Notes from the day’s lectures at the XVI Congreso Boliviana de Cirugia Cardiaca, Toracica u Vascular in Santa Cruz de la Sierra, Bolivia
This afternoon’s thoracic surgery offerings were provided in a more relaxed, round-table style discussion.
Dr. Edwin Crespo Mendoza, thoracic surgeon, of Santa Cruz, Bolivia led the discussion on diaphragmatic hernia repair and reminded the audience that over 50% of traumatic diaphragmatic hernias go undiagnosed at the time of initial presentation after trauma. To illustrate this, Dr. Crespo presented several cases including a case of post-traumatic hernia diagnosed 13 years after initial auto accident.
Dr. Fernando E. Jemio Ojara, MD (cardiothoracic surgeon) here in Santa Cruz at the Clinica Folanini presented a fascinating case of bilateral lung injury after blunt trauma. In this case, the patient was preparing to undergo urgent repair of a right-sided bronchial tear but during attempted intubation saturations dropped dramatically to 60%. At that time, the patient was placed on ECMO by venous cannulation to maintain oxygenation during the case. The surgeons proceeded with a right posteriolateral thoracotomy. Patient had a short successful ECMO run of 85 minutes, with extubated within 36 hours of surgery, and had no further problems post-operatively,
Dr. Ojara also discussed the mechanism of these type of acceleration – deceleration injuries that most commonly affect the right middle lobe, and how stabilization with ECMO is an effective strategy to repair what is essentially a functional pneumonectomy (in this particularly patient).
Dr. Fidel Silva Julio, Thoracic Surgeon also talked on a similar theme in his overview of closed chest trauma. He reminded the audience that 75-85% of all closed chest trauma patients need some sort of surgical management from chest tube placement to urgent surgery. He reviewed the classic presentations and radiographic findings in some of the most common conditions after chest trauma such as tension pnuemothorax/ sucking chest wounds, flail chest, pneumomediastinum, cardiac tamponade and pulmonary contusions. There were several medical students in the audience, taking notes – so I have included links to the radiology signs mentioned in his lecture, as well as a basic radiology primer.
He also highlighted the need to prevent the typical trauma pitfall of massive volume resuscitation which can prove extremely detrimental in these patients.
Discussion of a case report by Gonzalez, Paradela, Garcia & Dela Torre (2011) of a lobectomy by single incision thoracoscopic surgery.
Since there’s been quite a bit of interest in single-port thoracoscopic surgery (SITS) here at Cirugia de Torax.org – I’ve added information about SITS lobectomy. British surgeons, Rocco et. al had previously reported the outcomes of several wedge resections by uni-port (SITS) back in 2004 but this is the first case report that I’ve seen for lobectomies via this technique*.
Gonzalez et al. in Coruna, Spain published a case report of a lobectomy by SITS. The authors note that they have performed three cases by this technique at the time of article submission (November 2010).
As expected, the authors reported decreased post-operative pain and parathesias when using this technique. They also reported that while visibility is more limited with this approach, they feel that it is less problematic for surgeons already accustomed to, and familiar with double port lobectomies. This approach, in their experience, is best used for lower lobe lesions due to difficulties accessing and maneuvering for bronchial resection for upper lobectomies.
* If you’ve seen other published reports – please send the citations to the site.
Update: 25 July 2011
I contacted Dr. Gonzalez to inquire about his surgical experiences since the publication of the article this past March. Dr. Gonzalez reports that he and his colleagues (Dr. Mercedes De la Torre and Dr. Fernandez) have continued to practice SITS for lobectomies and other thoracic procedures, and that he is now using it for the majority of his cases.
Dr. Gonzalez states that many of his patients are discharged earlier (POD 2 or 3) and are experiencing less post-operative pain. He is planning future studies to demonstrate this.