Procedure

Elective anterior and posterior thoracotomies

Hôpitaux 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

	Summary

Top Summary Introduction Technique Pitfalls Discussion Anterior thoracotomy Conclusion References

 
Surgical techniques, indications and pitfalls of the elective posterior thoracotomy are described. Discussion and an overview of the literature are developed.

Key Words: Anterior thoracotomy • Posterior thoracotomy

	Introduction

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Posterior thoracotomy remains a lateral variant in as far as it leads to an intercostal incision. However, the designation originates from the positioning, and the posterior location of the skin incision.

Indication
While seldom used in contemporary surgery, this incision provides a direct access to the tracheobronchial tree and the main stem bronchi. The posterior approach in the prone position has been formerly designed to operate on patients with copious secretions originating from suppurative processes such as bronchiectasis or lung abscess. Dumbbell tumors have been the indication of choice for a long time. The approach of Paulson is completely satisfactory in dealing with posteriorly located tumors of the superior sulcus, although it is not fully adequate in the presence of invasion of anteriorly located structures such as subclavian vessels. This indication has been substituted with development of anterior approaches, and more specifically cervicosternothoracotomy or hemiclamshell incisions [1].

This incision can be useful in cardiac surgery and especially in a prepubescent population. It gained popularity in cardiac surgery for off-pump revascularization and atrial septal defect surgery [2,3].

It may be used for scoliosis surgery, anterior spinal surgery (spinal traumas and deformations) [4].

Position
The patient is placed in a prone position. A slight ventral rotation provides access to the posterior chest wall, the posterior mediastinum and the spine [4].

The homolateral shoulder is held vertically downwards to increase the distance between spine and the lower border of the scapula.

	Technique

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A long parascapular skin incision is performed above the level of the spine of the scapula and carried two finger breaths beyond the tip of the scapula and ending in the anterior axillary line.

This sloping transverse line is made to approximately 5 to 10 cm. A flap of skin and subcutaneous tissue is raised over the muscular fascia. The first muscular level is composed of the inferior part of the trapezius muscle and the posterior part of the latissimus dorsi: both of them are transected.

After dividing the trapezius and latissimus dorsi muscles, the posterior border of the serratus muscle and the rhomboideus major muscle are exposed. The serratus muscular attachments to the upper ribs, and the rhomboideus major muscle are divided, thus the scapula and the shoulder are retracted, exposing the apex of the chest cage. The intercostal space depends on the type of surgery, whether it includes or not resection of ribs. Usually, the chest is opened in the fourth or fifth intercostal space. A rib spreader is then placed between the undersurface of the scapula and the chosen rib. Closure is made as usual. No synthetic material is necessary following upper rib resection, as the scapula furnishes the posterior support. If more than five ribs are removed, a synthetic patch (MMCTSLink 101) will be used to avoid the scapula sliding inside the rib cage [5,6].

	Pitfalls

Top Summary Introduction Technique Pitfalls Discussion Anterior thoracotomy Conclusion References

 
An anecdotic case report relates postoperative wound disruption; this should not be considered as a real and classic pitfall following this incision [7].

	Discussion

Top Summary Introduction Technique Pitfalls Discussion Anterior thoracotomy Conclusion References

 
Posterior thoracotomy has been developed during the era of the surgery of tuberculosis and bronchiectases. Initially described by Overholt and Langert, the use of this incision is now exceptional [8,9,10].

The best contemporary indication may be Dumbbell tumors, which require a simultaneous neurosurgical approach [8].

This approach offers a very limited access to the vascular structures of the hilum. Therefore, its applications should be very limited, even if considering segmentectomies and lesser pulmonary resections, and should be undertaken only by those familiar with the special positioning required (Photo 1).

View larger version (74K): [in this window] [in a new window]   Photo 1 Posterior thoracotomy: Post operative aspect. Although the wound is cheloid, it is a good functional result: the patient can move his arm and his shoulder without any pain or any discomfort. An excellent integrity of the relief of muscles is visible.

	Anterior thoracotomy

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	Conclusion

Top Summary Introduction Technique Pitfalls Discussion Anterior thoracotomy Conclusion References

 
"To be well exposed, it's the half of the success of a surgical procedure"

	References

Top Summary Introduction Technique Pitfalls Discussion Anterior thoracotomy Conclusion References

 

1. Shaw RR. New approaches to treatment of bronchogenic carcinoma. Med Bull (Ann Arbor) 1961;27:231–238.
2. D'Ancona G, Karamanoukian H, Lajos T, Ricci M, Bergsland J, Salerno T. Posterior thoracotomy for reoperative coronary artery bypass grafting without cardiopulmonary bypass: peri-operative results. Heart Surg Forum 2000;3:18–22; discussion 22–23.[Medline]
3. Shivaprakasha K, Murthy KS, Coelho R, Agarwal R, Rao SG, Planche C, Cherian KM. Role of limited posterior thoracotomy for open-heart surgery in the current era. Ann Thorac Surg 1999;68:2310–2313.[Abstract/Free Full Text]
4. McCormick PC. Surgical management of dumbbell and paraspinal tumors of the thoracic and lumbar spine. Neurosurgery 1996;38:67–74; discussion 74–75.[CrossRef][Medline]
5. Paulson DL. Carcinoma in the superior pulmonary sulcus. Ann Thorac Surg 1979;28:3–4.[Medline]
6. Paulson DL. Carcinomas in the superior pulmonary sulcus. J Thorac Cardiovasc Surg 1975;70:1095–1104.[Abstract]
7. Lazio BE, Staab M, Stambough JL, Hurst JM. Latissimus dorsi rupture: an unusual complication of anterior spine surgery. J Spinal Disord 1993;6:83–86.[Medline]
8. Shadmehr MB, Gaissert HA, Wain JC, Moncure AC, Grillo HC, Borges LF, Mathisen DJ. The surgical approach to ‘dumbbell tumors’ of the mediastinum. Ann Thorac Surg 2003;76:1650–1654.[Abstract/Free Full Text]
9. Overholt RH, Wilson NJ. Benefits of surgery in pulmonary tuberculosis. Pa Med J 1951;54:324–329.[CrossRef][Medline]
10. Overholt RH. The recognition and management of bronchiectasis. Nebr State Med J 1951;36:315–322.[CrossRef][Medline]
11. Dürrleman N, Massard G. Sternotomy. Multimedia Man Cardiothorac Surg doi:10.1510/mmcts.2006.001875.[Abstract/Free Full Text]
12. Dürrleman N, Massard G. Clamshell and hemiclamshell incisions. Multimedia Man Cardiothorac Surg doi:10.1510/mmcts.2006.001867.[Abstract/Free Full Text]