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Pericardium and pericardial drainage

Core procedures Pericardiectomy Pericardiocentesis Pericardial harvesting, e.g. closure of atrial septal defect Thoracoscopic pericardial window creation Relief of pericardial tamponade post-cardiotomy Pericardial biopsy Surgical surface anatomy The surface projections of an average adult heart are modified by age, sex, stature, ventilation, the position of the diaphragm and posture. The projection of the cardiac borders on to the anterior thoracic wall forms a trapezoid. The upper border…

Thymus

Core Procedures Thymectomy Clinical anatomy The thymus is an encapsulated soft, bilobed organ; the two lobes are joined in the midline by connective tissue that merges with the capsule of each lobe. It is usually located in the anterior mediastinum. The thymus plays an important role in the immune system from the early part of life until puberty and, as a result, it is usually largest…

Lungs, bronchi and trachea

Core Procedures Tracheal resection: segmental resection Bronchoscopy: assessment Mediastinoscopy: assessment Wedge resection: non-anatomical wedge Segmentectomy: segment or multiple segments Lobectomy: lobe Sleeve lobectomy: lobe with segment of bronchus or pulmonary artery Pneumonectomy: whole lung Trachea Clinical anatomy The adult trachea averages 11.8 cm in length (range 10–13 cm). Typically, there are 18–22 cartilaginous rings. The larynx and the origin of the oesophagus are intimately related at the level…

Pleura and thoracic sympathetic trunk

Core procedures Pleural biopsy, pleural drainage, pleural debridement Spontaneous pneumothorax surgery, parietal pleurectomy Decortication of empyema Pleurectomy/decortication (extended) for mesothelioma Excision of solitary pleural tumour Thoracic sympathectomy, facial flushing, axillary and palmar hyperhidrosis, angina, splanchnicectomy Surgical surface anatomy of the pleura The surface marking of the lung represents the markings of the visceral pleura. The apex of the lung extends convexly upwards to a dist­ance of…

Oesophagus, thoracic duct and lymphatics

Core Procedures Transthoracic oesophagectomy Minimally invasive oesophagectomy (MIO) Thoracic lymphadenectomy Embryology The oesophagus develops from the primitive foregut, a ventral diverticulum caudal to the fifth pharyngeal pouch in the third week of gestation. It is initially a single common gastrointestinal (oesophagus) and respiratory (trachea) tube, which later develops a respiratory bud from which the tracheobronchial tree develops. Failure of division results in congenital problems, such as…

Great vessels: Surgical access

Core Procedures Surgical Repair of Aortic Arch Proximal aortic arch (so-called hemiarch) Distal aortic arch (so-called reverse hemiarch) Total aortic arch (involves at least one epi-aortic vessel) Total aortic arch and elephant trunk: conventional elephant trunk; reverse elephant trunk; frozen elephant trunk Surgical Repair of Descending Thoracic Aorta (DTA) Type A DTA (proximal third) Type B DTA (distal third) Type C DTA (entire thoracic portion) Core…

Breast

Core procedures Mastectomy: simple; skin-sparing; nipple-sparing, skin-sparing Wide local excision of breast lesion Wire-localized wide local excision Sentinel lymph node biopsy Microdochectomy Development Developmentally, the breast is a modified and highly specialized apocrine gland, composed of glandular tissue and ducts making up the breast parenchyma, supported by a connective tissue framework, adipose tissue and vasculature, which make up the breast stroma. Breast development begins in utero…

Overview of the thorax and diaphragm and surgical anatomy of the chest wall

Core Procedures Chest drain (tube) insertion Sternotomy Three-port thoracoscopic approach Posterolateral thoracotomy Anterolateral thoracotomy Left anterior thoracotomy Left thoraco-abdominal incision Right anterior mini-thoracotomy and minimally invasive approach to the mitral valve Hemi-sternotomy and minimally invasive approach to the aortic valve The chest wall is commonly affected in patients with both blunt and penetrating thoracic injury. The surgical approach to rib fractures, sternal fractures, flail chest and…

Wrist and hand

Core Procedures Dorsal and palmar approaches to the wrist, e.g. for access to joints, fractures; for tendon, ligament and nerve repair (see Table 41.1 ) TABLE 41.1 Core procedures: wrist Region Approach Indication Dorsal Arthroscopic Triangulo-fibro-cartilaginous complex (TFCC) injuries, synovectomy, ganglia Dorsal midline Open reduction internal fixation (ORIF) fractures, wrist fusion, wrist replacement proximal row carpectomy, etc. Mid-ulnar/dorso-ulnar Access to distal radio-ulnar joint, TFCC Anatomical snuffbox…

Elbow and forearm

The primary function of the elbow is to help position the hand in space. This is achieved by means of three joints: the radiocapitellar, humero-ulnar and proximal radio-ulnar joints. The functional range of movement has been described by Morrey et al as being 30–130° of flexion, 50° of pronation and 50° of supination, but for modern living more flexion is required. Core Procedures Lateral, medial, anterior and…

Shoulder girdle and upper arm

Core Procedures Surgical Exposures Around the Shoulder Girdle and Upper Arm Approaches to the shoulder girdle Approaches to the shoulder joint Medial extensile exposures Distal (brachial) extensile exposures While arthroscopy has allowed access to the glenohumeral, sternoclavicular and acromioclavicular joints and to the subacromial–subscapular space, enabling surgeons to undertake a variety of reconstructive procedures, it is not always possible to use a minimally invasive approach for…

Axilla

Core Procedures Axillary dissection Sentinel node biopsy Axillary reverse mapping (ARM) procedure Removal of tail of Spence during total mastectomy The lymph of the upper limb, most of the breast, and the skin of the trunk above the umbilicus (that is, above Sappey's line ) drains ultimately into the axillary nodes, making a knowledge of the anatomy of the axillary region essential for general and oncological…

Supraclavicular and infraclavicular regions

Core Procedures Excision of a lump from the neck Exploration of the supraclavicular brachial plexus Excision of the first rib Exploration of the infraclavicular brachial plexus Anaesthetic nerve blocks Surgical surface anatomy The margins of the posterior triangle, the superior border of the clavicle, the lateral border of sternocleidomastoid and the anterior border of trapezius are all palpable. The upper trunk of the brachial plexus can…

Overview of the upper limb

The upper limb functions as a series of articulated segments, which act in a coordinated manner to allow the hand to manipulate and sense its surrounding environment. The degree of coordination of these movements is such that the hand can be positioned with remarkable precision. The freedom of movement allowed by the highly mobile thoracoscapular and glenohumeral joints means that, when combined with the actions of…

Anatomy of lumbar puncture and epidural analgesia

Core Procedures Epidural injections: commonplace in obstetrical anaesthesia, as well as in the treatment of radiculitis throughout the spine Epidural catheterization: permits continuous administration of an anaesthetic agent Lumbar puncture: single injection of local anaesthetic into the subarachnoid space via lumbar puncture offers excellent surgical anaesthesia for abdominal, pelvic and lower-extremity procedures The epidural space is the potential space that lies outside the dura and is…

Lumbar spine, sacrum and coccyx

Core Procedures Posterior Approach Microdiscectomy Foraminotomy Laminectomy Posterolateral fusion (PLF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) Vertebroplasty, kyphoplasty Lumbar osteotomies Lateral Approach Lateral lumbar interbody fusion (LLIF) Oblique lumbar interbody fusion (OLIF) Anterior Approach Anterior lumbar interbody fusion (ALIF) Lumbar disc arthroplasty Clinical anatomy Lumbar spine The lumbar spine usually consists of five vertebrae, although anatomical variations with either four or six…

Thoracic spine

Core Procedures Direct posterior exposure Costotransversectomy Transpedicular approach to the thoracic disc space Anterior open transthoracic exposure Endoscopic approach to the thoracic spine Lateral extracavitary approach Trans-sternal approach to the cervicothoracic junction Surgical surface anatomy There are limited reliable surface anatomy cues about the thoracic spine. This contributes to the increased risk of performing wrong-level surgery. The spinous process of the first thoracic vertebra can be…

Cervical spine

Core Procedures Anterior and posterior approaches to the occipitocervical region Anterior and posterior approaches to the subaxial cervical spine Main indications for cervical spine surgery include excision of herniated discs with either a subsequent fusion or disc replacement, excision of tumours, reduction and stabilization of fractures or dislocations, and laminectomy to decompress the spinal cord, which may be combined with instrumented fusion or laminoplasty. Understanding the…

Intervertebral joints, foramina and ligaments

Core Procedures Anterior and posterior cervical foraminotomy Lumbar microdiscectomy Lumbar laminotomy and foraminotomy Endoscopic foraminotomy and discectomy Transforaminal lumbar interbody fusion (TLIF) A number of surgical procedures are performed in and around the foramina of the spine, commonly in the cervical or lumbar spine and occasionally in the thoracic spine. They generally consist of decompressive procedures such as a foraminotomy. Different approaches to accomplish a foraminotomy…

Overview of the back and spine

The patterned anatomy of the spine is not without its drawbacks. While the study of any individual level can enlighten the surgeon about several adjacent, or even all, levels, a blind reliance on repetition and consistency can be disorienting, leading to wrong-level surgery, patient injury or even death. It is essential for surgical exposure of the spine to be done in a responsible manner. Beyond the…