XXIII - Benign Esophageal Disease

Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.

Title: General Thoracic Surgery, 6th Edition

Copyright 2005 Lippincott Williams & Wilkins

> Table of Contents > Volume II > The Mediastinum > Section XXVII - Invasive Diagnostic Investigations and Surgical Approaches > Chapter 163 - Posterior Mediastinotomy

Chapter 163

Posterior Mediastinotomy

Thomas W. Shields

A posterior mediastinotomy approach to either paravertebral sulcus or the posterior (dorsal) portion of the visceral compartment of the mediastinum is indicated only infrequently. Most inflammatory or neoplastic lesions in these locations are satisfactorily exposed and managed by the appropriately sided standard posterolateral thoracotomy or video-assisted thoracic surgery (VATS) approach. However, a contained esophageal perforation or other posteriorly located abscess, or an impacted esophageal foreign body that cannot be extracted by endoscopic manipulation, may be approached by this incision without entering into the ipsilateral pleural space. This incision also may be used to permit the insertion of a mediastinoscope to take biopsy samples of enlarged lymph nodes in the posterior subcarinal nodal station, in the posterior (paraesophageal) lymph node stations, or in the paravertebral lymph node chain.

TECHNIQUE

The right-sided posterior mediastinotomy is preferred in most instances because it avoids exposure of the descending thoracic aorta. Exceptions are lesions lateralized to the left or impacted foreign bodies in the lowermost portion of the esophagus because the esophagus is left-sided in this location, whereas throughout the major portion of its course in the chest, it is basically right sided in location.

The patient is placed in the appropriate lateral decubitus position under general anesthesia with an endotracheal tube in place. Local anesthesia can be used but makes the procedure tedious and difficult for both the patient and the surgeon. In unusual situations, the patient may be placed in an upright sitting position.

A vertical paravertebral incision is made just lateral to the paravertebral muscles, about 3 to 4 cm from the midline, entering over the area to be exposed (Fig. 163-1). The trapezius and rhomboid muscles are divided vertically to expose the lateral border of the sacrospinalis. This muscle is retracted medially and the rib cage exposed. Depending on how cephalad the incision is, one or more of the lower serratus posterior superior muscles may have to be detached from the corresponding rib or ribs. The proximal portions of two to three of the selected ribs and the tips of the adjacent transverse processes are exposed. Short segments of each rib just medial to or up to the angle are freed subperiosteally to the transverse process, taking care not to enter the parietal pleura, and then excised (Fig. 163-2). Generally, there is no need to go proximal to the tubercle or to remove the transverse process, although this may be done if necessary. In doing so, the costotransverse ligament and levatores costarum breves muscle should be divided (Fig. 163-3). The intervening intercostal bundles are elevated and the intercostal vessels doubly transfixed and divided. Note that, in this area, the intercostal vessels lie between the internal intercostal muscle and the innermost intercostal muscle layers (see Fig. 163-3). The remaining intercostal tissues are then divided for the entire length of the wound. The pleural reflection is then bluntly swept away from the heads of the ribs and from the sides of the vertebral bodies. By blunt dissection, the sulcus and posterior portion of the visceral compartment are exposed as necessary to identify the abscess or esophagus as indicated (Fig. 163-4). Once the abscess is drained or the foreign body is removed from the esophagus, with closure of the esophageal wall with interrupted Vicryl or Dexon sutures, the incision is drained with rubber Penrose drains. No closure of the incision is necessary when an abscess is present, but if the field is uncontaminated, closure by loose approximation of the muscular layers and skin may be accomplished.

MORBIDITY AND MORTALITY

No major complications of the incision should be anticipated. When the wound has been left open, the incision granulates in and heals by secondary intention.

Fig. 163-1. Schematic illustration of posterior mediastinotomy on the left to expose a contained mediastinal abscess, showing position of patient and site of skin incision and sections of ribs to be removed. From Seybold WD, Johnson MA III, Leary WV: Perforation of esophagus: analysis of 50 cases and account of experimental studies. Surg Clin North Am 30:1155, 1950. With permission.

Fig. 163-2. Inferior (A) and superior (B) views of a typical rib. Section of rib to be removed extends from the angle to just distal to the tubercle.

Fig. 163-3. Exposure of posterior part of the intercostal spaces 8, 9, and 10. The intercostal vessels and nerves lie between the internal intercostal muscle and the innermost intercostal muscle layers. From the intervertebral foramen to the angle of the rib, these structures are covered ventrally by the internal intercostal membrane.

Fig. 163-4. Exposure of the paravertebral sulcus and posterior portion of the visceral compartment to the mediastinum. Note proximity of the parietal pleura to the collection of purulent material adjacent to the esophagus. Adapted from Seybold WD, Johnson MA III, Leary WV: Perforation of esophagus: analysis of 50 cases and account of experimental studies. Surg Clin North Am 30:1155, 1950. With permission.



General Thoracic Surgery. Two Volume Set. 6th Edition
General Thoracic Surgery (General Thoracic Surgery (Shields)) [2 VOLUME SET]
ISBN: 0781779820
EAN: 2147483647
Year: 2004
Pages: 203

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