When to call a

thoracic surgeon

Hussein Elkhayat,MD

Without a perfect

preoperative assessment

We are operating on the dark

Preoperative assessment

– History

– Imaging

– Lab.

– Interventional procedures

– Pulmonary function

– Treatment given

– Counselling

– metastatic workup

Assiut Cardiothoracic Surgery Dpt.

– Founded as a unit in 1987

– Started closed heart surgery before being a unit in 1980

– Started open heart surgery in 1987

– Expanded to be a department in 1999

– Specialized unit for pediatric cardiothoracic surgery founded in 2009 with one OR and 9 PICU beds

– Now dpt. includes 2 professors, 4 assistant professors , 7 lecturers, 9 assistant lecturers and 12

residents.

– Department is sharing in Assiut trauma unit.

1096bronchoscopy

&esophagescopy

from 2011-2015

Post chemoradiotherapy resection

PECTUS

VATS

Assiut university HEART

hospital 2016

– Soft opening in 26 Jan. 2016

– Total of 174 thoracic surgery cases (versus 211 cardiac cases)

– 82 by one thoracic surgery dedicated team so far ( total of 45 last year )

– 43 VATS (52.4% )

– 39 UNIPORTAL (TOTAL OF 57case since 2012) (thoracic duct ligation , achalasia , wedges, extraction of penetrating FB, clotted hemothorax, decortication for stage 3 empyema, sympathectomy and LEFT UPPER LOBECTOMY ,LEFT LOWER LOBECTOMY )

– 4 VATS lobectomy (7 in total from 2015) ( one bilobectomy for bronchactasis via 2 port , one uniportal pneumonectomy with expert , one uniportal LUL for aspergilloma and left lower lobectomy for sequestrated lobe).

– Two postoperative mortality in VATS cases (day 3 and 4 postop in IPF cases)

– 3 VATS cases need reoperation (2 for bleeding and open for esophageal perforation )

Do we really need VATS ?

The most dangerous phrase in the language is “ we’ve always done it this way “

Innovation There’s a way to do it better - Thomas Edison

Uniportal VATS

Video Assisted Thoracoscopic Surgery (VATS) Resection of Anterior Mediastinal MassCardiothoracic Surgery Department , faculty of Medicine , Assiut University

Removal of penetrating FB

Bullectomy

VATS LOBECTOMY

• 69 yrs old male pt• Cancer larynx from 8 yrs• Operated for total laryngectomy with permanent tracheostomy• Receive postoperative adjuvant chemotheryapy and radiotherapy • Esophageal stricture with frequent endoscopic dilatation • Accidentally discovered left upper lung zone opacity • CT scan left upper lobe mass with no detectable LNs.• Oncolgist consultation suggest it is a second primary NOT a mets

and recommend surgical treatment • PFT : !!!

Left VATS 2 ports access

VATS 2 ports LUL

Common conflicts

Between surgeons and phycisians

Chest tube; insertion

NEJM VIEDO !

Chest tube;indications

Chest tube;securing

Chest tube; common problems

– Malposition

– No drainage

– Bleeding

– Pain

– Perforation

– Massive air leak

– Surgical emphysema

Chest tube; care

– Dressing

– Pain management

– Chest x ray ?

– Follow up

– Removal

– Chest tube for how long ?

– CLAMPING

Empyema

– Definition ,stages ,clinical presentation

– Order of investigation ?

– Treatment options

Empyema; ttt options

– Chest tube

– Rib resection

– Early debridement

– Streptokinase

– Decortication

– VATS decortication

VATS decortication

Pneumothorax

BTS 2010 Accepted indications for surgical advice should be as follows:

– Second ipsilateral pneumothorax.

– First contralateral pneumothorax.

– Synchronous bilateral spontaneous pneumothorax.

– Persistent air leak (despite 5-7 days of chest tube drainage) or failure of lung re-expansion.

– Spontaneous haemothorax.

– Professions at risk (eg, pilots, divers).

– Pregnancy.

The future that we are looking

for

Thank you