the cyst with packs soaked in scolicidal agent, controlled evacuation of the cyst contents, keeping one or two good suckers ready to use and the frequent aspiration of the secretions from the airways by the anaesthesiologist are all necessary measures. Needless to say, very good chest physiotherapy is essential to get the goal of lung expansion. A plug of viscid sputum blocking a bronchus can spoil the most meticulous pulmonary operation.

SEVENTEEN YEAR OLD GIRL WITH GENERALIZED MG

Biopsy result: Follicular thymic hyperplasia

Preop.photograph Postoperative photo

POSTOPERATIVE CXR

A 29 year old female patient discovered to haveright- sided intra-thoracic mass by plain chest radiograph done

prior to emergency appendectomy 2 months earlier

NEUROFIBROMA

POSTOPERATIVE CXR

CHRONIC RUPTURE OF L HEMIDIAPHRAGM

POST REPAIR

POSTOPERATIVE CXR

EVENTRATION OF L HEMIDIAPHRAGM IN AN ADULT

REPAIR COMPLETED

POSTOPERATIVE CXR

Biopsy: Alveolar soft

tissue sarcomain a young adult man

01/03/2004 79Prof. Abdulsalam Y Taha/ CTV

Surgery in Sulaimani, the beginning

REPAIR (END TO END ANASTOMOSIS) OF SFA INJURY DUE TO STAB WOUND

A 26 yr. old man sustained a crush injury to his right knee,presented with a wound in popliteal fossa with signs & symptomsof leg ischemia. He had been explored 7 hours after the accident because of his family initial refusal to have surgery. Contusion of

artery and crushed muscles were found. Fasciotomy, thorough wound debridement and repair of artery by resection of damaged segment

and end to end anastomosis were done.

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Exploration and repair of brachial artery injury following a road traffic accident.

R LUMBAR SYMPATHECTOMY FOR CRITICAL LIMB ISCHEMIA

EXTENSIVE CONGENITAL AVM OF FACE

• The successful management of this challengingcase of AVM was due to the team work of general,plastic and vascular surgeons as well as theanaesthesiologist. The team strongly believed infeasibility of surgery for this patient who lived amiserable life for 3 decades and thus accepted allrisks.

• Extensive stage IV AVM of the head and neck areused to be considered either incurable, or theyare managed by therapeutic embolizationfollowed by surgery in 24 to 48 hours.

Diagnostic AnteriorMediastinotomy

Large cell Lymphoma

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A middle aged lady with encystedthick paste-like material in right

pleural space managed bythoracotomy

and drainage.

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TRAUMATIC ASPHYXIA DUE TO SEVERE COMPRESSION OF THE CHEST FOLLOWING A ROAD TRAFFIC ACCIDENT

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NEGATIVE SURGICAL EXPLORATION FOR SUSPECTED CARDIAC TAMPONADE Prof. Abdulsalam Y Taha/ CTV Surgery in Sulaimani, the beginning

GRADUALLY RECOVERED!

Traumatic asphyxia occasionally complicates compression injuries of the thorax. Petechial haemorrhages due to extravasation of blood from compressed venules, are seen in the skin, confined mainly to the face and neck, although they may be seen to a lesser extent on the thorax. The conjunctivae are bright red from conjuctival haemorrhages. In rare severe instances, the face is purple.

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DIAGNOSTIC THORACOSCOPY FOR A LADY WITH TUBERCULOUS PLEURAL EFFUSION

The endless support of the higher authorities in Kurdustan and in particular, his excellency the Minister of health Dr. Muhammad K. Khoshnaw played a major role in our success now and in the future. All the hospital staff gave us a good support also. I have a word to my colleagues, the

physicians and surgeons in Kurdustan: I came here to share you the honor of serving the kind people

of Kurdustan.

بسم الله الرحمن الرحيم:105]التوبة [( و قل اعملوا فسيرى الله عملكم و رسوله و المؤمنون(

In the name of God, the Most Gracious, the Most Merciful(And say {unto them}: Act! Allah will behold

your actions, and {so will} His messenger and the believers) [Quran Chapter Al-Tawba (9), Verse No. (105)

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