Discuss thoracic incisions(1) copy

THORACIC INCISIONS

1. THORACIC INCISIONS PRESENTER: DR DHANESH KUMAR

2. OUTLINE HISTORICAL PERSPECTIVE GENERAL WORKUP TYPES OF THORACIC INCISIONS CURRENT AND FUTURE TRENDS CONCLUSION

3. Historical perspective Development, evolution of thoracic incision is closely related to the development of thoracic surgery. First thoracotomy done by Howard Lilienthal in 1909. Used in ancient time for draining abscesses in the chest. Median sternotomy was described first of all by Milton ,1897 for management of mediastinal T.B.

4. General workup Patient evaluation & clinical assessment History, Examination, Lab & Radiological investigations- PFT, Spirometric measurement,SpO2, Chest- Xray Patient education/counseling/consent Start Chest physiotherapy Peri -op monitoring/medications

5. Analgesia Intra-op =I.V. pentazocine Epidural analgesia in perioperative period Post-operative - Opioid -:Ex. Pentazocine NSAIDs -: Ex.Diclofenac Acetaminophen;PCM

6. Prophylactic Antibiotics Intra-op =3 rd generation Cephalosporin e.g ceftriaxone + metronidazole , repeated after 8hrs Post-op =same extended X 3-7days

7. Surgical Goals To allow a successful surgical outcome Adequate exposure of area of interest Preserve chest-wall function & appearance Incision along Langers line or positioned to maximize cosmesis Closure-accurate approximation & strict layered closure

8. Optimal approach depends on -Bony anatomy -Location & extent of pathology -Location of the hilum -Objective of the procedure

9. Types of thoracic incisions Sternotomy Thoracotomy Axillary thoracotomy Anterior mediastinotomy Thoracoabdominal incision Bilateral Trans- sternal thoracotomy ( Clam-Shell incision) Extra-thoracic approaches to the thorax

10. Sternotomy incisions Partial Hemisternotomy (spares 6-8cm skin) Complete Suprasternal notch Xiphoid process Cosmetically appealing e.g. Inframammary ( bikini type ) incision

11. Median sternotomy

12. Median sternotomy Indications 1.Exposure of ant. & middle mediastinum 2.Lower cervical procedures 3.Tracheal resection & reconstruction 4.Excision of thyroid masses & parathyroid adenomas 5.Exposure of heart & great vessels for cardiopulmonary bypass. 6.Excision of cervical esophageal tumours

13. A dvantages Disadvantages Quick to perform Excellent exposure Safe Heals quickly Less incisional pain Poor cosmesis Gives limited exposure of the lower chest & posterior mediastinum May lead to serious post-op complications-unstable sternum, mediastinitis

14. Technique Standard sternotomy Re-operative sternotomy Partial sternal split

15. Less invasive sternotomy incisions Hemisternotomy - suprasternal notch , tee –off to the right at 4th interspace or xyphoid ,tee-off ,right, at 2nd interspace Full sternotomy with skin sparing Bikini-type ( inframammary ) incision- cosmesis

16. COMPLICATIONS Early- Haemorrhage , injury to contiguous structures, pneumothorax , haemothorax , Late- Empyema thoracis , Mediastinitis ( S.aureus - 31%,E.coli-3%,enterococcus -2%), Sternal osteomyelitis , Brachial plexus injury, incidence: 1.4-6.5%

17. Thoracotomy Defined in relation to the position of Latissismus dorsi muscle,which is laterally sited on the chest wall.

18. Types of thoracotomy incisions Lateral Anterior Anterolateral Posterolateral Posterior others

19. Nomenclature for standard thoracotomy incisions

20. Lateral thoracotomy Within confines of latissimus dorsi Transverse incision 1-2cm inferior to the scapular

21. Complications Post thoracotomy incision pain Infection Wound dehiscence Bronchopleural fistula-8% Empyema thoracis-2.2%

22. Anterior & anterolateral thoracotomy Indications Mainly historical interest Used for pulmonary resection Cardiac procedures Management of mediastinal masses Oesophageal pathology

23. Technique Supine position Chest elevated at 30-45 degree Curved submammary incision, extended laterally( anterolateral )

24. Anterolateral thoracotomy incisions

25. Muscle-sparing thoracotomy Variant of standard thoracotomy Well established Has less complications

26. Muscle sparing anterolateral thoracotomy incision

27. Advantages of muscle sparing Less early post-op pain Greater shoulder girdle strength Most result in quick closure Preserve chest wall muscle Prevent chest wall deformity

28. Indications for posterolateral incision Standard thoracotomy incision can be used for a wide range of surgical procedures involving; Heart Oesophagus Mediastinum Ipsilateral lung

29. Technique ( posterolateral ) Positioning –lateral decubitus position Cleaning/ draping Crescent or “lazy- S”incision , transversely Dissected down & scapular retracted Counting of intercostal spaces Pleural space entered Pleural/ mediastinal drainage Thoracotomy closure

30. Entering the pleural cavity after posterolateral thoracotomy

31. Intercostal approach - incising intercostal muscles Utilizing intercostal incision but to divide one or more ribs To resect a rib, enter through its periosteal bed

32. Advantages Disadvantages Flexibility of the incision Wide range of intra-thoracic exposure Proven experience with these incisions has made them the standard thoracic incisional approach Has potential for poor exposure ,if wrong interspace is chosen Unilateral hemithorax exposure Incisional pain Disability related to division of chest wall muscles Detrimental effect on pulmonary function

33. Axillary thoracotomy Indications 1 st rib dissection Apical bleb Dissection Management of spontaneous pneumo -thorax with apical pleurectomy or pleurodesis Staging of lung cancer

34. Patient positioning & incision for a vertical axillary incision

35. ADVANTAGES Disadvantage Small incision Quickly performed Muscle sparing Cosmetically appealing Ideal for pt with poor pulmonary function Limited exposure Intercostobrachial nerve injury Proximal long thoracic nerve injury

36. Complications Very minimal Infection-0.7% Limited shoulder mobility-0.5%

37. Anterior mediastinotomy (Chamberlain procedure) Used in scalene lymph node biopsy Exploratory thoracotomy In cases of lung cancer( inoperable)

38. Anterior mediastinotomy (Chamberlain)

39. Thoracosternotomy (Clam shell)

40. Left thoracoabdominal incision Provides excellent exposure for procedures involving Spleen Stomach Left hemidiaphragm Aorta lower oesophagus

41. Current trend Towards minimally invasive procedures Thoracic - VATS (video assisted thoracoscopic surgery) e.g. TEF LIGATION Cardiac- OPCAB (off-pump coronary art. Bypass) MIDCAB (minimally invasive direct coronary artery Bypass) Endoscopic aortic/mitral valve replacement

42. Conclusion Great achievements have been made in cardiothoracic surgery Emphasis now is on minimally invasive/ thoracoscopic procedures We still use thoracic incisions due to our own limitations There is great hope for the future.

43. THANK YOU