THORACOTOMY INCISION ppt by Dr. Amrit kumar

Thoracotomy incision

1. THORACOTOMY INCISION Dr. Amrit Kumar Senior Resident Dept of CTVS ABVIMS & RML Hospital

2. History First Thoracotomy by Howard Lilienthal in 1909 Median sternotomy was described first by Milton in 1897, for management of mediastinal TB

3. Goals Adequate exposure of area of interest Preserve Chest wall function and appearance Accurate approximation and layered closure Incision along langer’s line

4. Types Posterolateral Thoracotomy Anterolateral Thoracotomy Axillary Thoracotomy Bilateral Trans-sternal Thoracotomy Median and Partial Sternotomy Thoracoabdominal Incision

5. Posterolateral Thoracotomy Posterolateral thoracotomy is the standard workhorse for most thoracic surgeons. Good visualization of the entire thoracic cavity, including the posterior diaphragmatic sulcus. The incision is generally centered over the 5 th ICS. This provides an unobstructed view of the base of the fissure, the pulmonary artery, and the hilum. U sed for Anatomic lung resections. Easy for Radical lymphadenectomy. An extended type is used for Pancoast resection, E xtrapleural pneumonectomy, and aortic transection .

6. L ateral decubitus position with ipsilateral arm extended forward. The inferior tip of the scapula is palpated. The incision begins 3 cm posterior to the scapula tip and halfway between the scapula and the spinous process. The incision curves around the tip & lie along the top margin of the sixth rib (fifth intercostal space), Extends to the anterior axillary line. The latissimus dorsi muscle is divided. The auscultatory triangle, the space bounded by the lower border of the trapezius, the serratus anterior, and the medial margin of the scapula can be identified at this time. The serratus anterior muscle can be spared by freeing it from the soft tissue and the muscle rotated forward. It helps to preserve the motion of the shoulder girdle and quickens recovery time. An intact serratus anterior can limit the spread of the 5 th & 6 th ribs. This can be overcome by detaching the lower slips of attachment of the muscle from the 8th & 7th ribs.

7. The incision wraps around the tip of the scapula and parallels the course of the sixth rib.

8. S tay on the top surface of the lower rib to avoid injury to the neurovascular bundle of the upper rib. This is best done by proceeding from posterior to anterior along the line of the External intercostal fibers. In general, there is no need to disrupt the erector spinae ligament. The incision i s centered on the greater fissure of the lung ,providing access to the pulmonary artery at the base of the Fissure

9. “Shingling” - of a rib involves removal of A cm length of rib A nterior to the erector spinae ligament to allow further distraction of the 5 th and 6 th ribs without a midshaft fracture of the rib. These bony defects are less painful than midshaft fractures. It Increases the spread of the ribcage. A ) The initial periosteal cut is made and elevated. ( B ) Subperiosteal dissection protects the neurovascular bundle. ( C ) The osseous rib fragment is removed. ( D ) The nerve is susceptible to stretch injury unless freed from the undersurface of the rib

10. A. Anterior view of right lung. B. Posterior view of right lung. C. Anterior view of left lung. D. Posterior view of left lung A B C D

11. Closure begins with placement and securing of chest tubes. Paracostal sutures Taken . If a rib has been removed, 6-8 sutures are commonly required to prevent a chest wall hernia. Fracture ends are best treated by removing the jagged portion of the rib with a rib cutter . The ribs should not be brought tightly in apposition to each other because this causes the bones to fuse, which limit choices for Redo Thoracotomies. The serratus anterior is reapproximated to the soft tissue overlying the auscultatory triangle, and then the latissimus dorsi is sewn back together. Two additional layers of closure reapproximate Scarpa’s fascia and the skin.

12. Advantage The posterolateral thoracotomy incision provides the best unobstructed view of the entire hemithorax. Disadvantages L ong incision M ore injury to the E xtrathoracic musculature and soft tissue. L onger recovery time than almost any other incision (with the exception of the clamshell incision). T akes more time to open and close this incision compared with otther incisions. Both the Thoracodorsal nerve and the Long thoracic nerve can be injured. Ribs fracture more common.

13. Muscle-Sparing Posterolateral Thoracotomy After postero -lateral skin incision subcutaneous flaps are raised over the latissimus dorsi superiorly and inferiorly. Posterior aspect of the latissimus muscle is then freed from the thoracolumbar fascia after this maneuver, the latissimus dorsi can be reflected anteriorly several centimeters. .

14. Anterolateral Thoracotomy P opular incision in the 1950s for upper lobectomy Video-assisted techniques have Redeveloped interest in this incision. Provides good visualization for middle lobectomies and work within the anterior chest. It is smaller and better tolerated than a full posterolateral thoracotomy. Utility incisions used for VATS-lobectomy can be converted easily to anterolateral thoracotomy for quick improvements in visualization

15. Anterior, middle, and posterior axillary lines related to the extrathoracic muscles. Anterolateral thoracotomy incision runs beneath the pectoralis major and latissimus dorsi muscles.

16. Technique Incision usually in 4 th -5 th Intercostal space 4 th ICS good for Anterior mediastinum and hilum at level of superior pulmonary vein 5 th ICS for Middle Lobectomy The patient is placed in L ateral decubitus position.The arm is placed in classic “swimmer” position with 90-degree abduction of the Upper arm to allow easier access to the 4 th ICS

17. The Incision starts 1 cm posterior to the pectoralis major muscle runs along on top of the Rib for 10 to 15 cm. The latissimus dorsi muscle is not divided. The serratus anterior muscle is divided along the course of its fibers and not rotated. The IC muscle is lifted from the top of the inferior rib. It is important to remove the IC muscle from the top portion of the lower rib to avoid injury to the neurovascular bundle of the upper rib. “ S hingling,” is rarely needed because the intercostal space gets larger as the ribs pass anteriorly. The most important landmark is the long thoracic nerve that runs just beneath the anterior border of the latissimus dorsi.

18. Advantages The Incision is smaller. Q uicker recovery compared with the posterolateral incision. The latissimus dorsi muscle is not divided, So better shoulder function in post-op and future use of a latissimus dorsi flap if the patient is at risk of developing a bronchopleural fistula . Disadvantages P osterior hemithorax and inferior portions of the chest are n ot visualised . ( This can be reduce by the use of thoracoscopy, hence the frequent use of this incision in VATS). E xtension of the incision is Difficult dut to the potential of injury to the long thoracic nerve & the bulk of the pectoralis major muscle anteriorly

19. Axillary Thoracotomy It can be thought of as an anterolateral Thoracotomy incision in the 1 st , 2 nd , 3 rd ICS . P rovides access to the apex of the hemithorax and is useful for mobilizing a scarred apical segment from the parietal pleura during thoracoscopic procedures. Visualization of the posterior portion of the apex of the lung during bullectomy. M obilization of the thymus in thoracoscopic approach. Used for first rib resection via an axillary approach.

20. Technique I dentify the 2 nd & 3 rd ICS and even the 1 st ICS in very thin patients. 3 rd ICS is the easiest position for this incision in males and 2 nd ICS in females. I ncision extends across the base of the axilla b/w the anterior border of the latissimus dorsi & the posterior extent of the pectoralis major. It has no underlying muscles. It contains clavipectoral fascia and lymphatics and lymph nodes. It is important to ligate or cauterize these lymphatics to avoid post- op lymphoceles. I ncision lies at the level of the Azygos– C aval junction.

21. Advantages Adequate visualization of the upper mediastinum and posterior portion of the apex of the lung. Recovery time is very quick . P ain is less . In general, the higher the space, the lower is the pain because there is less excursion of the ribs during respiration. Disadvantages The correct interspace for the incision needs to be considered carefully based on the goal of the operation (A second interspace incision will not allow proper visualization of the superior pulmonary vein). Don’t allow Extension of the incision, if desired. I njury Chances to long thoracic nerve, the thoracodorsal nerve, and the intercostobrachial nerve

22. CLAMSHELL INCISION (B/L THORACOSTERNOTOMY ) This incision is used in rare circumstances where broad exposure is needed within both hemithoraces . Examples- D ouble lung transplant, Removal of bulky anterior mediastinal masses with lateral extensions beyond the midclavicular lines, R emoval of bilateral multiple suspected metastases.

23. Alternatively, arms may be positioned laterally

24. The patient in supine on the with rolls placed beneath the thorax in the shape of the letter I . The arms are extended above the head and suspended with the upper arms distracted from the thorax at approximately a 120-degree angle. The incision runs beneath each inframammary crease and crosses the sternum in the 4 th ICS . The incision extends into the inferior portion of each axilla. The intra - pleural space is entered at t he midclavicular line. Dissection then extends medially on both sides to the level of the internal mammary vessels. These vessels clipped before division. If injured prior to control, a finger within the intercostal defect can compress the vessel against the anterior chest wall until the sternum is divided. The internal mammary stumps then can be oversewn more securely under direct vision.

25. Rib spreaders are placed on each side. Closure requires multiple paracostal sutures to the 4 th & 5 th ribs. Surgical steel wire in a figure-of-eight pattern is used to reapproximate the sternum. The pectoralis major is sewn back onto the fifth rib. Scarpa’s fascia and skin make up the final two layers.

26. Advantages M ost extensive access of any thoracic incision to both hemithoraces and the anterior and mid - mediastinum. P rovides better exposure of the thorax lateral to the midclavicular line. P rovide an important lateral angle of the mid-mediastinum when resecting a bulky tumor. Disadvantages E xtensive disruption of muscle and bone, so E xtended R ecovery. D isruption of the Intercostal and A ccessory muscles of respiration at the level of the 4 th & 5 th ICS has a serious impact on chest wall excursion and breathing mechanism. Both the phrenic nerves are susceptible to injury. P rovides poor exposure of the posterior mediastinum.

27. MEDIAN STERNOTOMY U sed widely for C ardiac surgery R esection of A nterior mediastinal masses R adical thymectomies Dissections of the upper mediastinum Can provide access to both hemithoraces for B/L pulmonary nodules or lung volume reduction surgery.

28. Technique I ncision in the vertical midline of the sternum. The patient in supine with a transverse roll beneath the most kyphotic portion of the back. The hips must be even. The sternal notch and tip of the xiphoid are marked & palpation of the edge of the sternum in each ICS is used to mark the midline of the sternum. The skin incision should extend from the sternomanubrial junction to 2 cm below the tip of the xiphoid. A transverse venous branch frequently crosses the sternal notch and should be cauterized. The Interclavicular ligament can be palpated and divided with cautery.

29. The linea alba is divided for 2 cm caudal to the tip of the xiphoid process. A second transverse venous branch is found at the sterno -xiphoid junction and needs to be cauterized. A finger through the defect in the linea alba deep to the xiphoid to bluntly open the diaphragmatic hiatus directly behind the sternum. Likewise, finger passes deep to the manubrium at the cranial end of the incision to bluntly dissect the tissue away from the bone. The saw footplate is placed deep to the bone and pushed or pulled through the center in steady fashion.

30. Hemostasis is achieved by cauterizing the edges of the periosteum and the application of either bone wax or a topical coagulant, such as Gelfoam , soaked in thrombin. At the conclusion of the procedure, mediastinal drainage tubes are placed through the rectus sheaths with care not to injure abdominal organs. The bone is reapproximated with surgical steel wire. After placement of the wires, must check the undersurface of the bone for bleeding from the mammary vessels, and a hemostatic stitch may be required.

31. Sternal closure as proposed by Robicsek . The transverse wires must be placed outside the parasternal weave. Conventional sternal reapproximation

32. Advantages S imple incision, so easily mastered. H eals quickly. P ain is well tolerated. Excellent visualization of the anterior and upper mediastinum. Both pleural spaces can be opened for bilateral procedures in a single setting. It also can be used to expose the carina from a different angle than thoracotomy. This is achieved by displacing the SVC to the right and the aortic arch to the left and then opening the posterior pericardium. This exposes the Right pulmonary artery and the carina.

33. Disadvantages D ifficult to resect lesions from the posterior lower lobes of the lung. Doing a Redo sternotomy, care must be taken to avoid inadvertent entry into the heart, which may be adhered to the underside of the sternum ( A lateral radiograph can reveal the degree of adhesion). Risk of Unstable sternum and Mediastinitis are more.

34. Submammary incision( Bikini-type incision)- Subcutaneous tissue flaps are raised as depicted by the shaded areas . The lateral extent of the soft tissue dissection is not beyond the midclavicular line. Common complication- Wound hematoma S kin necrosis Decreased areolar sensitivity

35. PARTIAL STERNOTOMY It splits the manubrium and the upper portion of the body of the sternum. P rovides access to T horacic inlet U pper anterior and upper mid mediastinal structures P articularly useful in approaching the thymus gland E asily combined with Neck incisions to provide proximal and distal control of upper mediastinal arteries and veins.

36. Technique The patient in supine with a transverse roll behind the most kyphotic portion of the back. H ips must be even. A midline incision from the angle of Louis to inferiorly about 4 finger breadths. A subcutaneous tunnel is developed superficial to the pectoralis major fascia up to the sternal notch. Inter-clavicular ligament palpated & divided with cautery. I ncision can favor the right to displace the right sternal fragment laterally, favor the left to displace the left fragment, or combine with a transverse sternotomy to allow the combined displacement of both fragments. The pectoralis major insertion on the sternum and costal cartilages of the 2 nd & 3 rd ribs is lifted on the side. The periosteum of the manubrium is burned in the midline to the angle of Louis. The burn is then extended in a curvilinear manner to the interspace between the 2 nd and 3 rd or 3 rd and 4 th ribs .

37. A right angle is used to insure that the mammary vessels are safely displaced away from the bone. The saw footplate pushed or pulled through the center of the manubrium in a steady fashion. The saw is gently turned to the rib interspace after the angle of Louis . Alternatively, A sternal Lebsche knife can be used to finish the cut into the intercostal space. A sternal retractor then is placed. The lateral displacement of the fragment is not as much as that occurs with a full sternotomy, but is sufficient to do most dissections in the upper anterior mediastinum. At the conclusion of the procedure. The bone fragments are reapproximated with surgical steel wires.

38. Advantages P rovides nearly the same visualization of the upper anterior mediastinum. A ny structure above the level of the carina can be easily approached with this incision. The extension into the neck with a hockey stick incision or a transverse collar incision allows proximal and distal control of upper mediastinal arteries and veins. K eeps the lower body of the sternum and the costal margins intact. This preserves the respiratory function. There is Less pain and fewer lifting restrictions are required. (20 lbs or 9kg for 3 weeks, whereas with median sternotomy the lifting restrictions are generally imposed for 8 weeks).

39. Disadvantage V isualization limited at the inferior portion of the osteotomy and laterally at the edges of dissection. If the lateral portion of the osteotomy goes in the interspace between the 2 nd & 3 rd rib, the inferior portion of a very large thymus gland may not be seen. If a transverse sternotomy is made, a careful reapproximation of both fragments to the remnant of the body of the sternum must be made. Limited visualization into the pleural spaces, so pleural drain placement can be difficult.

40. Thoracoabdominal Incision P ermits simultaneous dissection in pleural and abdominal cavities. The left-sided approach is particularly attractive for esophageal surgeons. This exposure facilitates esophageal, gastric, splenic, and retroperitoneal surgeries. The patient is placed in a lateral position with the hips rotated back toward the operating table by 10 to 20 degrees. In cases of esophageal malignancy, the abdominal portion of the incision is made first to determine operability.

41. An oblique incision from the mid costal margin is utilized, the incision is continued obliquely across the costal margin and extended upward as a posterolateral thoracotomy. Latissimus and serratus muscles are divided and the chest is entered in either the 5 th or 6 th ICS. The exposure is completed by division of the diaphragm. Diaphragm can be incised circumferentially but a radial incision can be made if anterior branches of the phrenic nerve are identified and carefully avoided. The diaphragm is reconstructed, and the paracostal sutures are spaced by 2 to 3 cm. The costal margin is repaired with a heavy, absorbable, figure-of-eight suture. This suture is passed through the diaphragm to buttress the costal margin and prevent herniation. Each muscle layer is carefully closed with running absorbable suture.

42. Disadvantage The closure can be difficult and time consuming. Left lung isolation is necessary.

43. Thank You