Surgical Chest Conditions B y D r. J. C. V A N D E R S P U Y , M .B ., B .C h ., D ip . in Surg. T h o ra c ic S urgeon, P re to ria G e n e ra l H o sp ita l. Lecture given a t the N orthern Transvaal Branch Post-G raduate Course on C hests, on Saturday, 28th M a y . Page 6 P H Y S I O T H E R A P Y December, 1960 M r. P re sid e n t, M a d a m P rin c ip a l, L ad ies a n d G e n tle m en , I w ish to th a n k y ou fo r h av in g asked m e to ad d ress you on this very im p o rta n t occasion. I h a v e been re q u e ste d to ta lk o n th e su bject o f C a rd ia c Surgery. T h is I d o very gladly b ecause th is is p ro b a b ly the b ra n c h o f su rg e ry w hich d e m a n d s th e closest c o -o p e ra tio n betw een th e v a rio u s m em b ers o f the tea m including th e p h y sio th e ra p ist; a n d as th e m ost co m m o n a n d p ro b a b ly o n e o f the m o st serious c o m p lica tio n s to follow o p e n -h ea rt su rg e ry is re la te d to th e b ro n c h o -p u lm o n a ry system , it is a b so lu te ly e ssential th a t th e p h y sio th e ra p ist be fully a w are o f h is o r h e r m o st im p o rta n t re sponsibilities as a m em b e r o f a tea m w o rk in g to g e th e r in th e closest h a rm o n y w ith on ly o ne single goal in m ind. I t is n o t m y in te n tio n to discuss h e re w ith y ou to d a y th e p h y sio th e ra p e u tic a spects o f c a rd ia c surgery, b u t ra th e r to give you a b ro a d view on c a rd ia c surgery as pra ctised today. Heart lesions requiring surgical treatment T h e v a rio u s h e a rt lesions w hich re q u ire surgical tre a tm e n t in clude b o th co n g en ital a n d a cq u ired defects a n d include stenosis o f th e m itra l, a o rtic , p u lm o n a ry a n d tric u sp id valves, re g u rg ita tio n o f th e m itra l a n d a o rtic valves, defects in th e in te rv e n tric u la r and in te ra rte ria l septa, v a rio u s c o m b i­ n a tio n s o f v a lv u la r stenosis w ith se p tal defects, lesions o f th e m ain b lo o d vessels in close p ro x im ity to the h e a rt— e.g. p a te n t d u c tu s a rte rio su s a n d c o a rc ta tio n o f th e a o r ta — a n d lesions in th e c o ro n a ry a rte ria l su p p ly to th e m y o ca r­ d iu m . M a n y o f these lesions c a n b e m o re o r less com pletely c ured w ith p re se n t d a y surgical techniques, b u t th e c o rre c ­ tio n o f o th e r— e.g. m itra l a n d a o rtic re g u rg ita tio n and lesions o f th e c o ro n a ry a rte rie s— a re still in th e experim ental stage. Thoracic incisions V a rio u s th o ra c ic incisions a re em ployed fo r a p p ro a c h in g th e h e a rt. T h e m o st c o m m o n a n d firm ly established in ­ cisions e n te r th e rig h t o r left chest c avity by m eans o f an incision alo n g th e line o f a rib a n d th ro u g h a n inte rco stal space o r th ro u g h th e bed o f th e c o rre sp o n d in g rib w hich c an e ith e r be rem oved o r left in ta c t. Such incisions m ay be p o ste ro -la te ra l o r a n te ro -la te ra l a n d d e p e n d in g on th eir s itu a tio n will extend th ro u g h th e latissim us dorsi, se rra tu s a n te rio r a n d pe cto ralis m uscles. T h e a n te rio r tran s-stern a l incision m ay b e u n ila te ra l o r b ila te ra l a n d e x te n d s tran sv erse ­ ly th ro u g h th e ste rn u m and th e c o rre sp o n d in g in te rco stal space o n o ne o r b o th sides. T h e m o re re ce n tly in tro d u c ed , a n d no w m o re co m m o n ly used, v ertical tran s-stern a l incision bisects th e ste rn u m fro m th e su p ra ste rn a l n o tc h to th e xyphoid process. T h e m ain a d v an tag e s o f this incision a re th a t it c a n be d o n e m o re q u ick ly a n d is less p a in fu l p o sto p e rativ ely , w ith th e result th a t th e p a tie n t can c o -o p e ra te m o re read ily w ith th e p h y sio th era p ist. Cardiac approaches T h e lesion m a y be reached by m ea n s o f v a rio u s c a rd ia c a p p ro a c h e s . T h e m itra l valve, fo r exam ple, is reach ed via th e left a triu m , w hereas th e tric u sp id valve a n d an in ter- a tria l septal defects a re a p p ro a c h e d v ia the rig h t a triu m a n d a v e n tricu la r sep tal defect is reach ed th ro u g h an incision in th e rig h t ventricle. T h e a p p ro a c h to th e a o rtic a n d p u l­ m o n a ry valves is e ith e r th ro u g h th e c o rre sp o n d in g ventricle o r vessel. T h e size o f th e c a rd ia c incision m ay be such as to a c c o m m o d a te o nly a finger o r a special in stru m e n t in cases o f closed h e a rt o p e ra tio n s , o r th e incision m a y be sufficiently larg e so as to allow o f th e surgery being c arried o u t u n d e r d irec t vision. Two main techniques T w o m ain tec h n iq u es a re used in th e p e rfo rm a n c e o f h e a rt o p e ra tio n s d ep en d in g o n w h e th er th e o p e ra tio n is o f th e c lo sed -h e art type o r o f th e o p e n -h e a rt type. Closed heart operations In closed h e a rt o p e ra tio n s th e valve, such as th e m itral a n d tric u sp id valves, is reached via an incision in the left a n d in th e rig h t a triu m respectively o f sufficient size to a cc o m m o d a te on ly a n index finger, w hich is used to force o p e n th e valve alo n g its fused c om m issures. Sim ilarly, a valve d ila to r can b e passed th ro u g h a sm all w o u n d in th e rig h t o r in th e left ventricle in to the p u lm o n a ry o r the m itra l a n d a o rtic valves, w hich a re forced o pen blindly. T h is closed tra n s v e n tric u la r a p p ro a c h is to d a y th e o p e ra tio n o f c hoice in cases o f m itra l stenosis a n d u n d e r c e rta in c irc u m stan c es also in a o rtic s te n o s is ; in th e fo rm e r case th e tip o f the in stru m e n t in th e m itra l valve is c o n tro lle d by m ean s o f a second finger w hich is in tro d u c e d in to th e left a triu m th ro u g h a sm all w o u n d in th e left a u ric u la r a p p en d a g e. Open heart operation. S ince th e first successful in tra -c a rd ia c o p e ra tio n , tw elve y ears a g o , for m itra l stenosis, m uch ex p erim e n tal w o rk , c h iefly in th e U .S .A ., h a s m ad e it possible to e x p lo re the in te rio r o f th e h e a rt u n d e r d irec t vision em p lo y in g in the first in stan c e h y p o th e rm ia a n d follow ed a few y ears la te r by th e use o f th e h e a rt-lu n g m achine. H y p o th e rm ia is in u se to d a y in m an y c a rd ia c c entres fo r th e re p a ir chiefly o f a tria l septal defects a n d for p u lm o n a ry v a lv o to m y via th e p u lm o n a ry a rte ry . A t th e n o rm al b ody te m p e ra tu re o f 37 °C th e b ra in c a n sta n d , w ith o u t d a m a g e, a n o x ia fo r a p e rio d o f th ree to fo u r m inutes. W hen, how ever, th e bod y te m p e ra tu re h as b een re d u ce d , by placing the p a tie n t fo r exam p le in a tu b w ith ice w ater, to a te m p e ra tu re o f 29 °C th e b ra in will w ith sta n d a perio d o f a n o x ia o f a b o u t eight to te n m inutes. U n d e r th e la tte r c irc u m stan c es th e su p e rio r a n d in ferio r v e n a c av a c a n b e clam p ed off, th e inflow in to th e rig h t a triu m th u s e lim inated a n d th e rig h t a triu m be o p ened a n d a se p tal defect su tu re d u n d e r d irec t vision, p ro v id ed th a t the o p e ra tio n o f su tu rin g th e d efect be c o m ­ p leted w ithin eig h t to te n m inutes. U n d e r th e sam e set o f c irc u m stan c es th e p u lm o n a ry a rte ry im m ediately d ista l to th e p u lm o n a ry valve c a n be incised a n d th e c om m issures o f th e stenosed p u lm o n a ry valve be incised u n d e r d irec t vision. H e art-lung machine. T h e m ain d ra w b a c k o f o p e n -h e a rt su rg e ry u n d e r h y p o ­ th e rm ia is the very lim ited p e rio d o f tim e a t th e s u rg e o n ’s d isp o sa l to re p a ir m o re co m p lica te d in tra -c a rd ia c defects.) F o r such defects th e h e a rt-lu n g m ac h in e is used. T h e prin cip le o f the m ac h in e is the follow ing. V enous b lo o d is sucked o u t o f th e su p e rio r a n d in ferio r vena c av a by m ea n s o f c a n n u la e w hich a re passed in to these veins via th e rig h t a triu m . B y m eans o f tap e s placed a ro u n d th e su p e rio r a n d in ferio r v e n a c a v a th ese vessels are c o n stric ted a ro u n d th e c a th e te rs w ith th e re su lt th a t no venous b lo o d c a n re a c h th e rig h t a triu m . T h e v e n o u s b lo o d is p u m p ed b y m ean s o f a m echanical p u m p to a m echanical lu n g o r ox y g e n ato r, fro m w here it is p u m p ed by a second p u m p to the fe m oral a rte ry . T h is oxygenated o r a rterialised b lo o d re ac h in g th e fem oral a rte ry passes re tro g ra d e alo n g th e a o r ta a g ain st th e closed a o rtic valves, a n d fro m the a o r ta a lo n g all its b ra n ch e s. T h is b lood p asses th ro u g h th e w hole b o d y a n d re tu rn s via th e su p e rio r a n d in ferio r v e n a c av a w hence it is a g ain d ra in e d to p u m p N o . 1 arid th e o x y g e n ato r. T h e h e a rt is th e re fo re e m p ty except fo r c o ro n a ry a rte ria l b lo o d w h ic h d ra in s via th e c o ro n a ry sinus in to th e rig h t a triu m . W ith th e aid o f th e h e a rt-lu n g m achine, o p e ra tio n s on th e o p e n h e a rt c a n b e d o n e fo r p e rio d s o f as lo n g as tw o hours. T h e h e a rt-lu n g m ac h in e is m o st c o m m o n ly used fo r ven­ tric u la r septal defects, b u t is a lso c o m m o n ly em ployed fo r (C ontinued on p age 5 ) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1960 P H Y S I O T H E R A P Y Arch of aorta-^-") P h r e n i c n e r v e y p e r i c a r d i u m - ^ O e s o p h a g u s a n d t r a c h e a ----- V agus ------- P u lm o n a r y r o o t ^ — —Di a p h r a g m F i g . 5 i Structures seen through the left mediastinum. The Trachea a n d Lungs T he trac h ea begins in the n eck a t the low er end o f the larynx. It en ters the th o ra x o p p o site th e u p p e r b o rd e r o f the m a n u b riu m sterni a n d te rm in a te s a t the low er b o rd e r o f the m a n u b riu m o p p o site the 4 th th o rac ic v e rte b ra by dividing in to a rig h t a n d left b ro n c h u s. Its th o rac ic p a rt therefore lies in th e su p e rio r m ed ia stin u m . T he trachea, b e ing an e lastic stru c tu re , elo n g ates d u rin g inspiration a n d its b ifu rc a tio n m ay th u s descend to the level o f the bod y o f the fifth o r even th e sixth th o rac ic vertebra. Bronchi E ach b ro n c h u s passes d o w n w ard s a n d sid ew ard s to the hilum o f the c o rre sp o n d in g lu n g a nd thence d o w n w ard s in the substance o f the lung to w a rd s its base. T h e p rim a ry bronchi can th ere fo re be divided in to e x tra p u lm o n a ry a nd intra p u lm o n a ry p o rtio n s , k e p t p a te n t by rings— a n d plates o f cartilage, respectively. T he right b ro n c h u s is sh o rte r th an th e left b ro n c h u s, it is m ore vertical th an the left a n d is slightly w ider. It gives off one b ra n c h , w hich arises close to the h ilu m o f the lung a n d is called th e e p a rte ria l b ro n c h u s b ecau se it o rig in ­ ates im m ediately a b o v e the p o in t w here the right p u lm o n a ry artery crosses in fro n t o f the b ro n c h u s. The left b ro n c h u s gives off n o b ra n ch e s in the hilum . The Lungs T he lungs a re a p a ir o f c o m p a rativ ely light organs. T h e 6 *^e h ealthy lung su b sta n c e is re m a rk ab le . T he lungs, w hen h ealthy, lie free in the c avity o f the chest and a re atta ch e d o nly by th eir roots. Each lung p re sen ts fo r e x am in atio n a n apex, a base, a costal surface a n d a m edial su rfa ce se p a ra ted by a n te rio r, P °ste rio r a n d in ferio r b o rd e rs. J ™ a Pex rises in to the ro o t o f the n eck fo r a n inch a nd Th ? ° o v e the level o f the a n te rio r p a r t o f the first rib. . e _Pase ° f e ach lung has a sem i lu n a r o u tlin e a n d is Pled to the u p p e r surface o f the d iap h ra g m . Lo b es o f the Lungs T h e left lung is divided in to tw o lobes by a lo n g deep fissure w hich p e n e tra te s its su b sta n c e to w ith in a sh o rt distan c e o f the hilum . A n o b liq u e fissure a n d a h o riz o n ta l fissure divides the right lu n g in to th ree lobes. J u s t as the lobes c o n stitu te m a jo r segm ents o f th e lung w ith th eir ow n b ro n c h ia l, a rte ria l a n d v e n o u s supply, so do the b ro n c h i w ith in a lo b e b ra n c h a nd re b ra n c h to supply sm aller a nd sm aller segm ents o f lung tissue. I n p ractice o nly the m a jo r b ro n c h o p u lm o n a ry segm ents su p p lied by te rtia ry b ro n c h i a re n a m e d o r n u m b ere d . •(C ontinued fr o m p age 6) a tria l septal defects, a o rtic stenosis a n d re g u rg ita tio n , m itra l re g u rg ita tio n a n d o th e r com p lica te d co n g en ital h e art lesions. O w ing to the m ark e d d ra w b a c k o f h a v in g to w o rk on a n actively b e atin g b u t e m p ty heart, th e te c h n iq u e o f injecting a 2-J-% so lu tio n o f p o tassiu m c itra te in a rterialised b lood in to the asc en d in g a o r ta o f a pa tie n t o n th e h e art-lu n g m ac h in e w as in tro d u c e d by M elrose a b o u t five years ago, as this p ro c e d u re b rin g s a b o u t c ard iac sta n d still w hich m ark e d ly facilitate s th e p e rfo rm a n ce o f th e in tra -c a rd ia c o p e ra tio n . M o re recently it h a s been show n th a t be m erely c la m p in g o ff th e asc en d in g a o r ta a n d so de p riv in g th e h e art o f oxygen s p o n ta n e o u s c a rd ia c sta n d still will be p ro d u c e d w h ich will recover a g ain sp o n ta n e o u sly a fte r re m o v a l o f the clam p. W e shall n o w sh o w you a film, very kin d ly lent to us by W in th ro p P ro d u c ts, o f an o p e ra tio n pe rfo rm e d by D r. Je ro m e K a y in the U .S .A ., e m ploying the p rinciple described a b o v e o f a n oxic c a rd ia c a rre st w ith incision o f th e left ventricle to rem ove a tu m o u r fro m th e cavity o f this ventricle, exte n d in g in to b o th the left a triu m and a o r ta via th e m itral a n d a o rtic valves. I ♦ t ♦ I ♦ I♦ ( ♦ I♦ (♦ I♦ I ♦ I ♦ I ♦ I ♦ I ♦ I ♦ $ ♦ I ♦ I ♦ I♦ I ♦ I ♦ I ♦ I ♦ I♦ I BARF0 RD& JONES (SURGICAL SUPPLY CO.) Makers of: ARTIFICIAL LIMBS and ORTHOPAEDIC APPLIANCES SU R G IC A L INSTRUMENT REPAIRERS. P E R S O N A L A T T E N T IO N G IV E N T O ALL CASES. 1 5 8 P R E S I D E N T S T R E E T Corner N U G G ET STREET Phone 22-5 238 P.O. Box 5484. I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ ♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ I♦ 0♦ e R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )