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MMCTS
(August 10, 2006). doi:10.1510/mmcts.2006.001834 Copyright © 2006 European Association for Cardio-thoracic Surgery
Procedure Axillary thoracotomyHôpitaux 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
Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. Axillary thoracotomy has increased the interest in muscle-sparing approaches. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature are developed.
Key Words: Axillary thoracotomy • Muscle-sparing technique
Indication Initially developed for operations on the upper thoracic sympathectomy, it was modified secondarily for first rib resection to allow the approach of the thoracic outlet syndromes. This method is used by a majority of thoracic surgeons for all pulmonary resections. Its major indication is now for pneumothorax surgery, allowing easily apical resection and pleurectomy with excellent long-term results. This incision has been advocated and used in chest wall, pulmonary (lobectomy, pneumonectomy, wedge resections), esophageal (transthoracic hiatal hernia repair) and cardiovascular operations (patent ductus arteriosus) [1,2,3,4].
Position
The skin incision may vary in accordance to the surgeon's preference and the goal of operation. Although vertical skin incisions along the anterior border of the latissimus dorsi have been described, most surgeons would use a horizontal incision [5]. Landmarks of skin incision are delimited by a posterior axillary line (corresponding to the anterior portion of latissimus dorsi) and an anterior axillary line (posterior border of the pectoralis major muscle). The length of the incision depends on the procedure and the selected intercostal space: for instance, a 4-cm incision at the axillary hair-line is optimal for treatment of spontaneous pneumothorax or performance of lung biopsy through the second intercostal space. Most procedures, however, will require an approach through the 4th or 5th intercostal space; the incision will basically follow the 5th or 6th rib and can be extended anteriorly into the submammary fold (Video 1). Upper lobe lesions are approached through the fourth interspace; middle and lower lesions through the fifth interspace. Mediastinal lymph node dissection is easier through the 4th intercostal space. The incision is carried down through the subcutaneous fat and superficial fascia to the body of the serratus anterior muscle (Video 2). Skin flaps are then developed to expose the accessible part of the latissimus. The latissimus is then reflected backwards to expose the serratus anterior muscle (Videos 3 and 4). The pectoralis major muscle is exposed anteriorly. Subsequently, the serratus is separated in the avascular space between two digitations (discision). More anteriorly, its insertions are dissected off the rib marking the inferior border of the selected intercostal space (Video 5).
The intercostal muscles are deinserted in a classic way, near their inferior attachment to the rib, and the pleural space is entered (Videos 6, 7 and 8). A small retractor is used to spread the ribs and incision of the intercostal space is completed posteriorly, while perithoracic muscles are reflected with a Deaver retractor – MMCTSLink 103. A second spreader is often placed at right angles to the first to retract the skin anteriorly and the latissimus dorsi posteriorly.
Some surgeons use only one rib spreader. In all cases, exposure must allow for a hand to pass into the thorax. The spreaders are always opened progressively (Videos 9 and 10). After having accomplished thoracotomy closure by pericostal sutures, the serratus anterior muscle is closed with a running absorbable suture as is the subcutaneous fascial layer. Skin closure technique is at the surgeon's discretion.
As for all decubitus positioning, a protective hydrogel must be applied on every area of potential compression (legs, knees, heel, ...) (see Photos 3 and 4 in Posterolateral thoracotomy – doi:10.1510/mmcts.2005.001453 – Ref [6]).
Care should be taken to secure the arm in a manner that allows some motion of the scapula and shoulder to facilitate operative exposure, chest closure and avoid the possibility of brachial injury during retraction. Surgeons must be warned that the position of the arm may be extremely disturbing especially in lower lung procedure. This is the reason why we prefer the ‘Weissmuller's touch’ (see procedure on Modified lateral thoracotomy – doi:10.1510/mmcts.2006.001842 – Ref. [7]). The antecubital fossa over the armrest must be padded because of the risk of postoperative cubital paresia (Photo 2).
The best method is to put the arm in a strait hold with an elastic strip and to avoid putting it in a tension axis (Photo 3). The surgeon should not divide the serratus too far posteriorly because of the risk of injuring the long thoracic nerve and, theoretically, the subsequent wing scapulas (Video 11).
To optimize the surgical exposure, the spreading of the intercostal space can be extended by disconnecting the anterior cartilage, thus eliminating the risk of rib fracture and ameliorating the postoperative pain. In the same manner, a second spreader placed at right angles to the intercostal retractor may retract the muscles to improve intrathoracic exposure. Closure of the axillary thoracotomy is accomplished with pericostal sutures. However, intercostal space widens anteriorly to the insertions of the serratus muscle and cannot be approximated in an airtight fashion. This pitfall is particularly dreadful in a cachectic patient, and in the case of pneumonectomy because of the risk of parietal complications (post pneumonectomy "seroma" and wound disruption). We recommend, therefore, to insert the anterior sutures into the intercostal muscle above, and in a pericostal fashion below. When repairing the serratus, the most anterior stitches should include the pectoralis.
We particularly recommend reading of the following literature: Mitchell's (1990), Ponn's (1992), Siegel's (1982), and more particularly Noirclerc's (1973) articles [8,9,10,11]. These authors do not recommend axillary thoracotomy as first choice for bulky tumors, repeat thoracotomies, sleeve resections and radical pneumonectomies. Advantages are to be simple and rapid with minimal muscular transections and reduced postoperative discomfort and pain. In fact, the only muscle transected is the intercostal space. It is important to note that this incision is credited with limited access and hence is designed for experienced surgeons. Because of the limited exposure, it is not recommended for occasional thoracic surgeon or a predicted difficult surgery. To optimize the surgical exposure, vertical incision has been advocated by Ginsberg and Baeza [2,4]: an incision beginning at the level of the third rib in midaxillary line and extending in a caudal direction to approximatively the eighth or ninth rib. This thoracic incision has been proposed in paediatric surgery to avoid complications due to standard posterolateral thoracotomy in both neonates and children: winged scapula, scoliosis.... It has been successfully used in this population to treat pulmonary and mediastinal lesions, and both begnin and malignant diseases (oesophageal atresia, tracheoesopageal fistula, patent ductus arteriosus, congenital cystic adenomatoid malformation, neuroblastoma and lobectomies) [12,13]. A still ongoing debate concerns optimal approach for pleurodesis in patients with spontaneous pneumothorax. Axillary thoracotomy has been the first "victim"of VATS, quickly and erroneously considered the gold standard technique to treat pneumothorax [14]. Regarding pneumothorax, the rating of VATS and axillary thoracotomy has not been firmly established. Freixinet [15] recently reported a series comparing axillary thoracotomy to VATS without obviating any significant difference in immediate outcome. But in terms of long-term results on recurrence, thoracotomy has been considered superior to VATS [14,16]. Recent reports seem to confirm what Murray already wrote in 1993 [17]: "the axillary incision is the operation of choice when spontaneous pneumothorax requires surgery with excellent results for the patients, hastening the hospital discharge, offering a limited pain, preventing short time recurrence and cosmetically acceptable".
"To be well exposed, it's the half of the success of a surgical procedure".
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Summary
Introduction
