Modified Muscle-Sparing High Approach to the Thoracoabdominal Aorta
Iuri V Belov, PhD,
Anna B Stepanenko, PhD,
Andrei P Gens, PhD,
Dmitri D Savichev, MD,
Roman N Komarov, PhD
National Research Center of Surgery, Moscow, Russia
Dmitri D Savichev, MD, Tel: +7 499 248 1015, Fax: +7 499 2468988, Email: 7332326{at}mail.ru, Department for Surgery of the Aorta and its Branches. 2 Abrikosovsky per., Moscow, 119992, Russia.
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ABSTRACT
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A modified muscle-sparing high approach to the thoracoabdominal aorta is described, which improves surgical access for thoracoabdominal aortic aneurysm repair. Since 2000, 16 patients with type I and II thoracoabdominal aortic aneurysms have undergone aortic graft replacement using this approach via the 3rd intercostal space. There were no hospital deaths. Three (18.8%) patients had severe postoperative pain requiring prolonged analgesia. This approach is a good alternative to the standard approach via the 6th intercostal space.
Key Words: Aortic Aneurysm • Abdominal • Aortic Aneurysm • Thoracic • Blood Vessel Prosthesis Implantation • Thoracotomy
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INTRODUCTION
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Traditionally, thoracoabdominal aortic aneurysm (TAAA) repair has been performed using a left thoracoabdominal incision through the 5th to 8th intercostal space, depending on the extent of proximal aortic involvement.1–3 Yet, surgical access and exposure may be difficult if the aortic arch or proximal descending aorta is involved in the aneurysmal disease (Crawford types I and II). Most surgeons routinely remove the 5th or 6th rib for additional proximal exposure. Moreover, the standard approach requires division of the latissimus dorsi and serratus anterior muscles widely, which may cause postoperative pain and limit shoulder mobility.4–6 A modified muscle-sparing high approach to the thoracoabdominal aorta is described, which may improve surgical access.
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TECHNIQUE
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Left atrial femoral bypass and cerebrospinal fluid drainage are used in all patients. The patient is placed in the lateral decubitus position, with the left side of the body elevated 75° to 90°. The legs and pelvis remain as flat as possible to facilitate groin exposure. The left arm is lifted overhead and secured with a padded armboard. A transverse incision is made, beginning a few centimeters below the hair growth line at the posterior axillary line and continuing toward the anterior axillary line. At the anterior axillary line level, the incision is curved downwards along the anterior axillary line to extend below the abdominal flank (Figure 1A
). Subcutaneous tissue is divided until the fasciae overlying the large thoracic muscles. The flat muscles of the abdominal wall are divided along the lateral border of the rectus sheath until the parietal peritoneum. The anterior border of the latissimus dorsi muscle is freed from the chest wall and serratus anterior muscle by blunt dissection, and drawn posteriorly. The pectoralis major muscle requires no division, and it is mobilized from the chest wall and drawn anteriorly (Figure 1B). A part of the serratus anterior muscle is divided along the 3rd rib, but most of this muscle is preserved. The chest is entered via the 3rd intercostal space. All ribs located below are transected (Figure 1C). The ribs are spread by a large thoracic retractor. The rib spreader is placed as posteriorly as possible and opened gradually. The peritoneal cavity is not entered. The diaphragm is divided gradually during retroperitoneal dissection. The peritoneal sac is swept off the anterior aspect of the abdominal wall. The left kidney is elevated anteromedially along the peritoneal contents. The right iliac vessels can be
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Figure 1. (A) Schematic illustration of patient placement and line of skin incision for the modified approach. (B) The latissimus dorsi muscle is drawn posteriorly. The pectoralis major muscle is drawn anteriorly. (C) The serratus anterior muscle is partially divided, and the chest is entered through the 3rd intercostal space. All ribs located below are transected. easily approached when necessary. Following completion of aortic repair, the ribs are re-approximated with simple paracostal sutures. The wound is closed in a standard fashion.
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DISCUSSION
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From January 2000 to December 2007, 10 men and 6 women (mean age, 45.1 years) with TAAA were surgically treated using the modified thoracoabdominal approach. Complete follow-up was available in 11 patients. Mean follow-up was 2.3 years (range, 6 months to 5 years). The patients were contacted by telephone and a systematic questionnaire was completed. There were 14 Crawford type I TAAA and 2 type II. Thoracoabdominal aortic aneurysm consisted of 15 chronic dissecting aneurysms and 1 non-dissecting aneurysm. Mean aneurysm size was 7.4 cm (range, 6.7–8.1 cm). Comorbid conditions included hypertension in 13 patients, chronic obstructive pulmonary disease in 4 and diabetes in 2. There were no hospital deaths, no infection or seroma formation, and 1 (6.3%) patient required reexploration for bleeding. This patient developed gastrointestinal bleeding and acute renal insufficiency requiring 4 sessions of hemodialysis. Two (12.5%) patients had postoperative respiratory failure requiring prolonged ventilation (>48 h), 3 (18.8%) had severe postoperative pain requiring prolonged analgesia, one of whom was discharged with residual pain for 4 months. Mean intensive care unit stay was 3.6 days (range, 3–12 days). Median hospital stay was 25.1 days (range, 18–53 days). There were no late reoperations. One patient developed postoperative ventral hernia. In the same period, we operated on 54 patients using the standard approach.
The goal of the modified approach to TAAA is to facilitate manipulations on the aortic isthmus during TAAA repair. Although we should investigate features of this approach regarding postoperative pain, it is hard to say whether the standard costal arch transecting approach with rib removal causes less injury.7,8 In our opinion, this modified thoracoabdominal approach provides better surgical access and proximal aortic control.
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ACKNOWLEDGMENTS
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We would like to express our gratitude to Anastasia Parkhotik and David Ysebaert for significantly improving this manuscript by reading and correcting the text and giving valuable criticism.
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REFERENCES
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- Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term postthoracotomy pain. Chest 1991;99:270–4.[Medline]
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Asian Cardiovasc Thorac Ann 2009;
17:86-88
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102512
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ABSTRACT
INTRODUCTION
