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Thoracotomy is the surgical procedure with an incision made to access the pleural space and the contents of the thoracic cavity. Given the structures to be accessed with in the cavity, different incisions have been established to easy the procedure and these incisions qualify the types of thoracotomies to be studied hereunder. PRE OP OPTIMIZATION FOR SPECIFIC FACTORS The outcome of surgical procedures is not measured only by clinical end points but also shorter stays and lower costs. Patients’ discharge is delayed commonly due to inadequate pain relief, infection, arrhythmias, prolonged air leak and debility. Many complications that occur from thoracic operations can be anticipated. An aggressive preoperative work up mitigates morbidity and shortens convalescence. APPROACH CONSIDERATIONS There are about three principles that can guides the choice of the thoracotomy incision to be used I. Adequate exposure must be achieved. The choice of incision is aided by a thorough understanding of the surface anatomy and a comprehensive review of the radiographic images that are obtained preoperatively. II. Chest-wall function and appearance should be preserved to the extent possible. This principle include non-spreading video-assisted thoracoscopic surgery (VATS) procedures, muscle-sparing techniques, avoidance of excessive rib retraction, and rib preservation when possible. III. The third principle is that closure must be meticulous and appropriate. Strict layered closure is the rule for thoracic surgical incisions. Every effort should be made to approximate the individual divided chest-wall muscles in appropriate layers; otherwise, a significant delay in the recovery of range of motion (ROM) may result. Care must be taken to avoid over approximating the ribs and to prevent an override; this will help minimize postoperative pain. POST-OPERATIVE CARE AND MONITORING

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Learning Objectives: Contrast the neural and local control of circulations through special regions. Compare the physiological significance of variation in circulations through special regions. Content Overview: This lecture provides a comprehensive exploration of circulation in specialized regions of the body, including coronary, cerebral, splanchnic, cutaneous, fetal, skeletal muscle, and pulmonary circulations. The physiological and anatomical considerations, regulation mechanisms, and unique features of each type of circulation are discussed. Key concepts such as autoregulation, local metabolic factors, and neural influences are covered in detail. Key Topics: Coronary Circulation: Anatomy and physiology of coronary blood supply. Phasic changes in blood flow during systole and diastole. Regulation by autonomic nervous system and local metabolic factors (hypoxia, adenosine). Cerebral Circulation: Control by local metabolic factors (CO2, H+). Autoregulation and hyperemia. Anatomy of cerebral blood supply and special features of cerebral blood vessels. Splanchnic Circulation: Anatomy and regulation of blood flow to the gastrointestinal organs. Role of sympathetic and parasympathetic nervous systems. Chemical factors and the concept of autoregulatory escape. Cutaneous Circulation: Thermoregulatory function and dense nervous innervation. Mechanisms of vasodilation and vasoconstriction. Blood reservoir function and responses to mechanical stimuli. Fetal Circulation: Unique aspects of fetal blood flow including umbilical vessels, ductus venosus, foramen ovale, and ductus arteriosus. Changes in circulation at birth and the stimuli for these changes. Skeletal Muscle Circulation: Regulation during rest and exercise. Role of nervous and local metabolic control. Circulatory adjustments during physical activity. Pulmonary Circulation: Characteristics and regulation of pulmonary blood flow. Zones of blood flow in the lungs and the effect of gravity. Response to hypoxia and other factors influencing pulmonary vascular resistance

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