Asian Cardiovasc Thorac Ann 2002;10:194-195
© 2002 Asia Publishing EXchange Pte Ltd
A Technique Facilitating Muscle-Sparing Thoracotomy
Yi
it Akçali, MD,
Hasan Demir, MD,
Bekir Tezcan, MD
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Department of Thoracic and Cardiovascular Surgery Erciyes University Medical Faculty Kayseri, Turkey
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Yig it Akçali, MD Tel: 90 352 437 3511 Fax: 90 352 437 5285 email: yigit.akcali{at}isbank.net.tr Mustafa Kemal Pa a Bulvari, No. 131/20, Kayseri 38090, Turkey.
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ABSTRACT
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The muscle-sparing thoracotomy technique preserves the latissimus dorsi and serratus anterior muscles and provides excellent exposure for most thoracic and mediastinal operations. It also reduces postoperative pain and complications, and preserves pulmonary function. The technique has been developed further to facilitate subcutaneous dissection by insufflation of air from a syringe connected to a large-bore needle via a 3-way tap.
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INTRODUCTION
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The muscle-sparing thoracotomy, regarded as "a reasonable alternative to the standard posterolateral approach," is associated with reduced shoulder girdle disability, less postoperative pain, and improved respira-tory function.1 The time from incision to retractor place-ment (opening time) in this procedure can be lessened by insufflation of air into the areas where subcutaneous dissection is planned.
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TECHNIQUE
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After intubation with a double-lumen endotracheal tube, the patient is positioned in a lateral decubitus position with pillows between the knees and padding under the elbows. Before starting the skin incision, the incision line and the areas scheduled for dissection are insufflated subcutaneously with air from a 60-mL syringe connected to a large-bore needle via a 3-way tap (Figure 1
). The skin is incised in an S-shape, beginning in front of the anterior axillary line, curving 2 cm under the tip of the scapula, and continuing a further 2 cm posteriorly. The subcu-taneous attachments of the latissimus dorsi are mobilized with electrocautery by dissecting just superficial to the fascia. The entire anterior border is freed from its superior aspect in the axilla to its inferior insertion at the iliac crest. After freeing the deep aspect of the latissimus dorsi, it is retracted posteriorly to expose the serratus anterior muscle. The serratus anterior is freed superiorly beyond the tip of the scapula, and inferiorly to its attachment on the anterior aspect of the 6th rib. The deep aspect of the serratus is mobilized with cautery and retracted forward. After incision of the intercostal muscles, the chest is entered, and two rib retractors are positioned; one to retract the ribs, and the other oriented perpendicular to the first retractor to separate the serratus anterior and latissimus dorsi muscles. In patients over 40 years old, a 1-cm segment of the lower rib at the intercostal incision is resected at the costovertebral angle, to decrease the incidence of costal fracture.
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Figure 1. Illustration of subcutaneous air insufflation through a 60-mL syringe connected to a large-bore needle via a 3-way tap.
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On completion of the pulmonary operation, a single intercostal dose of 0.25% bupivacaine is administered to anesthetize the two nerves above and below the intercostal space. The thoracotomy is closed by approximating the ribs with pericostal heavy absorbable sutures. Two soft closed-suction drains are placed in the subcutaneous space. The drains are removed on the 3rd postoperative day or when drainage is less than 50 mL per day. To prevent seroma along the wound, the patient's chest is wrapped with an elastic bandage, so as not to impede ventilation.
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DISCUSSION
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A prospective randomized blinded study of 60 consecutive patients was carried out to compare the standard posterolateral technique (30 patients, group 1) with the muscle-sparing thoracotomy (30 patients, group 2). The patients were undergoing surgery for bronchiectasis, empyema, spontaneous pneumothorax, hydatid cyst, lung cancer, solitary pulmonary nodule, or bronchogenic cyst. Those with a history of previous thoracotomy were excluded. There was no difference statistically between the groups in terms of surgical approach time. Although it took on average 9 minutes longer to open the chest in group 2 (42.03 ± 5.59 minutes) than group 1 (33.9 ± 6.58 minutes), closure was much quicker in group 2 (30.23 ± 5.78 minutes) than group 1 (49.9 ± 3.83 minutes) where suture approximation of the thoracic musculature was required. Total operating times were 83.8 ± 7.21 minutes in group 1 and 72.26 ± 10.64 minutes in group 2.
The muscle-sparing thoracotomy described by Bethencourt and Holmes2 in 1988 does not involve transection of the major thoracic muscles, but the subcutaneous tissue should be dissected thoroughly so that extrathoracic muscles can be dissected easily. The addition of subcutaneous insufflation was based on two observations. The first was the method that has been used for centuries by the Turks to skin slaughtered sheep in accordance with Islamic rites. A small skin incision is made in one of the back legs of the sheep, and the whole carcass is insufflated to allow quick and easy skinning. Secondly, in patients with subcutaneous emphysema due to chest injury, the subcutaneous tissue and vasculature are easily seen, and this aids manipulation during a thoracotomy.
Subcutaneous air helped the creation of subcutaneous and muscular planes prior to the skin incision. Hemostasis was achieved using less cautery and fewer miniclips because the courses of perforating vessels within these layers were clearly visualized. It was considered that this allowed subcutaneous and muscular dissection to be performed faster and more safely. Although the duration of surgery has been reported to be either longer or the same with the muscle-sparing procedure compared to the standard posterolateral thoracotomy, in this study, the total operating time for the standard technique was approximately 9 minutes longer.1,3 It can be seen that the time from incision to retractor placement in the muscle-sparing thoracotomy, called a "time-eater" by supporters of the standard posterolateral thoracotomy, may be shortened by the insufflation technique described herein.
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Acknowledgments
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The authors wish to thank Mr. Metin Tatli for his excellent technical assistance.
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REFERENCES
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Hazelrigg SR, Landreneau RJ, Boley TM, Priesmeyer M, Schmaltz RA, Nawarawong W, et al. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg
1991;101:394–400.[Abstract]
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Bethencourt DM, Holmes EC. Muscle-sparing postero-lateral thoracotomy. Ann Thorac Surg
1988;45:337–9.[Abstract]
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Sugi K, Nawata S, Kaneda Y, Nawata K, Ueda K, Esato K. Disadvantages of muscle-sparing thoracotomy in patients with lung cancer. World J Surg
1996;20:551–5.[Medline]
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ABSTRACT
INTRODUCTION
