Into the chest

Ask the room

You are doing this case. Where is the danger, and what is your first move if it happens?

Take answers before advancing. The point of the debrief is what they say now, not what the next slide says.

• In full expiration the diaphragm rises and the lung retracts upward, opening a safe corridor; a puncture taken in inspiration, or above the 11th rib, crosses the pleura.

supracostal access view (fluoroscopic, prone)

1. Cystoscopy, place a retrograde ureteric or balloon occlusion catheter, and opacify the collecting system.
2. Position prone with chest and pelvis supported; confirm the upper-pole target calyx on fluoroscopy.
3. Plan the supracostal tract onto a posterior calyx, ideally entering the skin lateral to the mid-scapular line at or below the 12th rib.
4. Ask the anaesthetist to hold ventilation in full expiration, then puncture the calyx with the needle passing just over the upper border of the rib to spare the subcostal neurovascular bundle.
5. Confirm intracalyceal position, pass the guidewire, and exchange for a stiff working wire down the ureter.
6. Dilate the tract over the wire and seat the Amplatz sheath under direct vision.
7. Nephroscopy, lithotripsy and stone clearance; check for residual fragments.
8. Place a nephrostomy or stent, take an end-of-case image, and inspect the tract.

• The posterior pleural sac dips below the 12th rib in the mid-scapular line.
• A high supracostal needle reaches the upper pole only by passing through it.
• This happens to the patient who needs an upper-pole or staghorn clearance, where the geometry pushes the puncture cephalad.
• The moment is needle entry, and the breath governs it.
• In full expiration the diaphragm rises and the lung retracts; in inspiration both descend across the tract.
• Above the 12th rib the margin is small, above the 11th rib it largely disappears.
• Once the pleura is open, the consequence depends on what crosses it.
• Air gives a pneumothorax.
• Irrigant tracking up the tract gives a hydrothorax, often the larger problem because it builds silently under positive-pressure flow.
• Diaphragm and lung may be injured together, producing a hydropneumothorax.

• Puncture above the 11th rib, where the margin is lost, more than above the 12th
• Puncture timed to inspiration rather than full expiration
• Upper-pole or staghorn stone forcing a cephalad tract
• High-volume or high-pressure irrigation tracking up the sheath
• Tall, thin habitus or deep inspiration lowering the pleural reflection

1. Stop irrigation and drop intrarenal pressure: lower the irrigant bag and decompress through the sheath.
2. Tell the anaesthetist at once. Ask for airway pressures, oxygen saturation and tidal volumes, and request a switch to manual ventilation if needed.
3. Read the signs together: rising airway pressures, falling saturations, reduced air entry at the base, and fluid or air tracking on screening images.
4. Image the chest. A formal end-expiratory CXR on table or in recovery sizes any pneumothorax or effusion; bedside ultrasound is a quick adjunct.
5. A large or symptomatic hydrothorax, a tension picture, or progressive desaturation is the trigger to place an intercostal chest drain and call the senior or thoracic team. A small asymptomatic collection can be observed with serial imaging. escalation trigger
6. Decide the tract: leave a nephrostomy to drain the kidney away from the chest, and consider abandoning further supracostal work this sitting.
7. Document the rib level, the breath phase at puncture, the signs, the imaging, the drain or observation decision, and the anaesthetic discussion in the op note.

Three questions

1. Why is a hydrothorax often more troublesome than a pneumothorax here?
2. How does timing the puncture to expiration reduce the risk?
3. When would you observe rather than drain?

Answers are on the card under the viva section. Hold them back until everyone has tried.

• Anyone can say chest drain.
• The strong answer ties the pleural reflection to the 11th versus 12th rib level, explains in mechanical terms why full-expiration puncture is protective, separates hydrothorax from pneumothorax in both cause and behaviour, and names early anaesthetic communication and a draining nephrostomy as part of the management.