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MMCTS
(August 10, 2006). doi:10.1510/mmcts.2005.001420 Copyright © 2006 European Association for Cardio-thoracic Surgery
Procedure Thoracic incisions – general considerationsHôpitaux Universitaires de Strasbourg, Département de Chirurgie Thoracique, Hôpital Civil, 1 Place de l'Hôpital, 67000 Strasbourg, France * Corresponding author: * Tel.: +33-38-811 6202; fax: +33-38-811 6077. E-mail: gilbert.massard{at}chru-strasbourg.fr
Peri-operative management of thoracotomies is detailed. Discussions and an overview of the literature are developed.
Key Words: Analgesia • Chest tubes • Muscle-sparing procedure
Thoracic incisions are simple but strategic procedures initiating every intrathoracic surgery. The success of the intrathoracic operation is often underlined by an optimal exposure of the operating field comprising a series of simple, well-choreographed surgical steps. A special caution is required regarding preoperative management. Before any thoracic incision, the surgeon should check the patient's skin and cutaneous preparation a few hours before the surgical procedure. The lay-out of the operating room is primordial to optimize efficiency and to decrease the risk of contamination of the surgical field. These critical steps of preparation and draping are frequently delegated to junior staff. However, the thoracic surgeon should keep in mind that each detail is important, as a breach in the sterile procedure and an approximative thoracic incision may sentence the patient to heavy and sometimes fatal complications. Every thoracotomy requires prophylactic antibiotics, managed with adequate timing (within the hour preceding the skin incision [1,2]) by the anesthesiologist staff. Antibiotic prophylaxis has been found to produce a five-fold reduction in wound infection rate in several randomized controlled trials [3]. The incision should be planned carefully to allow easy access to the operative site: the best approach is the one which is a compromise between the least aggressive and the safest exposure. Only current approaches are reviewed here. Rare incisions are just cited for memory. The subperiosteal resection of the rib should be the best way to get a tighter closure of the thoracic wall. It is as the resection of a posterior portion of the rib (or total excision), at the surgeon's experience and preference. It is mandatory to control any rib fracture to prevent bleeding and postoperative overriding.
Generally two tubes are used if a significant resection has been performed as the surgeon can expect both air and fluid accumulation. In a selected patient such as a local excision of a lung lesion, when no air leak exists, a single tube may suffice. The size of the chest tube to be used depends on the preference of the operating surgeon, the size of the intercostal space, and the nature of the surgical procedure. Classically, the posterior tube designed to drain fluids is about 32F; the anterior, expected to drain air leaks, is 28F. The authors' preference is 24F (MMCTSLink 98), which decreases postoperative pain and hence facilitates adequate physiotherapy. Chest tubes are inserted through separate stab wounds, which we advise to locate anteriorly to the vertical line crossing the anterior end of the iliac crest. Tubes are secured with a skin stitch; a second untied stitch is inserted to close the stab wound at the removal of the tubes. The tubes are connected to a ‘y’ tube connector which is fixed to an appropriate chest drainage system. The authors' criteria to remove chest tubes are: (1) fluid drainage less than 200 ml/24 h and (2) stop of air leak >24 h. Ideally, chest tubes could be removed 48 h after an uneventful lobectomy.
We used to close intercostal spaces with 6 to 8 sutures. Posterior and lateral aspects of the ribs are closed with a pericostal figure of eight sutures; anterior to the insertions of the serratus, the intercostal space widens and requires suture of the intercostal space above to the rib below to ascertain airtightness. The anterior serratus muscle and superficial fascia are closed by a running absorbable suture (MMCTSLink 99). Most of the time, because we promote the muscle-sparing concept, we place two Redon drains (MMCTSLink 100) in the subcutaneous plan, to avoid the development of postoperative seroma. They will be removed as soon as the drainage volume is less than 20 ml per 24 h.
In our team, the preferred type of analgesia is epidural analgesia. The catheter is placed before induction and kept for 4 to 6 days. It is connected to a device delivering a continuous perfusion, but managing a partial ‘patient controlled analgesia’ through patient-triggered injections. Other analgesics (NSAI, paracetamol) may simultaneously be administered per os or intravenously. In case epidural is not feasible, we use alternatively patient controlled analgesia with intravenous morphine. Although early postoperative chest pain is caused by direct nerve injury by the rib retractor [4], it has been reported that the most common cause of chronic pain is presumed to be secondary to post-traumatic intercostal neuroma formation [5].
Because thoracotomies are proved to injure the respiratory muscles of the chest wall and to reduce total chest compliance [6,7,8], less invasive techniques have been designed. Increased interest in alternative approaches has risen because of the considerable morbidity associated with the standard posterolateral thoracotomy. The transection of large muscle groups has proved to contribute significantly to postoperative pulmonary insufficiency, early and chronic chest pain and upper musculoskeletal dysfunction [9,10]. Further, such incisions damage large muscles and hence prohibit their further use as muscle flaps for potential intrathoracic transfer. Initially described by Bethencourt in 1988 [11], muscle-sparing incisions have gained considerable recent attention. The trend is actually to use shorter posterolateral incision and to spare the division of the major muscles of the chest wall as much as is compatible with appropriate surgical exposure. Several reports have documented the feasibility of employing muscle-sparing incisions for a wide variety of thoracic operations, ranging from lung biopsies to pneumonectomy [12,13]. Most of the time muscle-sparing thoracotomy offers adequate exposure for standard lymph node dissection, decortication and some cases involving combined pulmonary and chest wall or diaphragmatic resections. Actually, benefits of muscle-sparing incisions are well documented: this population of patients showed a significantly better late preservation of forced vital capacity and flow during the midportion of the forced vital capacity [14], a decreased postoperative pain [15,16,17], a better postoperative strength of the shoulder at one week [15,18,19,20] without additional morbidity except a potential higher incidence (up to 23%) of seroma owing to subcutaneous preparation of skin flaps [21]. A compressive dressing with elastic strips around the chest wall can lower the incidence of seroma. In an animal model study, talc seems to be efficient to avoid postoperative seromas [21]. Muscle-sparing incisions seem to be more difficult to perform in heavily muscled individuals [5,11]. Muscle-sparing incision can actually be advocated as a means of reducing postoperative pain, preserving pulmonary function and mobility of the shoulder girdle, and lessening postoperative complications. The surgical exposure is adequate for most pulmonary resections, the access to the mediastinum is complete and allows for complete lymphadenectomy [16]. Preserving the latissimus dorsi muscle seems to be one of the most important factors in maintaining an adequate pulmonary function after surgery [22]. More important, it also preserves extrathoracic musculature such as latissimus dorsi and anterior serratus for the preparation of pedicled muscle flaps, should post resectional space problems or bronchopleural fistula occur [21]. Muscle-sparing incisions have been a revolution in the approach of thoracotomy allowing to demonstrate that this technique had the same results in terms of duration chest tube drainage, length of hospital stay, post thoracotomy pain than a videoassisted procedure without its disadvantages.
Although some enthusiastic pioneers have tried to popularize videoassisted thoracoscopic surgery for performing lobectomy in lung cancer, the real interest of this procedure over muscle-sparing thoracotomies is still a matter of debate [23,24]. The technical feasibility of a VATS lobectomy has been confirmed for lung cancer surgery and its subjective advantages, decreased postoperative pain, shortened chest drainage time, shortened hospital stay and faster return to activity, have been reported in several studies [24]. In a randomized trial comparing VATS and muscle-sparing thoracotomies for lobectomies in 55 lung cancer patients, no significant difference was seen in terms of operation time, intraoperative blood loss, chest tube drainage duration, postoperative pain or length of hospital stay. In contrast, disadvantages found in VATS procedure were accidental intrasurgical bleeding, insufficient mediastinal node dissection, and prolonged postoperative air leakage [25,26]. These results are confirmed by Nomori [27] who concluded that the only advantage of VATS compared to anterior limited thoracotomy was a decrease in chest pain during the first week after surgery. No significant difference was found in terms of operating time, intraoperative blood loss, postoperative chest tube drainage or in impairment of postoperative pulmonary function, respiratory muscle strength. Although VATS may decrease postoperative pain, the most important feature of cancer surgery is its ability to ascertain complete tumor clearance and to cure the disease. We do not doubt that such is feasible in expert hands, but question the reproducibility of VATS techniques. Our recommendation, therefore, is to stay with limited and/or muscle-sparing thoracotomies which provide all warranties and which can easily be taught to our trainees.
"To be well exposed, it's the half of the success of a surgical procedure"
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Summary
Introduction