Muscle-sparing thoracotomy: Anatomy and technique.

The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes.  However, subsequent study results  have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.

The impact of junior surgical jobs in cardiothoracic surgery on career choice in the United Kingdom.

OBJECTIVES: Cardiothoracic surgery is a small specialty, often with a limited presence on the undergraduate curriculum. In the past, there was a heavy reliance on postgraduate exposure to inform career choice. Recent changes in recruitment to the specialty in the United Kingdom may reduce exposure of the best trainees to the specialty, and reduce the quality of future surgeons. This study will evaluate the impact of junior surgical jobs on future career preferences. METHODS: We asked all 126 core surgical trainees in the Northern Ireland Deanery their surgical specialty preferences over 2 years. Trainees were asked for their first and second preferences on each occasion. In total 502 first and second preferences were declared. Past and present postings were then correlated with this information to see if working in a cardiothoracic unit impacted on specialty preference choices. RESULTS: Cardiothoracic surgery is the least popular of all the surgical specialties amongst junior surgical trainees (3.6%)-with general surgery, breast surgery, and orthopaedic surgery, drawing 53% of trainees. In trainees who had previously worked in cardiothoracic surgery, 75% expressed a wish to return to the specialty, making it the most dominant. CONCLUSIONS: The role of junior surgical jobs in the specialty is immensely important on career choice. Moving to a more junior recruitment may exclude excellent candidates who have simply not experienced cardiothoracic surgery.

Perioperative detection of circulating tumour cells in patients with lung cancer.

Lung cancer is a leading cause of mortality and despite surgical resection a proportion of patients may develop metastatic spread. The detection of circulating tumour cells (CTCs) may allow for improved prediction of metastatic spread and survival. The current study evaluates the efficacy of the ScreenCell® filtration device, to capture, isolate and propagate CTCs in patients with primary lung cancer. Prior to assessment of CTCs, the present study detected cancer cells in a proof-of-principle- experiment using A549 human lung carcinoma cells as a model. Ten patients (five males and five females) with pathologically diagnosed primary non-small cell lung cancer undergoing surgical resection, had their blood tested for CTCs. Samples were taken from a peripheral vessel at the baseline, from the pulmonary vein draining the lobe containing the tumour immediately prior to division, a further central sample was taken following completion of the resection, and a final peripheral sample was taken three days post-resection. A significant increase in CTCs was observed from baseline levels following lung manipulation. No association was able to be made between increased levels of circulating tumour cells and survival or the development of metastatic deposits. Manipulation of the lung during surgical resection for non-small cell lung carcinoma results in a temporarily increased level of CTCs; however, no clinical impact for this increase was observed. Overall, the study suggests the ScreenCell® device has the potential to be used as a CTC isolation tool, following further work, adaptations and improvements to the technology and validation of results.

Surgeon and haematologist: a review of comprehensive care for patients with inherited bleeding disorders in Northern Ireland.

BACKGROUND: Management of patients with inherited bleeding disorders has improved since the introduction of Comprehensive Care Centres (CCC) in the United Kingdom (UK). In the event such patients need surgery, the aim of the multidisciplinary team is to facilitate outcomes as good as what would be expected in a non-bleeding disorder patient. A review of such comprehensive care was carried out in patients with inherited bleeding disorders when they needed surgery at Northern Ireland CCC. Aims of the study were to evaluate surgical morbidity and mortality in these patients. METHODS: All patients with inherited bleeding disorders who underwent non-orthopaedic surgery between 2008 and 2012 were identified from the CCC records within the Belfast Health and Social Care Trust (BHSCT) in Northern Ireland (NI) and their case records reviewed. RESULTS: 28 patients received elective and emergency surgery during this period. There was minimum morbidity and no mortality in this cohort. CONCLUSIONS: Surgery in patients with inherited bleeding disorders has become safe with the advent of multidisciplinary CCCs. Close communication between surgeon and haematologist is key in the successful management of these complex patients.

Malignant primary cardiac tumours.

OBJECTIVES: Management of malignant tumours of the heart remains a poorly investigated clinical area due to the scarcity of presentations. The purpose of this series and review is to present an outline of the management emphasized by our personal experience in a regional cardiothoracic centre. METHODS: We reviewed all cases presenting with primary cardiac tumours in our institution within the last 10 years, looking at presentation, management and outcomes. RESULTS: Of these, the records of 3 patients, who attended the Royal Victoria Hospital in Belfast and were treated for a cardiac sarcoma, were fully evaluated. A review of current literature was conducted through a search of Pubmed and Medline databases. A review of the presentation of these patients and the generally accepted management deterioration of patients diagnosed with cardiac sarcoma is discussed. CONCLUSIONS: With reference to our case series, we want to draw attention to the rapid deteriation of these patients following presentation.

A 15-cm aneurysm of the right coronary artery presenting as a pericardial cyst.

We report an unusual case of a giant right coronary artery aneurysm, measuring 15 cm in diameter, in a 76-year old woman. The aneurysm was initially identified when the patient was investigated for signs of congestive cardiac failure with a computed tomography scan of her thorax; at this stage, the lesion was misdiagnosed as a large pericardial cyst. The aneurysm was successfully excised at surgery and her heavily diseased right coronary artery was secured with a saphenous vein graft.

Defunctioning loop ileostomy: not always a safe option.

A 74-year-old woman underwent a low anterior resection and defunctioning loop ileostomy for a T1 N1 M0 rectal adenocarcinoma. Three months following surgery she attended complaining of pain inferior to the loop ileostomy. A clinical examination demonstrated an extensive area of spreading cellulitis on the lower abdominal wall inferior to the loop ileostomy with associated crepitus and skin necrosis. The clinical diagnosis of necrotising fasciitis was confirmed radiologically on emergency computed tomography. The patient underwent an emergency debridement of the anterior abdominal wall.