MMCTS
(August 10, 2006). doi:10.1510/mmcts.2006.001842
Copyright © 2006 European Association for Cardio-thoracic Surgery
Procedure
Modified lateral thoracotomy
Nicolas Dürrleman and
Gilbert Massard*
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
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Summary
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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. We will describe the lateral muscle-sparing thoracotomy in the Weissmuller's position which is, according to us, the universal thoracotomy. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature for this incision are developed.
Key Words: Lateral thoracotomy • Muscle-sparing technique
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Introduction
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Indication
In our opinion, this approach is the universal thoracotomy, which provides an excellent exposure including extended procedures such as sleeve resections of the bonchi or intrapericardial pneumonectomy. It is an excellent thoracic incision for single lung transplantation [1]. Only extension to the upper ribs cannot be safely performed.
Position
The patient is placed in a lateral position, with a soft rotation of the coxa (15 to 20°) towards the surgeon (back of the patient). The homolateral arm is placed on a padded arm rest without any tension, with a softly flexed elbow (Photo 1).
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Photo 1 Details of the position of the patient. The most important points are the position of the upper arm and the soft rotation of the coxa towards the surgeon.
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Three stands are used to stabilize the patient's position. The first is placed posteriorly in the back, standing the vertebral column, the second on the buttock and the last one anteriorly, on the pelvis spinous (Photo 2).
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Photo 2 Stabilization of the patient using three stands. It is important to underline that the good axis of the position is given by a soft rotation of the coxa (15 to 20°) towards the surgeon, and the back of the patient.
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We use this so-called Weissmuller's position in memory of the famous swimming champion: in this position, the patient seems to crawl... (Photo 3).
Straps secure the position (Photo 4).
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Technique
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Though large, this incision is a muscle-sparing lateral thoracotomy.
The skin incision is made on a horizontal line passing below the tip of the scapula to the submammary fold (Video 1). The latter is a landmark for the cartilage of the 6th rib. In case of a standard lobectomy, the incision would be between 12 and 15 cm long, according to the patient's adiposity. In obese patients, the incision is extended anteriorly through the submammary fold. For bulky tumors or carinal approach, the incision is carried further to the back, behind the tip of the scapula.
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Video 1 The skin incision is made on a horizontal line passing below the tip of the scapula to the submammary fold.
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The subcutaneous tissue is divided until the fasciae are overlying the latissimus dorsi muscle and anterior serratus muscle (Video 2). A large and extensive plan of dissection is performed inferiorly and superiorly to these fasciae (Video 3).
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Video 2 The subcutaneous tissue is divided until the fasciae are overlying the latissimus dorsi muscle and anterior serratus muscle. It is useful to spread both edges with the fingers to be sure to be median. The use of electrocautery provides a bloodless exposure.
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Video 3 Extensive plan of dissection performed inferiorly and superiorly to fasciae overlying the latissimus dorsi muscle. This is the corner stone of this muscle-sparing incision. By freeing the latissimus dorsi muscle, you can respect its integrity and obtain the same exposure rather than with a non muscle-sparing incision. The use of electrocautery decreases significantly the risks of post operative hematoma and seroma.
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The entire anterior border of the latissimus dorsi is freed from its superior aspect in the axilla to the area below. After this the deep aspect of latissimus dorsi is freed from the serratus by a blunt finger dissection in the upper part of the field (facing the 3rd, 4th and 5th ribs); below, there are some fibrous adhesions which need to be divided with the cautery. The muscle is elevated and retracted posteriorly to expose the anterior serratus (Video 4). The serratus anterior muscle is freed anteriorly from the lower border of the pectoralis major muscle. The 6th and 5th costal cartilages are identified, and the serratus is subsequently split between its digitations (Video 5). At this low level, the pedicle may be severed if additional exposure is required. The ribcage is then exposed by inserting a deaver retractor – MMCTSLink 104 – below the serratus and scapula. An adequate intercostal space is opened anteriorly by separating the muscle sharply from the lower rib of the space (Video 6); a ribspreader is gently inserted and opened, which allows to separate the posterior aspect of the intercostal space from inside with a long-tip cautery. We prefer the 4th intercostal space for most procedures, as the exposure of the hilum is optimal. If dense adhesions are expected, the 5th intercostal space provides an improved access to the diaphragm and posterior pleural sinus. A first rib retractor is applied after placing protective towels on each edge. A second spreader placed at right angles to the intercostal retractor may retract the muscles to improve intrathoracic exposure (Video 7) [2]. Closure is performed as usual but two soft-closed suction drains must imperatively be placed in the subcutaneous space and be removed when drainage is less than 25 cc.
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Video 4 The entire anterior border of the latissimus dorsi is freed from its superior aspect in the axilla to the area below. After this the deep aspect of latissimus dorsi is freed from the serratus by a blunt finger dissection in the upper part of the field (facing the 3rd, 4th and 5th ribs); below, there are some fibrous adhesions which need to be divided with the cautery. The muscle is elevated and retracted posteriorly to expose the anterior serratus.
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Video 5 The serratus anterior muscle is freed anteriorly from the lower border of the pectoralis major muscle. The 6th and 5th costal cartilages are identified, and the serratus is subsequently split between its digitations.
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Video 6 The ribcage is then exposed by inserting a deaver retractor below the serratus and scapula. The adequate intercostal space is opened anteriorly by separating the muscle sharply from the lower rib of the space.
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Video 7 A first rib retractor is applied after placing protective towels on each edge. A second spreader placed at right angles to the intercostal retractor may retract the muscles to improve intrathoracic exposure.
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Pitfalls
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A special mention is made about freeing the latissimus dorsi muscle: the dissection should stay close to the fibers of the muscle, below the fascia, to avoid nasty oozing.
A too extensive and aggressive dissection does not promote a better mobilization of the muscle but can generate a postoperative seroma. We warn against excessive dissection towards the axilla (Photo 5).
The long thoracic nerve should ideally be respected.
The intercostal space should be opened anteriorly beyond the costo-chondral junction to the vicinity of internal thoracic artery, to guarantee optimal spreading. Posteriorly, the incision extends to the vicinity of the sympathetic chain.
To promote an optimal exposure, the rib spreader must be placed the more posteriorly as possible; first to retract the latissimus dorsi muscle, second to avoid chondral cartilage disconnection and internal thoracic artery disruption. As for all thoracotomies, the rib retractor is opened progressively, step by step. As for all lateral and anterior thoracotomies, the closure may be difficult in the anterior portion. The solution is to divide the major pectoralis and to pass in the last anterior pericostal suture, to promote a hermetic closure of this anterior diastasis. The most frequent complication involved in this incision is the postoperative seroma. It can be easily avoided by using systematically two soft-closed suction drainages and by performing a good hemostasis of the subcutaneous tissue.
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Discussion
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Described by Bethencourt and Holmes in 1988 [2], this muscle-sparing incision allows most of pulmonary resections with an omnipresent availability to convert in a standard procedure.
Lateral position permits the best access to the hilus of the lung. Structures of the hilus may be approached by either the anterior or the posterior way. It is a safe procedure allowing to preserve a potential flap which can be useful in cases of postoperative complications.
Its major disadvantage, found in the literature, is that the ventilation of the remnant lung is more difficult than in the posterior or supine position: in our experience, we did not observe this fact and did not find any real disadvantage in this approach in the limits of its indications (Photo 6).
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Photo 6 Post operative aspect of a Weissmuller's incision. Observe the excellent preservation of the relief and function of the latissimus dorsi muscle (female). The result is well illustrated in younger patients (male).
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Conclusion
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"To be well exposed, it's the half of the success of a surgical procedure"
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References
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- Pochettino A, Bavaria JE. Anterior axillary muscle-sparing thoracotomy for lung transplantation. Ann Thorac Surg 1997;64:1846–1848.[Abstract/Free Full Text]
- Bethencourt DM, Holmes EC. Muscle-sparing posterolateral thoracotomy. Ann Thorac Surg 1988;45:337–339.[Abstract]
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Summary
Introduction
