Procedure

Antero-lateral thoracotomy

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

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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 antero-lateral thoracotomy. Although these incisions are seldom used, it should be part of the surgeon's ‘general culture’. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature are developed.

Key Words: Antero-lateral thoracotomy • Lateral thoracotomy

	Introduction

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Indication
Some colleagues prefer this type of incision for less invasive procedures such as open lung biopsy or biopsy of mediastinal tumor. It has also been recommended for Ivor-Lewis-type resection of esophageal carcinoma, in order to avoid loss of time due to the repositioning of the patient after the intra abdominal step of the operation. We are not convinced that the exposure of the posterior mediastinum is adequate.

It may be an option for a critically ill patient with extremely alterated pulmonary or cardiac function, who would not tolerate lateral decubitus and single lung ventilation.

Though feasibility of pneumonectomy and sleeve tracheal pneumonectomy have been reported, we consider that the lateral approach offers the optimal exposure and comfort to the surgeon [1].

Anterior thoracotomy has been a classic approach for mitral commissurotomy. In contemporary cardiac surgery, the supine position is adequate for video-assisted harvest of the mammary artery and coronary revascularization [2].

Position
The patient is placed in a supine position and the operative side is elevated 20 to 45° from the table by sliding a padded sand bag below the buttocks and back. The ipsilateral arm is placed either back onto the table, or on an elevated armrest, at the surgeon's preference. A strip is passed across the patient's hips to the edges of the operating table to secure the position. Rotation of the operating table can improve exposure.

	Technique

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The skin incision follows the submammary fold and extends from the sternum anteriorly to the midaxillary line. The aim is to get access to the fourth or fifth intercostal space. The skin incision is carried down through the subcutaneous tissue and superficial fascia to the pectoralis major muscle. Posteriorly to the anterior axillary line, the digitations of the serratus anterior muscle are exposed. The superficial pectoral fascia and the pectoralis major muscle are divided with electrocautery over the selected interspace. At the lateral end of the wound, the pectoralis minor muscle is sectioned and a portion of the serratus anterior muscle is divided between two digitations. The intercostal space is opened as usual and the chest cavity is entered; special care is given if adhesions are expected. In case of major resections, exposure may be facilitated by dividing one or two cartilages parasternally, improving the surgical view. In this event, the internal thoracic pedicle must be ligated and divided to avoid tearing during retraction. In women, it may be necessary to reflect the lower portion of the breast upwards if the thoracotomy is carried through the 4th interspace.

	Pitfalls

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Special attention is given to the internal thoracic pedicle. When opening the intercostal space, the muscle should be divided first in the middle portion of the incision. The mammary artery may then be located by palpation of its pulsations. If not, the intercostal muscle which is close to the sternum (1–2 cm lateral) should be divided very gently to avoid direct injury of the vessel. If energic retraction is anticipated, it should be ligated to avoid tearing or postoperative bleeding.

Further exposure can be gained with this incision in several ways. Disarticulation of the chondrosternal joint at the anterior margin of the incision allows for wider retraction and is used currently by some authors [3,4]. In exceptional situations, the incision may be extended across the midline, with horizontal transection of the sternum.

On either side, exposure of the hilum can be improved by elevating the lung with packing: two or three large moisted gauze pads are inserted into the posterior mediastinum. Care is taken on the right side to avoid atrial compression. However, on the left side, the heart will impede access to the lower lobe and to the posterior mediastinum.

	Discussion

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The anterior thoracotomy has the distinct advantage of allowing the patient the best physiologic position, with a resulting improvement in cardiopulmonary function, but offers a very limited exposure. If a major resection is required, one or two costal cartilages may be divided parasternally to facilitate exposure of the surgical field.

This incision is actually less used because of improvement of sensitivity and specificity of percutaneous techniques, the option of median sternotomy, the development of mediastinal staging procedures such as mediastinoscopy and the rapid development of VATS for lung biopsies. Although it offers a poor access to the hilum, the approach has been largely promoted by Nomori who tried to demonstrate its interests over other thoracotomies, especially standard posterolateral thoracotomy. This incision, compared with the standard posterolateral thoracotomy, seems to lessen diminished impairment of postoperative pulmonary function and reduced chronic postoperative pain [5]. In a complementary study, Nomori [6] observes significant differences over the standard posterolateral thoracotomy with less blood loss during surgery, a reduced postoperative drainage volume with shorter chest tube drainage, reduced pain from day 1 and 6 months after surgery and diminished impairment of vital capacity (VC) for 1 week to 6 months after surgery. To optimize the exposure of this underestimated incision, Nomori [7] describes an original alternative: the anterior limited thoracotomy light-assisted. To illuminate the posterior and apex portions of the thoracic cavity, a flexible fiber light is simultaneously inserted in the eighth intercostal space at the posterior axillary line via a thoracoport. This incision is used to insert a chest tube.

	Conclusion

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

	References

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1. Muscolino G, Valente M, Ravasi G. Anterior thoracotomy for right pneumonectomy and carinal reconstruction in lung cancer. Eur J Cardiothorac Surg 1992;6:11–14.[Abstract]
2. Semrad M, Bodlak P, Stritesky M, Vondracek V, Urban T, Vyhnalova P, Holm F, Vanek I. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the Symmetry Aortic Connector System. J Thorac Cardiovasc Surg 2003;125:129–134.[Abstract/Free Full Text]
3. Noirclerc M, Dor V, Chauvin G, Kreitman P, Masselot R, Balenbois D, Hoyer J, Broussard M. Extensive lateral thoracotomy without muscle section. Ann Chir Thorac Cardiovasc 1973;12:181–184.[Medline]
4. Hatz RA, Kaps MF, Meimarakis G, Loehe F, Muller C, Furst H. Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg 2000;70:253–257.[Abstract/Free Full Text]
5. Nomori H, Horio H, Fuyuno G, Kobayashi R. Non-serratus-sparing antero-axillary thoracotomy with disconnection of anterior rib cartilage. Improvement in postoperative pulmonary function and pain in comparison to posterolateral thoracotomy. Chest 1997;111:572–576.[Abstract/Free Full Text]
6. Nomori H, Horio H, Fuyuno G, Kobayashi R, Morinaga S, Suemasu K. Lung adenocarcinomas diagnosed by open lung or thoracoscopic vs bronchoscopic biopsy. Chest 1998;114:40–44.[Abstract/Free Full Text]
7. Nomori H, Horio H, Suemasu K. Anterior limited thoracotomy with intrathoracic illumination for lung cancer: its advantages over anteroaxillary and posterolateral thoracotomy. Chest 1999;115:874–880.[Abstract/Free Full Text]