Deck 14: Thoracic Surgery

Question 1

Roger Waring, a 46-year-old male with early-stage lung cancer, was listening to his surgeon describe the surgical plan in preparation for signing the informed consent. The surgeon described a procedure that would be done before the thoracoscopic lung surgery. The surgeon described an examination of Roger's middle chest lymph nodes and the area below where the bronchi branch into the right and left lungs, and possibly taking biopsies of suspicious tissue. The procedure uses a hollow lighted tube with fiberoptic light-carrying fibers. What diagnostic procedure will precede Roger's thoracoscopic lung surgery?

A)Thoracoscopy
B)Mediastinoscopy
C)Bronchoscopy
D)Panendoscopy

Answer 1

B
Mediastinoscopy is the direct visualization and possible biopsy of lymph nodes or tumors at the tracheobronchial junction, under the carina of the trachea, or on the upper lobe bronchial subdivisions. Mediastinoscopy may precede an exploratory thoracotomy in known cases of lung carcinoma or may be completed to assist in accurately staging the patient's lymph node status. The mediastinoscope is a hollow tube with a fiberoptic light carrier. A fiberoptic light source with a light-intensity dial provides power and control of illumination.

Question 2

The perioperative team will need to collaborate with the anesthesia provider, since continuous hemodynamic monitoring, oximetry, and ventricular function assessment by transesophageal echocardiography (TEE) are all performed intraoperatively. Cardiopulmonary bypass (CPB) may also be required. Select all the procedures from the list below for which these preparations are indicated.

A)Donor harvesting
B)Living-related single-lung transplant
C)Cadaveric single-lung transplant
D)Double-lung transplant

Answer 2

B, C, D
Procedural considerations for both single- and double-lung transplants include continuous hemodynamic monitoring, oximetry, and ventricular function assessment by transesophageal echocardiography (TEE) performed intraoperatively. Cardiopulmonary bypass (CPB) may be required.

Question 3

Pneumonectomy is removal of an entire lung, usually to treat malignant neoplasms. What structures are excised or resected in order to remove the entire lung and complete the surgery?

A)A section of rib, bronchus, pulmonary artery and vein, and hilar pleura
B)The lung, peripheral adhesions, and pulmonary ligament
C)Mediastinal lymph nodes, portions of the chest wall or diaphragm, and parietal pleura
D)All of these structures may be resected during a pneumonectomy

Answer 3

D
Other resections are often combined with pneumonectomy, such as resection of mediastinal lymph nodes, resection of portions of the chest wall or diaphragm, and removal of parietal pleura. If a rib is to be excised, bone instruments are required. The surgeon frees any peripheral adhesions to mobilize the lung and divides the pulmonary ligament. The superior pulmonary vein is gently retracted, and the pulmonary artery is dissected. The surgeon clamps and divides the branches of the pulmonary artery and vein of the involved lobe. The inferior pulmonary vein is exposed by incising the hilar pleura and retracting the lung anteriorly. The inferior pulmonary vein is clamped, doubly ligated, and divided. The surgeon divides the bronchus near the tracheal bifurcation. The lung is removed from the chest.

Question 4

What is the ideal position for bronchoscopy?

A)Supine
B)Left semilateral
C)Supine with a shoulder roll
D)Semi-Fowler with neck extended

Question 5

Video-assisted thoracic surgery (VATS) is a minimally invasive operative technique that has evolved over the past decade. It uses an endoscopic approach to visualize the thoracic cavity for diagnosis of pleural disease or treatment of pleural and lung conditions. In the adult, the surgeon creates a 2- to 3-cm incision between the ________ intercostal spaces for insertion of the 10- or 12-mm trocar. The trocar sites can also be used for insertion of a ____________.

A)fourth and sixth; robotic EndoWrist grasper
B)fifth and seventh; chest tube
C)fifth and seventh; zero-degree scope
D)sixth and eighth; video camera

Question 6

The nerves of the lungs are a part of the autonomic nervous system. What structures are constricted and relaxed by their influence?

A)The bronchi and the blood vessels
B)The alveoli and the pulmonary vein
C)The pulmonary artery and vein
D)The bronchi and bronchioles

Question 7

The indications for single-lung transplantation (SLT) include restrictive lung disease, emphysema, pulmonary hypertension, and other nonseptic end-stage pulmonary diseases, while the indications for double-lung transplantation (DLT) include patients with:

A)bilateral early-stage sarcoma without systemic disease.
B)bilateral chronic infection causing end-stage renal failure.
C)cystic fibrosis in end-stage pulmonary failure.
D)bilateral disease, recent ex-smoker with a suitable living-related donor.

Question 8

The thoracic outlet is a junction bound anteriorly by the manubrium, anterolaterally by the first ribs, and posteriorly by the first thoracic vertebrae and posterior angles of the first ribs of the space. The great vessels of the head, neck, and arm pass through this space. What syndrome is caused by the compression of these structures?

A)Brachial plexus palsy
B)Vertebral tipping syndrome
C)Thoracic outlet syndrome
D)Thoracic plexus compression

Question 9

Inspiration normally takes place when the intrathoracic pressure is slightly below atmospheric pressure and when a partial vacuum exists between the parietal and visceral pleural (intrathoracic) surfaces. As the muscles of inspiration contract to enlarge the chest cage, what action by the lungs occurs to facilitate air intake?

A)The lungs recoil and expand to draw air into them.
B)The lungs are passive and follow the diaphragm and chest wall.
C)The lungs produce a pressure gradient that suctions air.
D)The alveolar sacs expand when triggered by neural triggers in all 10 lung segments.

Question 10

Thoracotomy can be performed with the patient in one of three common positions: lateral, semilateral, and supine. While the supine position is used for the median sternotomy approach, which of the lateral positions is used for an anterolateral approach?

A)Semilateral
B)Lateral
C)Prone
D)Lateral decubitus

Question 11

Lung volume reduction surgery (LVRS) is an alternative surgical treatment for patients with which pulmonary condition?

A)Chronic pulmonary asthma with oxygen needed to keep saturation at 90%
B)Acute unilateral pulmonary emphysema
C)Severe bilateral heterogeneous or homogeneous emphysema
D)Unsuccessful or failed laser surgery for giant lung bulla

Question 12

Direct visualization of the mucosa of the trachea, the main bronchi and their openings, and most of the segmental bronchi may also include the removal of material for microscopic study, and is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing, hemoptysis, obstruction, and abnormal roentgenographic changes. What diagnostic modality has been described?

A)Standard bronchoscopy
B)Flexible bronchoscopy
C)Rigid bronchoscopy
D)All bronchoscopic approaches apply

Question 13

An example of a true statement about TNM and staging diagnostic classification for lung cancer is:

A)the staging system is based on the TNM classification system.
B)the TNM system is based on the staging classification.
C)nodal involvement refers to a second primary lung cancer tumor.
D)a patient with T1, N0, M0 has a benign tumor.

Question 14

Pleurodesis is undertaken as a treatment for malignant pleural effusion and for unresolved spontaneous pneumothorax. The endpoint goal of a pleurodesis is to:

A)prevent accumulation of pleuritic secretions.
B)bond the parietal pleura to the lung.
C)achieve permanent pneumothorax.
D)cause adherence of the pleural layers.

Question 15

During an endoscopic thoracic sympathectomy for hyperhidrosis, what action by the anesthesia provider ensures exposure and minimizes damage to the lung?

A)Positions the patient in the anterolateral position with an expandable axillary roll.
B)Decreases ventilatory pressure to decrease lung expansion during dissection.
C)Deflates the lung on recommendation of the surgeon during dissection and resection.
D)Decreases positive end-expiratory pressure until resection is complete.