THORACIC INCISIONS
INTRODUCTION
Incision;- Is a surgical wound made by a surgeon on the skin, with intension of gaining access to a lesion beneath or cavity. Such wounds created anywhere on the chest (thoracic) wall is thoracic incision
Anatomy of the chest
CHEST WALL
Bony rib cage;- manubrum, sternum, 12 pair of rib, coastal cartilage & thoracic vertebrae Soft tissue covering:- muscles, neurovascular bundles, other connective tissues Two aperture Superior=root of the neck Inferiorly=separated from abdominal cavity by diaphragm
Types of thoracic incisions
Sternotomy Thoracotomy Axillary thoracotomy Anterior mediastinotomy Thoracoabdominal incision Bilateral Trans-sternal thoracotomy( clam-shell incision) Extra-thoracic approaches to the thorax
Sternotomy incisions
Partial
Hemisternotomy (spares 6-8cm skin)
Complete
Suprasternal notchxyphoid process Cosmetically appealing type of incision e.g inframammary (bikini type) incision
Median sternotomy incision
Sternal spreader applied
Median sternotomy
Indications exposure of ant. & middle mediast lower cervical procedures Tracheal resection& reconstruction
Indications
Excision of thyroid masses & parathyroid adenomas Excision of cervical oesophageal tumours Exposure of heart & great vessels In cardiopulmonary bypass
Advantages
Quick to perform Excellent exposure Safe Heals quickly Less incisional pain
Disadvantages
Many finds the vertical incision unsighty Gives limited exposure of the lower chest & posterior mediastinum May lead to post-op complications-unsteable sternum, infections
Technique
Standard sternotomy Open sternotomy Re-operative sternotomy Partial sternal split
CLOSURE:Interlucking wire suture technique
Less invasive sternotomy incisions
Hemisternotomy- suprasternal notch,tee-off to the R at interspace 4 or xyphoid,tee-off,R, at interspace 2 Full sternotomy with skin sparing Bikini-type (inframammary) incision- cosmesis
Less invasive sternotomy incisions
COMPLICATIONS
Anaesthetic:- arrhythmias, laryngeal spasm Specific :- Early; haemorrhage,injury to contiguous structures, pneumothorax, haemothorax, Late; infection, empyema thoracis, post surgery pain
Complications
Mediastinitis (S.aureu31%,E.coli3%,enterococcus 2%) Sternal osteomyelitis Brachial plexus injury,incidence:1.4-6.5%
Thoracotomy
Standard thoracotomy incisions Defined arbitrarily in relation to the position of Latissismus dorsi muscle,which is laterally sited on the chest wall
Types of thoracotomy incisions
Lateral Anterior Anterolateral Posterolateral Posterior others
The numenclature for std thoracotomy incisions
Indications for posterolateral incision
Standard thoracotomy incisions can be used for a wide range of surgical procedures involving; The Heart Oesophagus Mediastinum Ipsilateral lung
Advantages
Flexibility of the incision Wide range of intra-thoracic exposure Proven experience with these incisions has made them the standard thoracic incisional approach
Disadvantages
Has potential for poor exposure , if wrong interspace is chosen Unilateral hemithorax exposure Incisional pain Disability related to division of chest wall muscles Detrimental effect on pulmonary function
Technique (posterolateral)
Induction using single/double lumen tube Appropriate monitoring Anaesthesia-G.A+ETT Positioning lateral decubitus position Cleaning/drapping
Crescent or lazy-Sincision, transversely Dissected down & scapular retracted Pleural space entered Pleural/mediastinal drainage Thoracotomy closure
Option for entering the pleural space after posterolateral thoracotomy
Intercostal approach-incising i.c muscles Utilizing intercostal incision but to divide one or more ribs To resect a rib, enter through its periosteal bed
Anterior & anterolateral thoracotomy
Indications Has greater use historically Used for pulmonary resection Cardiac procedures Management of mediastinal masses Oesophageal pathology
Technique
Monittoring Anaesthesia are same as posterolatral Supine position Chest elevated at 30-45 Curved submammary incision, extended laterally(anterolateral)
Anterolateral thoracotomy incisions
Lateral thoracotomy
Within confines of latissimus dorsi Transverse incision 1-2cm inferior to the scapular
Complications
Post thoracotomy incision pain Wound infection Wound dehiscence Bronchopleural fistula-8% Empyema thoracis-2.2%
Muscle-sparing thoracotomy
Indications
As in std thoracotomy Variant of std thoracotomy Well established Has less complications
Muscle sparing anterolateral thoracotomy incision
Advantages
Less early post-op pains Greater shoulder girdle strength Most result in quick closure Preserve chest wall muscle Prevent chest wall deformity
Axillary thoracotomy Indications
1st rib disection Apical bleb Dx Mgt of spontaneous pneumothorax with apical pleurectomy or pleurodesis Staging of lung cancer
Patient positioning & incision for a vertical axillary incision
ADVANTAGES
Small incision Quickly performed Muscle sparing Cosmetically appealing Ideal for pt with poor pulmonary function
Disadv
Limited exposure Intercostobrachial nerve injury Proximal lung thorcic nerve injury
Complications
Very minimal Infection-0.7% Limited shoulder mobility-0.5%
Anterior mediastinotomy (chamberlain procedure)
Used in scalene lymph node biopsy Exploratory thoracotomy In cases of lung cancer( inoperable)
Anterior mediastinotomy(Chamberlain)
Thoracosternotomy(Clam shell)
Left thoracoabdominal incision
provides excellent exposures for procedures involving the spleen Stomach L hemidiaphragm Aorta lower oesophagus
Current trend
Towards minimally invasive procedures Thoracic- VATS (video asst thoracoscopic surgery) e.g TEF LIGATION Cardiac- OPCAB (off-pump coronary art. Bypass) MIDCAB (mini invas dir coron art. Bypass)
Endoscopic aortic/mitral valve replacement
