19 - Pulmonary Physiologic Assessment of Operative Risk

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 I - The Lung, Pleura, Diaphragm, and Chest Wall > Section VII - Pulmonary Resections > Chapter 25 - Thoracic Incisions

Chapter 25

Thoracic Incisions

Willard A. Fry

The most popular incision for open general thoracic surgical procedures is the lateral thoracotomy, sometimes also called the axillary thoracotomy. For years, the posterolateral thoracotomy was considered the incision of choice for most operations involving the lung and esophagus. However, with increased use of double-lumen endotracheal tubes and refinement of instrumentation, particularly the stapling devices, the traditional posterolateral incision is reserved for difficult operations in which wide exposure is mandatory. Likewise, interest in using median sternotomy for operations on the lung has waned, although median sternotomy is still considered the incision of choice for most anterior mediastinal lesions. With increasing use of video-assisted thoracic surgery (VATS), small accessory incisions, as suggested by Lewis and colleagues (1992), are becoming more popular (see Chapter 32).

When the patient is positioned for thoracotomy, especially in the lateral decubitus position, pressure points should be padded around the elbows using foam pads, an axillary roll should be placed under the dependent axilla to take pressure off the brachial plexus, and one or two pillows should be placed between the legs. Measures to discourage venous thrombosis in the lower extremities, such as special elastic hose and a sequential compression device, should be considered. These measures, if used, should be in effect at the beginning of the operation. Salzman (1985) and Scurr and associates (1987) suggested that external pneumatic compression with sequential compression sleeves connected to a sequential compression device is the safest and most cost-effective prophylaxis against venous thromboembolic disease. If the patient has a number of risk factors toward developing deep vein thrombosis, the perioperative use of heparin should be considered, as described by Hyers (1999).

The use of prophylactic antibiotics for general thoracic surgical procedures remains controversial. Cameron (1981) and Ilves (1981) and their associates reported conflicting results in controlled trials. In general, a first- or second-generation cephalosporin is used, and the main emphasis is on prophylaxis of the wound from Staphylococcus aureus infections. On the basis of the work of Olak and associates (1991), I cannot recommend giving more than a single intravenous dose before making the skin incision. This recommendation is supported by Meakins (1998) writing on behalf of the American College of Surgeons.

POSTEROLATERAL THORACOTOMY

The posterolateral thoracotomy incision is made with the patient in the lateral decubitus position, with proper padding to the elbows, knees, and dependent axilla. Various maneuvers are available to hold the patient in an appropriate lateral position, including placing a sandbag under the operating table mattress, rolled sheets front and back, and bean bags. Two straps of 2-inch adhesive tape are used as well. The dependent arm is flexed at the elbow. The superior arm can be flexed similarly and appropriately padded, obtaining the so-called praying position, or it can be extended on a padded Mayo stand (Fig. 25-1A).

Only hairy portions of the skin that will be directly in the line of the incision or the chest tubes or their taping should be shaved, and if shaving is necessary, it should be done immediately before the operation, as recommended by Cruse and Foord (1973). My colleagues and I often find that shaving is not necessary at all.

It is helpful to outline the proposed incision with a felt-tipped marking pen. Most pulmonary operations are best performed through a fifth interspace incision.

As shown in Fig. 25-1B, the incision starts in front of the anterior axillary line, curves 4 cm under the tip of the scapula, and then takes a vertical direction between the posterior midline over the vertebral column and the medial edge of the scapula. It is usually not necessary to go farther cephalad than the level of the spine of the scapula.

The electrosurgical unit is used for hemostasis and musculofascial dissection. It is not generally recommended for dissection in the skin or subcutaneous tissues, and I usually

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reserve its use for cutting until I have reached the muscular fascia, based on the extensive wound healing studies of Cruse and Foord (1973). Glover and associates (1978) emphasized that use of the cutting current destroys less tissue than constant use of the coagulation current. On the other hand, my colleagues and I use the electrosurgical unit more frequently when operating on patients who have positive test results for human immunodeficiency virus or hepatitis. The lower portion of the trapezius muscle is divided, and, in the same plane more anteriorly, the latissimus dorsi muscle is divided also. Next, the lower portion of the rhomboid muscle, if the thoracotomy is high, and the continuous plane with the serratus anterior muscle are divided.

Fig. 25-1. Posterolateral thoracotomy. A. The patient is positioned in the praying position with pillows between the knees and padding under the elbows. Wide adhesive tape secures the position. Note the axillary roll and the sequential compression device. B. The incision curves in an S shape, passing 4 cm under the tip of the scapula over in the fifth interspace anteriorly.

The desired interspace is located by placing a large right-angle retractor beneath the scapula and passing the hand up paraspinally. Sometimes, the first rib is obscured to easy palpation, but attachments of the serratus posterior superior muscle to the second rib serve as an added guide.

Rib section at the costovertebral angle level is recommended for patients older than 40 years of age to decrease the incidence of rib fracture (Fig. 25-2). Generally, small portions of the superior and inferior rib are excised subperiosteally to prevent the cut edges from overriding in the postoperative period. Although some recommend section over clips or ligatures of the neurovascular bundle, it is not necessary. It is unusual to resect a long segment of rib for a routine thoracotomy, although it was usually done in the past. For repeat thoracotomies, however, it is often advisable to resect a long rib segment subperiosteally and to approach the pleural space through the bed of the resected rib because extensive adhesions are often encountered on such reoperations, and the wider entry into the pleural space through the bed of a resected rib can be beneficial (Fig. 25-3).

Fig. 25-2. Posterolateral thoracotomy. A. One or two ribs are sectioned at the costovertebral angle. A small portion of bone is removed to prevent overriding of the fragments at the time of closure. B. Four or more sutures of heavy absorbable suture are placed as pericostal sutures. The interspace distance is maintained. It is not necessary to suture the divided intercostal muscles except when a tight seal is desired for pneumonectomy.

The intercostal muscle incision down to the parietal pleura is made carefully in the lower portion of the interspace to avoid injury to the neurovascular bundle. The surgeon pauses to see whether the lung moves freely under the pleura. If it does move freely, then few adhesions in the area of the interspace can be expected. If the lung does not move

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freely, the surgeon must anticipate a significant number of adhesions and the need to divide them with care, particularly when the operation is a repeat thoracotomy. A large Finochietto-type rib spreader is inserted, placing the large superior blade behind the scapula. If desired, a smaller, Tuffier-type rib spreader can be placed more anteriorly to ensure a wide surgical field. The rib spreader is opened slowly and in stages to minimize the chance for rib fracture.

Fig. 25-3. Posterolateral thoracotomy. A. The fifth rib is resected subperiosteally, and the pleural cavity is entered through an incision in the rib bed. Long rib resection is recommended for repeat thoracotomy. B. The rib bed is closed with running absorbable suture. The retained periosteum regenerates rudimentary bone. The interspace distance is maintained.

Closure of the incision is begun by inserting one or two chest tubes through a separate stab incision inferior to the skin incision in the anterior and midaxillary lines. The tract for the tube is tunneled for several centimeters to direct the tube, low and posterior for the back tube to drain fluid and high and anterior for the front tube to remove air. Tunneling the tube tract also reduces the chance for a pleurocutaneous fistula in the event that the tubes must remain in place for a long time, as in the case of a prolonged postoperative air leak. Generally, two tubes are used if a significant resection has been performed because the operator can expect both air and fluid accumulation. In selected cases, such as a local excision of a lung lesion when no air leak exists or an esophageal operation in which the lung has not been cut, a single tube suffices. The size of the chest tube to be used depends on the preference of the operating surgeon, the size of the patient, and the nature of the particular operation. In general, it is not necessary to use a posterior tube larger than No. 32F or an anterior tube larger than No. 28F. Tubes smaller than No. 24F tend to kink. Plastic tubes are preferred over rubber because they are less likely to clot. The chest tubes should be secured, when inserted, with a heavy suture; our preference is the No. 1 nylon to prevent slippage. The tubes are attached to a Y-tube connector, which is in turn affixed to an appropriate chest drainage system.

In the past, my colleagues and I (1990) preferred a continuous epidural analgesia (CEA) for our posterolateral and axillary thoracotomy patients. More recently, we have used an extrapleural, paravertebral catheter (PARA), with a continuous infusion of fentanyl (5 g/mL) with bupivacaine 0.1%, as described by Bimston and colleagues (1999) from our group. We initially described a fentanyl concentration of 10 g/mL, but we believe that the lower dose of 5 g/mL lessens some of the side effects, such as drowsiness and nausea. Kaiser and associates (1998) also have described an experience in which they prefer the PARA over CEA. More recent discussions with thoracic surgical colleagues suggest, however, that most sugeons prefer CEA. Regnard (personal communication, 2000) and Grunenwald (personal communication, 2000) from France have mentioned that their anesthesiologists and intensive care colleagues will not permit patients with CEA or PARA catheters to be outside of the intensive care unit; thus, they have tended in recent years to rely on intravenous patient controlled analgesia (PCA), thereby permitting early transfer of such patients who are doing well from a clinical point of view to the floors. In instances of repeat thoracotomy or upper chest wall resection in which denuding or removal of the paravertebral parietal pleura is anticipated, the surgeon would be advised to have the anesthesiologist place a CEA catheter before induction of anesthesia. In the event that CEA or PARA is not feasible, we would recommend an intercostal nerve block with a long-acting local anesthetic, such as 0.5% bupivacaine with epinephrine, at the time of chest wall closure. Gallo and colleagues (1983) emphasized that an intercostal vascular injection must be avoided because the intravascular injection of such compounds can have dire cardiovascular consequences. Generally, we block from the second to the seventh interspace. The injection should be at least 8 cm off the midline to avoid a subdural injection that would produce spinal anesthesia.

Pericostal sutures, usually four, of heavy absorbable material such as No. 2 polyglycolic acid are then placed. Each of the two musculofascial planes is closed with running suture of a similar material, usually size No. 1-0 or 0-0, the subcutaneous tissues with a size 2-0 running suture of the same material, and the skin with the surgeon's preferred material. Sadighi and Woodworth (1998) recommend placing a transcostal suture to minimize postoperative pain. We have not found it necessary to drill such holes in the rib.

The main advantage of the posterolateral thoracotomy is the superb exposure for most general thoracic procedures. The main disadvantages are the time expended because of the length of the incision and the amount of muscle and soft tissue transected. Khan and colleagues (2000) have demonstrated that there is diminished muscle strength following a posterolateral thoracotomy compared with a muscle-sparing thoracotomy.

AXILLARY THORACOTOMY

The axillary thoracotomy was originally developed for operations on the upper thoracic sympathetic nerve system. It was modified for first rib resection for thoracic outlet syndromes. Jensik (personal communication, 1993) used it preferentially for many years for pulmonary resections. Siegel and Steiger (1982) described how it has been rediscovered for more extensive general thoracic surgical procedures. Mitchell (1990) and Ponn and associates (1992) report several large series of axillary or lateral incisions with excellent results, although the largest series with which I am familiar comes from Noirclerc's group (1973). Some groups refer to it as a lateral thoracotomy to avoid confusion with small, high axillary incisions for first rib resections or apical bleb resections. Other groups refer to it as a minithoracotomy or muscle-sparing thoracotomy, but such nonspecific terminology should be discouraged. I prefer this incision for uncomplicated and straightforward pulmonary operations. It is not recommended for bulky tumors, sleeve resections, radical pneumonectomies, or repeat thoracotomies. This incision is particularly useful when a double-lumen endotracheal tube is used because the controlled atelectasis, combined with the ability of the anesthesiologist to elevate the mediastinum toward the operative field by applying positive end-expiratory

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pressure of 5 to 10 cm to the dependent lung, provides favorable operating conditions. The chief advantages are the speed of opening and closing, the reduced blood loss from minimal muscle transection, and the resulting reduced postoperative discomfort. As shown in Figure 25-4, the only muscle group that is actually transected is the intercostals.

Upper lobe lesions are best approached through the fourth interspace. Middle and lower lobe lesions are easily handled through the fifth interspace. For operations involving the lower esophagus we recommend using the sixth interspace. The patient is placed in a lateral decubitus position with the arm abducted at 90 degrees and positioned on an armrest.

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The antecubital fossa over the armrest is padded. The skin incision is made over the desired interspace, the latissimus dorsi muscle is elevated bluntly for a short distance and retracted posteriorly, and the serratus anterior muscle is split in the direction of its fibers. The surgeon should not divide the muscle too far posteriorly to avoid injuring the long thoracic nerve to the serratus anterior muscle. The intercostal muscles are divided in a way similar to that described for a posterolateral thoracotomy, and the pleural space is entered. The incision is so limited that wound towels and intercostal towels are not used. The intercostal muscle incision is carried forward to the anterior curve of the ribs and posteriorly to the level of the sacrospinalis muscle group. A Finochietto rib spreader is placed between the ribs, and a Tuffier rib spreader is placed in the opposite direction to retract the skin and latissimus dorsi muscle.

Fig. 25-4. Axillary thoracotomy. A. The arm is abducted 90 degrees on a rest and padded with care. Note the sequential compression device on the legs and the axillary roll. B. An incision is made in line with the desired interspace. It is not necessary to raise skin flaps. C. The latissimus dorsi muscle is retracted posteriorly to expose the serratus anterior muscle. D. The serratus is spread in the direction of its fibers, using the electrosurgical unit with care, being careful to avoid injury to the long thoracic nerve to the serratus anterior muscle. E. The anterior portion of the serratus is divided with the cutting current to expose the intercostal muscles. F. The intercostal muscles are divided near their inferior attachment to the rib. G. Two rib spreaders facilitate exposure. H. Generally, two chest tubes are used, and they are brought out near each other, so that a single maneuver suffices at the time of tube removal. From Landreneau RJ, et al: General Thoracic Surgery Current Trends. Norwalk, CT: Appleton & Lange, 1993. With permission.

Closure of the axillary thoracotomy is accomplished with three pericostal sutures of No. 2 polyglycolic acid after the placement of one or two chest tubes and usually the placement and positioning of a PARA catheter, if that technique is to be used for postoperative analgesia. Generally, traction on the pericostal sutures suffices to close the chest wall because it is difficult to use a ratchet-type rib approximator through the small axillary thoracotomy incision. If a problem with rib approximation develops, a towel clip can be used to bring the ribs together. The serratus anterior muscle is closed with a running absorbable suture, as is the subcutaneous fascial layer. Skin closure technique is again at the surgeon's discretion. Some female patients have disliked the incision's scar leading up to the breast or occasional breast soreness when some breast tissue has been incised. If the surgeon anticipates these issues when operating on a female patient, a vertical axillary incision, as suggested by Ginsberg (1993), could be used.

The axillary thoracotomy is not recommended for the occasional thoracic surgeon or for a difficult operation because the exposure is more limited than that of a posterolateral thoracotomy. However, it is a useful incision that deserves wider application than it has received in recent years. The axillary thoracotomy is associated with less postoperative discomfort than is noted with either the posterolateral thoracotomy or the median sternotomy. Kirby and co-workers (1995) have emphasized how little difference exists between a muscle-sparing thoracotomy and a VATS approach for lobectomy in terms of length of chest tube drainage, postoperative stay, and postoperative discomfort.

MEDIAN STERNOTOMY

The development of cardiac surgery has made median sternotomy the most common thoracic incision. It is the incision of choice for most cardiac operations and is used by preference by many thoracic surgeons for anterior mediastinal lesions, bilateral procedures such as the surgical treatment of bilateral spontaneous pneumothorax, and resection of multiple pulmonary lesions. Urschel and Razzuk (1986) wrote that they prefer it for many elective pulmonary resections, except for left lower lobe pulmonary resections. Cooper and colleagues (1978) demonstrated less alteration in pulmonary function by median sternotomy than by posterolateral thoracotomy. Median sternotomy was recommended by Baldwin and Mark (1985) and Perelman and colleagues (1987) for anterior transpericardial repair of postpneumonectomy bronchopleural fistula. Orringer (1984) described a partial median sternotomy for exposure of the lower cervical and upper thoracic esophagus.

The patient is positioned supine, with one or both arms extended, at the preference of the surgeon and the anesthesiologist. Both arms are often placed at the patient's side. The vertical skin incision is made from just below the suprasternal notch to a point between the xiphoid process and the umbilicus (Fig. 25-5). The pectoral fascia is divided, and the periosteum is scored with the electrosurgical unit. Care is needed when mobilizing tissues off of the area of the manubrium and dividing the tough interclavicular ligament. The tissues just to one side of the xiphoid process

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are mobilized, and the sternum is divided with a power saw, from the top down or from the bottom up. The anesthesiologist should cease ventilatory efforts as the sternum is being cut to lessen the chance of injury to the lung. Once the sternum is split, the two edges are gently but firmly retracted, and periosteal bleeding points are controlled with the electrosurgical unit. Bone wax is often not necessary in general thoracic surgical procedures because the patient is not anticoagulated, as is usual for patients undergoing cardiac procedures. Robicsek and colleagues (1981) suggested that the foreign body effect of bone wax can have a deleterious effect on wound healing. A sternal spreader is placed low in the incision to minimize excessive traction on the upper ribs, with attendant occult fracture and neurologic insult, as described by Van der Salm and associates (1980). The use of the Lebsche sternal blade should be familiar to the thoracic surgeon so that sternotomy can be performed if the power saw fails or is unavailable.

Fig. 25-5. Median sternotomy. A. The incision is made from the suprasternal notch to a point between the xiphoid process and umbilicus. B. The interclavicular ligament is divided with care. C. The sternal saw can be used in either direction. The anesthesiologist should not ventilate the lungs while the sternum is being divided. D. The upper two wires of No. 5 monofilament steel are passed through the manubrium.

Chest tubes or mediastinal drains, if the pleural space has not been entered, are passed through separate stab incisions. Sternotomy closure is accomplished with four to seven parasternal sutures of No. 5 stainless steel wire, the ends of which are securely twisted and buried in the sternal tissues. The pectoral fascia is closed with a running polyglycolic acid suture, as is the linea alba. The subcutaneous tissues are closed with running absorbable suture, and the skin is closed with the surgeon's preferred material.

The scar from the usual vertical median sternotomy incision is a source of concern to some patients, especially young women. Various alternatives have been proposed, and the transverse submammary skin incision described by Laks and Hammond (1980) appears to have definite cosmetic advantages for certain patients. Those authors do caution about skin flap viability for prolonged operations, as rather extensive undermining of the skin flaps is required.

The main advantages of median sternotomy for general thoracic surgical procedures are its speed in opening and closing, its familiarity to many surgeons, and its outstanding exposure for anterior mediastinal lesions. The major disadvantage is poor exposure of posterior hilar structures, especially those of the left lower lobe. My colleagues and I think that a median sternotomy is more painful in the postoperative period than an axillary thoracotomy and that it is similar in the degree of postoperative discomfort to a posterolateral thoracotomy, although others disagree. I prefer to have the anesthesiologist place a CEA catheter before making the skin incision for a sternotomy. Many cardiac surgeons eschew the CEA. When effective pain control following sternotomy is mandatory, such as after thymectomy for myasthenia gravis, CEA is an asset to good patient care.

ANTERIOR THORACOTOMY

The anterior thoracotomy has the distinct advantage of allowing the patient to remain supine, with a resulting improvement in cardiopulmonary function. It has been used with decreasing frequency because of improvement of anesthetic techniques and management, the option of median sternotomy, the development of mediastinal staging procedures

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such as mediastinoscopy and mediastinotomy, and the rapid development of VATS for lung biopsy. It remains the incision of choice of some surgeons for open-lung biopsy. It is occasionally used in the Ivor Lewis procedure for carcinoma of the esophagus to eliminate the need for repositioning the patient after the intraabdominal portion of the operation. Its main disadvantage is the limited exposure it provides.

Fig. 25-6. Anterior thoracotomy. A. Outline of skin incision. B. Pectoralis major muscle divided over the fourth interspace. C. Closure of the intercostal incision by placement of pericostal sutures of heavy polyglycolic acid as well as sutures of the same material through the sectioned costal cartilage.

The patient is positioned with a roll under the back and hips to elevate the operated side. The ipsilateral arm is placed under the back, on an elevated arm board, or on an over-armrest at the preference of the surgeon. An incision is made over the fourth or fifth interspace from the midaxillary line to curve parasternally (Fig. 25-6). In women, the incision is made in the inframammary crease. The pectoral muscles are divided with an electrosurgical unit, and the intercostal incision is made in the usual fashion. If a major resection is expected, one or two costal cartilages may be divided parasternally to facilitate exposure of the surgical field. If the cartilages are divided, the neurovascular bundles are divided over clamps and ligated to avoid tearing and excessive stretching of the blood vessels.

Closure of the anterior thoracotomy is similar to that of the other thoracotomy incisions. A heavy absorbable suture is placed through each end of the cartilage parasternally, if it has been divided.

A limited anterior thoracotomy should receive strong consideration when open-lung biopsy is needed in the critically ill patient. In such a patient, the traditional VATS type of lung biopsy might be inappropriate because it would require a double-lumen endotracheal tube and single-lung ventilation for a period of time. A small incision combined with the use of VATS-designed staples can be efficacious.

TRANSVERSE THORACOSTERNOTOMY

Cooper (1991) and Pasque and associates (1990) redescribed the transverse thoracosternotomy, and many refer to it now as the clamshell or crossbow incision. Its primary role in recent years has been for bilateral lung transplantation. I, however, recommend it as an alternative to median sternotomy for bilateral general thoracic surgical procedures, such as the resection of bilateral metastatic lesions to the lungs and bilateral simultaneous treatment of spontaneous pneumothorax.

Bains and co-workers (1994) have emphasized its usefulness in thoracic oncology interventions.

The incision is made over the fourth or fifth interspace, and the sternum is transected with an oscillating saw (Fig. 25-7). Closure is accomplished with pericostal sutures of heavy polyglycolic acid, with a figure-eight maneuver around the sternum. I recommend placement of several Kirschner wires in the reapproximated sternum to reduce override and shift of the sternal ends (Fig. 25-8).

Fig. 25-7. Clamshell incision has become popular for bipulmonary lung transplantation and also for bilateral procedures on the lung when excellent exposure is mandatory.

Several well-known European thoracic surgical groups have recommended doing bilateral anterolateral thoracotomies rather than a clamshell incision. Taghavi (1999) and Macchiarini (1999) and their associates describe how they have abandoned the clamshell incision.

THORACOABDOMINAL INCISION

The thoracoabdominal incision provides extended exposure, particularly for operations in the lower thorax and upper abdomen. It has been used less frequently in the past and has been maligned more by hearsay perhaps than by actual fact. It can be particularly useful for difficult operations involving the lower esophagus. A seventh or eighth interspace incision is extended on the same oblique line into the upper quadrant over toward the midline. The costal margin is cut with a knife. Ginsberg (personal communication, 1993) recommended not excising a segment of cartilage and placing pericostal closure sutures securely on either side of the transected costal margin but not through the cartilage. He suggested that the incision results in a stable thorax with no significant increase in discomfort or dysfunction over a standard posterolateral thoracotomy. A curvilinear or radial incision can be made in the diaphragm to facilitate exposure. The diaphragm is closed with a running nonabsorbable suture such as No. 0 Prolene. Costochondritis has been reported in some series. Its incidence is low, but if it occurs, it is a troublesome complication. Heitmiller (1988) gave an excellent review of the incision.

Fig. 25-8. Posteroanterior (A) and lateral (B) radiographs of a closed clamshell incision demonstrating Kirschner wires in place to stabilize the sternum. The patient had undergone successful simultaneous bilateral excision of giant bullae with an excellent result.

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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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