**3. Operative factors**

#### **3.1. VATS vs. OPEN**

preoperative pulmonary rehabilitation may improve preoperative exercise capacity and so operability. [7], [8] The future development and adoption of innovative strategies is required to reduce the impact of post operative complications in an ageing co morbid population.

In this section will cover the routine care of a postoperative thoracic patient with specific

The outcome of surgical procedures is not measured only by clinical end points but also shorter stays and lower costs [9]. Patients' discharge is delayed commonly due to inadequate pain relief, infection, arrhythmias, prolonged air leak and debility [9]. Many complications that occur from thoracic operations can be anticipated. An aggressive preoperative work up

Preoperative cessation of smoking prevents postoperative complications to a large extent.

Support groups, counselling and nicotine replacement therapy should be used [10]. Histori‐ cally, 6 weeks of smoking cessation before surgery is recommended to avoid the copious bronchorrhea that accompanies regeneration of the cilia that clear mucus between 2 and 4 weeks after smoking cessation [11].there are few studies which challenge this challenge this notion of timing of smoking cessation. Even 3-5 days of stopping could improve clearance and decrease of secretions. Vaporciyan el al showed that patients who quit smoking 4 weeks or more before surgery had a lower incidence of pulmonary complications than patients who continued to smoke or quit fewer than 4 weeks before pneumonectomy [12]. However, Barrera and co-workers found no difference in the incidence of pulmonary complications between patients who were still smoking at the time of surgery and those who had quit fewer than 2 months before thoracotomy for lung resection [13]. In many centres including ours the recommendation is to stop smoking at any time and provide support services to help out with

Preoperative physiotherapy and education is done in many centres as part of work up for thoracotomy. Physiotherapists and thoracic ward medical and other staff perform a variety of care for patients undergoing surgery both pre and post operatively. All these are done to prevent postoperative complications like atelectasis, pneumonia, effusions and empyema. Various manoeuvres include education, deep breathing and coughing manoeuvres, chest physiotherapy and early mobilization education post sugery [14]. According to few studies this has led to an improvement in the prevention of atelectasis, collapse and consolidation. Many other interventions like incentive spirometry and respiratory muscle strengthening have

emphasis on prevention and management of common complications.

**2. Preoperative optimisation of specific risk factors**

mitigates morbidity and shortens convalescence.

58 Principles and Practice of Cardiothoracic Surgery

**2.2. Preoperative education and physiotherapy**

**2.1. Smoking**

the same.

Video assisted Thoracoscopic procedures are done with increasing frequency for many indications. The incidence of postoperative complications is 9% after VATS and they include haemorrhage, empyema, air leak, pneumonia and surgical emphysema [17] commonly but most of the complications which happen in thoracotomy could potentially happen with video assisted Thoracoscopic procedures.

Most importantly the incidence of postoperative pain is much less in VATS than open procedures and they have shorter hospital stay. The proponents of VATS have published many series about the feasibility, lesser complication rate, reduced pain, early mobility and discharge [18], [19]. There are groups who did not find any statistical benefit in performing VATS and have quoted a higher bleeding and intraoperative complication rate [20]. In our unit we perform VATS for all kinds of thoracic procedures if patients are suitable for it. VATS lobec‐ tomy is a safe procedure, which reduces peri operative pain and improves postoperative physical status. The results obtained with early stage lung cancer are excellent and may reflect inherent oncologic advantageous consequent upon reduced operative trauma. Detection of early stage lung cancer is potentially rewarding and will become a practical imperative if survival results are to be improved. Thus the scope for VATS resection may increase signifi‐ cantly. In our view VATS lobectomy is the procedure of choice for early stage lung cancer and multicentre prospective randomised trials comparing this therapy against conventional open resection are overdue.

#### **3.2. Use of staplers and glues to reduce and seal air leaks**

Various procedures like wedge resections, lobectomies, excision of bullae may cause pro‐ longed air leaks especially if patients have COAD. Traditionally diathermy dissection and ligation was used and later staplers were used for parenchymal resections. Although certain studies pointed towards improved results with regards to air leaks using staplers [21] and reported that surgical morbidity due to air leaks decreased with this technique other studies have not shown any particular reduction in duration of air leaks using staplers alone. [22]

minimize motor and sympathetic blockade maintain conscious level and cough reflex and reliably produce increased analgesia with movement and increased respiratory function after thoracotomy [29]. Generally the most popular regimens are fentanyl or diamorphine combined with levobupivacaine [29]. The regimens can be administered as an infusion, patient controlled

Postoperative Care and Complications After Thoracic Surgery

http://dx.doi.org/10.5772/55351

61

Potential issues include failure, technical difficulty and hypotension. It can also reduce the effectiveness of coughing, especially in patients who already have a low FEV1. It is not offered

Paravertebral block is an effective modality to provide pain relief. It can be done by the anaesthesiologist before the start of surgery or by the surgeon before closure. It offers several technical and clinical advantages and is indicated for anaesthesia and analgesia when the afferent pain input is predominantly unilateral from the chest and/or abdomen. We prefer placing the catheter under direct vision during thoracic surgery and give pain relief as a continuous infusion. The chest drain loss of local anaesthetic is four times lower than that of

Opioids remain the mainstay of postoperative analgesia and have demonstrated their efficacy in the management of severe pain. The side effects include nausea, vomiting, ileus, biliary spasms and respiratory depression, Opioids can be administered IM, subcutaneously, or IV.

A very efficient method of delivery of opioids is via PCA (Patient Controlled Analgesia) devices. Numerous studies have demonstrated the safety and opioid-sparing effect of PCA. After thoracic surgery PCA is often combined with other modalities to offer adequate pain

Intrapleural local anaesthetics produce a multi-level intercostal block. However, the analgesia is extremely dependent on patient position, infusion volume, and the type of surgery. With the drains insitu most of the anaesthetic is drained out and hence the efficacy of the procedure is less. In spite of occasional successes most clinicians have not found the reliability of

Cryoanalgesia is the application of a -600ºC probe to the exposed intercostal nerves intraoperatively produces an intercostal block that can persist for up to six months. This can be moderately efficient to decrease post-operative pain, but is associated with an incidence of chronic neuralgia that has lead many centres to abandon the technique [32]. Transcutaneous electrical nerve stimulation (TENS) may be useful in mild to moderate pain but is ineffective

intrapleural techniques adequate to justify their use on a routine basis. [31]

analgesia or both.

interapleural block [30].

*4.1.2 Systemic analgesics*

relief.

*4.1.3. Intrapleural*

*4.1.4. Other techniques*

when pain is severe. [33]

when there is local or systemic sepsis.

The air leaks caused by the holes of the suture needles are of the same magnitude as that caused by the surface tension between the parallel staple lines when the lung inflates. Nevertheless staplers are quicker to use and they have a big role in minimally invasive Thoracoscopic procedures

Polyglycolic acid fabric, polydioxan ribbon, bovine pericardial strips, bovine collagen, and recently, expanded polytetrafluoroethylene have been employed in an attempt to reinforce the staple lines, especially for resections performed in emphysematous lungs [23]- [27]. Other techniques like the electrothermal bipolar sealing have shown good results in lung parenchy‐ mal surgery.

Air leaks are common after pulmonary resections. They can be inspiratory, expiratory, continuous and forced expiratory. Most of the leaks are expiratory or forced expiratory. Inspiratory leaks happen on positive pressure ventilation. If there is no pleural space then they are managed by underwater seal. If there is a space negative suctions is applied to the underwater seal. If the leak persists beyond a particular time frame then TALC or reopening should be considered.
