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© 2004 European Association of Cardio-Thoracic Surgery
Feasibility of latissimus dorsi and serratus anterior muscle-sparing vertical thoracotomy in general thoracic surgeryDepartment of Thoracic and Cardiovascular Surgery, Seoul Veterans Hospital, 6-2 Dunchon-dong Kangdong-gu, Seoul, South Korea
* Corresponding author. Tel.: +82-2-2225-1349; fax: +82-2-477-5605 Received October 1, 2003; received in revised form December 16, 2003; accepted January 30, 2004
Postero-lateral thoracotomy has many complications such as postoperative pain, limitation in the motion of the shoulder, decreasing pulmonary function from immobilization, increasing lung atelectasis from over-use of analgesia, and increasing pulmonary morbidity, especially in elderly patients. So, muscle-sparing thoracotomy appears to be a good alternative. But it has also many disadvantages such as seroma and the needs for drains, limitation of an accessible operative field, and difficulties with risky procedures. We have modified muscle-sparing vertical thoracotomy. We performed 134 procedures on 131 patients from October 2000 to September 2003, including 15 cases of esophageal cancer, 95 cases of lung cancer, and 24 cases of other disease. Operative procedures were lobectomy in 74 cases, bilobectomy in 12 cases, pneumonectomy in 10 cases, wedge resection in 8 cases, decortication in 2 cases, Ivor Lewis procedure in 13 cases, and others in 15 cases. There was no occurrence of wound infection, arrrhythmia, fibrillation, and subcutaneous seroma except the first two cases. We had seven reoperations (two postoperative bleeding, three postpoperative BPF, one EGstomy leak, one RML torsion) and four operative mortalities (one postpneumonectomy BPF, two pneumonia, one heart failure). Our muscle-sparing vertical thoracotomy can be done safely in most thoracic surgery including lung and esophageal cancer, therefore it is a feasible procedure.
Key Words: Vertical thoracotomy
Postero-lateral thoracotomy is accepted as a standard incision in general thoracic surgery because of wide exposure of the thorax to conduct any operations; it is an easy procedure in technique and takes a relatively short time to enter the pleural cavity. In patients with thoracic malignancy, when we encounter difficult hilar dissection, chest wall resection, bronchoplasty, vasculoplasty, adhesiolysis of lung, etc., we realize that a safe and easy method is the best for the thoracic surgeon. However, the number of elderly patients is increasing and postoperative pulmonary morbidity is also increasing. Standard postero-lateral thoracotomy needs to divide the large thoracic muscles, latissimus dorsi and serratus anterior, which can lead to postoperative pain, limitation in the motion of the shoulder and upper extremities. As a result, patients usually experience decreased pulmonary function from immobilization, increased lung atelectasis from over-use of analgesia, and increased pulmonary morbidity, especially in elderly patients. Many authors [1–6] reported that muscle-sparing thoracotomy is an excellent alternative because of less postoperative pain and morbidity and better cosmetic results than standard postero-lateral thoracotomy. The demand for minimal invasiveness in surgery is increasing nowadays, and some technical advances have been made, such as one-lung ventilation anesthesia, the auto-stapler device, illumination device, etc. We conduct operations more easily than before with smaller incisions without subcutaneous drains. Thoracoscopic surgery has been introduced but is still not feasible and can take too much time generally. We have modified muscle-sparing vertical thoracotomy as a new and easy method and conducted the procedure to confirm the feasibility.
We performed muscle-sparing vertical thoracotomy without dividing the latissimus dorsi and serratus anterior muscles totally in 134 procedures on 131 patients from October 2000 to September 2003. Among them, there were 15 cases of esophageal cancer, 95 cases of lung cancer, and 24 cases of other benign disease (Table 1).
2.1. Technique The patient is placed in a lateral decubitus position with the arm abducted at 90° and flexed slightly to minimize extensions of latissimus dorsi and serratus anterior. (Avoid the arm flexed at 90°, or else the operative field is limited due to over-extension of latissimus dorsi and forwarding of scapula.) A vertical incision is made 12 cm (4.8inch) length in posterior axillary line (more posterior to the anterior border of latissimus dorsi) below the scapula tip. The subcutaneous tissue and superficial fascia are developed in one layer to allow exposure of the anterior border of latissimus dorsi. To avoid seroma formation, it is necessary to minimize the dissection as much as possible. Latissimus dorsi is mobilized and retracted posteriorly, until the postero-inferior border of serratus anterior is exposed. Serratus anterior is developed along the postero-inferior border and retracted anteriorly to expose the thoracic rib cage. It is necessary to be careful to avoid injury on the long thoracic nerve to serratus anterior. Serratus anterior originates from the upper eight ribs and is inserted into the medial border of scapula (Fig. 1). If we enter via the 4th intercostal space, we must detach four fleshy digitations of serratus anterior from the 5th, 6th, 7th and 8th ribs. If we enter via the 5th intercostal space, we must detach three fleshy digitations of serratus anterior from the 6th, 7th and 8th ribs and if we enter via the 6th intercostal space, we detach only two fleshy digitations of serratus anterior from the 7th and 8th ribs. So, we routinely enter via the 6th intercostal space, and the 7th in lower esophageal surgery, to save more fleshy digitations of serratus anterior. The intercostal muscle is divided at its lower rib attachment as far anteriorly as 1 cm prior to internal thoracic artery, posteriorly as erector spinae. Placing a Canadian cardiac retractor to spread the ribs, a Tuffier retractor is inserted perpendicularly, to retract latissimus dorsi and serratus anterior (Video 1). There is no need to resect any ribs to achieve more exposure. After completion of the operative procedure, closure is very simple and quick. Chest tubes are inserted below the incision, the ribs are approximated with two absorbable pericostal sutures using Mexon 1–0 by the figure-of-eight method. No inter-costal suture is needed. The muscles, including two detached fleshy digitations of serratus anterior from the 7th and 8th ribs, put naturally into place without suture. Closure is accomplished with reapproximation of subcutaneous tissue and superficial fascia in one layer using Dexon 1–0 by simple running suture. No drain is needed. A pressure dressing is applied with fabric binder before changing position. In my Video 2.mpg, you can see the motion of the arm and shoulder of a 72-year-old lung cancer patient who underwent LLLobectomy (2nd postoperative day), and an esophageal cancer patient who underwent esophago-jejunostomy due to prior total gastrectomy 10 years previously (14th postoperative day).
The mean age of the patients was 67 years (range 43–81). The operative procedures were as follows: lobectomy in 74 cases, bilobectomy in 12 cases, pneumonectomy in 10 cases, wedge resection in 7 cases, decortication in 2 cases, Ivor Lewis procedure in 13 cases and others in 16 cases. There was no occurrence of wound infection, arrrhythmia, fibrillation, and subcutaneous seroma except for the first two cases. We had seven reoperations (5%): postoperative bleeding in two cases, postpoperative BPF in three cases, EGstomy site leak and RML torsion in one case, respectively. We had four operative mortalities (3%): postpneumonectomy BPF in one case, pneumonia in two cases, and heart failure in one case.
Since Denis Browne described vertical thoracotomy in 1952 to avoid long thoracic nerve damage [7], many authors [1–6] have reported it with or without dividing muscles. The advantages are generally accepted, but it is felt to be a burdensome procedure for occasional or unskillful surgeons. But, with experience, the procedure becomes easier. Although it is a smaller incision than other vertical procedures, the exposure created by my modified incision, is adequate for most operations including decortication and the Ivor Lewis procedure. It has become my incision of choice when performing all thoracic surgical procedures, and it is a time-saving procedure. This modification of muscle-sparing vertical thoracotomy can be done safely in most thoracic surgery including lung and esophageal cancer, and is a feasible procedure.
ICVTS on-line discussion Author: Dr. Luciano Solaini, S. Maria delle Croci Hospital, Department of Surgery, V. le Randi 5, Ravenna, 48100 Italy Date: 15-May-2004 Message: This article describes a modified vertical axillary thoracotomy and emphasizes its use in many thoracic surgical procedures. In the past I used a similar vertical approach, but I abandoned it because of the limited operative working space allowed. Indeed this incision involves some difficulties in performing adhesiolysis between the lung and the diaphragm or in the costophrenic angle. For this reason I registered two cases of postoperative bleeding in which a reoperation was necessary. Did the authors find the cause of the reported cases of hemorrhage in bleeding adhesions just near the diaphragm? I believe that this problem could be solved by the use of an added thoracoscope, but the procedure could take a lot of time and become very tedious. I am of the opinion that muscle-sparing thoracotomy has many advantages over the standard postero-lateral one and therefore it has to be used as much as possible. Currently I am adopting the incision over the auscultatory triangle [1] which has the advantage of being easily extended in postero-lateral thoracotomy when necessary. I think this incision is a good compromise between safety and limited chest wall damage. Reference [1]Horowitz MD, Ancalmo N, Ochsner JL. Thoracotomy through the auscultatory triangle. Ann Thorac Surg 1989;47:782–3. Response Author: Dr. Doosang Kim, Seoul Veterans Hospital, Dept. of Thoracic and Cardio-vascular Surgery, 6-2 Duncheon-dong Kangdong-gu, Seoul, 134060 South Korea Date: 18-May-2004 Message: My modification of vertical muscle-sparing thoracotomy has a smaller incision (less than 5 inches) than other procedures. So, the limited operative working space is troublesome to us, but, with experience, the exposure created by my modified incision, is adequate for most procedures including decortication and Ivor Lewis procedure. I performed 174 cases on 162 patients from Oct 2000 to May 2004. Patients' mean age is 67 with range from 20 to 82 years. I have 3 bilateral cases and 9 redo cases. Among the 9 reoperations, 3 cases had postoperative bleeding. The first patient, a 69 year-old male underwent LULobectomy for T2N0 Lung cancer on May 10th 2001, and the second patient, a 74 year-old male, underwent Ivor Lewis for T1N0 Esophageal cancer on May 23rd 2003, and they were reoperated for hemostasis of bronchial artery bleeding, respectively. The third patient, a 72 year-old male, underwent LULobectomy for T2N0 Lung cancer on January 16th 2004. He was reoperated for exploration, but there was no definite bleeding focus, so I evacuated only hematoma and later, the Lab showed bleeding tendency with prolonged aPTT level. I realized that it had not been necessary to redo him for exploration. The 3 bleeding cases were not related to pleural adhesion. Among 174 cases, I experienced 41 cases of adhesion of entire pleural cavity including diaphragm and costophrenic angles (lung cancer in 25, bullae in 5, empyema in 3, BPF and fungus ball in 2 respectively, esophageal cancer, diaphragm eventration, tuberculosis granuloma, and bronchiectasis in 1 respectively), so I conducted adhesiolysis and other procedures including decortication. Still, I do not use thoracoscope aid during operation. But I hope we will use it with more ease someday through advanced technology. And I also hope to see the method of Dr. Luciano Solaini, and to develop together easier and less invasive techniques in the general thoracic surgery sector.
We thank Ahyoung Jee of J&J for video-technical assistance.
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.icvts.2004.01.017.  Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003. doi:10.1016/j.icvts.2004.01.017
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Abstract
1. Introduction