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The posterolateral thoracotomy is still probably the most commonly used incision in general thoracic surgery. It provides not only excellent access to the lung, hilum, middle and posterior mediastinum, endothoracic trachea, and endothoracic esophagus, but it also allows for the safe control of pulmonary blood vessels during pulmonary resection. Posterolateral thoracotomy offers more accessibility to all areas of the hemithorax than any other incision.
The 2 potential disadvantages of posterolateral thoracotomy are that it is painful, and that it may disturb the respiratory mechanics through division of respiratory muscles and decreased mobility of the chest wall. Obviously, these disadvantages are magnified in older patients with compromised cardiopulmonary function. However, these difficulties can be minimized using modern techniques of postoperative care, such as epidural analgesia.
Posterolateral thoracotomy provides excellent exposure to the pleural space and its contents. Unfortunately, it is an incision that has gained the unenviable reputation of being very painful postoperatively and one that surgeons try to avoid. In our view, this reputation is unjustified if one is very meticulous with surgical technique. This technique begins with positioning the patient, which must be done carefully if one is to avoid shoulder or brachial plexus injuries. The skin incision must be placed properly and be slightly oblique in the front. The serratus muscle must not be divided, and the pleural space must be entered through the proper intercostal space. This space should be spread slowly to avoid rib fractures. Chest tubes must be properly placed and the chest closed in a systematic fashion. Attention to all these details will decrease the amount of postoperative discomfort. Ultimately, it will decrease the incidence of pulmonary complications and postoperative deaths.
Address correspondence to Jean Deslauriers, MD, Centre de pneumologie de l'Hôpital Laval, 2725, chemin Sainte-Foy, Sainte-Foy QC Canada G1V 4G5.