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Muscle-sparing Axillary Thoracotomy

Open ArchivePublished:March 05, 2018DOI:https://doi.org/10.1053/j.optechstcvs.2018.02.004
      The standard posterolateral thoracotomy provides excellent exposure to the chest and has traditionally been the incision of choice for major intrathoracic operations. However, this approach comes at the cost of muscle-splitting, with significant postoperative pain and impairment in function, particularly in elderly patients. Consequently, muscle-sparing approaches have been met with enthusiasm due to improvements in postoperative pain, morbidity, and cosmesis. Although concerns regarding exposure initially limited the use of this incision, advances in technology and experience have led to more widespread use of the muscle-sparing approach. Today, the muscle-sparing thoracotomy is the incision of choice for many surgeons, as it can be used as an adjunct to video-assisted thoracoscopic surgery and has successfully been employed in complex thoracic procedures.

      Keywords

      Successful thoracic surgery relies on adequate exposure to the chest. The standard posterolateral thoracotomy incision provides excellent exposure for nearly all intrathoracic procedures, with adequate functional and cosmetic results. However, this incision comes at the price of muscle division and significant postoperative pain.
      Muscle-sparing alternatives to the posterolateral thoracotomy have been met with enthusiasm by many surgeons. These approaches are advantageous technically due to increased ease and speed of chest entry and closure, and have the benefit of leaving the major thoracic muscles intact. Although no study has definitively shown improved long-term outcomes with a muscle-sparing compared to a muscle-dividing approach, postoperative improvements in pain, shoulder function, forced expiratory volume in 1 second, and forced vital capacity have been reported.
      • Murthy S.C.
      Thoracic incisions.
      Additionally, cosmesis is improved as these incisions are typically shorter and lower profile than the standard posterolateral thoracotomy.
      Initially underutilized due to limitations of exposure, the muscle-sparing approach has garnered favor more recently due to improvements in thoracoscopic instrument technology (eg, stapling devices) and increased surgical experience. This approach provides excellent exposure to the hilum of the lung, and consequently works for most thoracic procedures including lobectomy, pneumonectomy, and esophagectomy. Exposure to the apical or diaphragmatic areas is more limited, and thus procedures such as posterior chest wall resections or resection of Pancoast tumors may be better-suited for a standard posterolateral thoracotomy. Although some authors have argued that complex resections, such as bronchial sleeve resections or pulmonary arterial reconstructions, should not be performed via this approach, successful use of this incision for these procedures has been documented.
      • Marshall M.B.
      Thoracic approaches.
      In the video-assisted thoracoscopic surgery (VATS) era, the muscle-sparing approach can be advantageous if problems are encountered during a thoracoscopic procedure. One port site can be incorporated into the vertical skin incision, and another can be used for instrumentation (eg, insertion of forceps or stapling devices) or eventually become the chest tube site. Additionally, a thoracoscope can be inserted into this port to improve visualization during the procedure, allowing greater access to the lung apex, and to allow both surgeons, students, or operating room personnel to follow the operation. The operative technique is described in detail in the pages that follow (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9).
      Figure 1
      Figure 1The patient is positioned in the lateral decubitus position on the operating table and rotated slightly posteriorly. The axilla is opened by flexing and abducting the ipsilateral arm to 90 degrees. The sterile field is extended posteriorly to the spine to allow for conversion to standard posterolateral thoracotomy if necessary.
      Figure 2
      Figure 2A 5- to 7-cm incision is then made parallel to the anterior border of the latissimus dorsi muscle. The incision may be oriented vertically or obliquely, and is usually centered on the fourth intercostal space. Placing this incision too far posteriorly may result in injury to the long thoracic nerve.
      Figure 3
      Figure 3After division of the subcutaneous tissues, the anterior aspect of the latissimus dorsi muscle is identified. It is then carefully dissected off the underlying serratus anterior and retracted posteriorly.
      Figure 4
      Figure 4The serratus anterior is then divided along its fibers over the appropriate interspace (typically fourth or fifth). The chosen interspace is then entered in the typical fashion. The intercostal muscles are divided anteriorly and posteriorly well beyond the confines of the skin incision, almost to the vertebral bodies, to facilitate rib spreading.
      Figure 5
      Figure 5A standard chest (eg, Finochietto) retractor is used to spread the ribs. A second chest retractor (eg, Balfour) is placed perpendicular to the first to retract the latissimus dorsi posteriorly. The planned operation can now proceed.
      Figure 6
      Figure 6After placement of chest tubes, the chest is then closed in the typical fashion. Retractors are removed, and the ribs are reapproximated with absorbable pericostal sutures.
      Figure 7
      Figure 7The serratus anterior muscle is repaired in a running fashion with braided suture.
      Figure 8
      Figure 8The latissimus dorsi is allowed to return to its anatomical position, and the subcutaneous tissue and skin are closed with running absorbable sutures.
      Figure 9
      Figure 9(A) The muscle-sparing incision can be a useful adjunct during a VATS procedure. Here, a stapling device is inserted into 1 port site while the lung is retracted through the primary incision. VATS = video-assisted thoracoscopic surgery. Continued (B) Alternatively, a wound protector may be used to retract soft tissue, providing a large working port site. This may also be used as the so-called “accessory incision” to extract the specimen.
      Figure 9
      Figure 9(A) The muscle-sparing incision can be a useful adjunct during a VATS procedure. Here, a stapling device is inserted into 1 port site while the lung is retracted through the primary incision. VATS = video-assisted thoracoscopic surgery. Continued (B) Alternatively, a wound protector may be used to retract soft tissue, providing a large working port site. This may also be used as the so-called “accessory incision” to extract the specimen.

      Special Considerations

      Early descriptions of the muscle-sparing thoracotomy describe the use of the standard muscle-splitting incision in a muscle-sparing manner, with elevation of skin flaps superiorly and inferiorly to allow for mobilization of the latissimus dorsi muscle.
      • Bethencourt D.M.
      • Holmes E.C.
      Muscle-sparing posterolateral thoracotomy.
      However, this technique was often complicated by postoperative seroma formation. The modern-day vertical incision eliminates the need for skin flaps and prophylactic subcutaneous drain placement, and has resulted in a dramatic improvement in the incidence of postoperative seroma.
      • Hennington M.H.
      • Ulicny K.S.
      • Detterbeck F.C.
      Vertical muscle-sparing thoracotomy.
      Special attention must be paid to the location of the initial skin incision. A more posterior incision may result in long thoracic nerve injury and necessitates greater mobilization of the latissimus dorsi muscle, contributing to both inadequate exposure and postoperative pain. Additionally, the intercostal brachial nerve runs in the superior half of this incision. Patients should be counseled preoperatively that they may have numbness in this distribution if preservation during the procedure is not possible.

      Postoperative Care

      Postoperative pain is generally improved compared to the posterolateral thoracotomy. Recovery time is often improved as well due to better shoulder and arm function, resulting in less morbidity, particularly in elderly patients. Studies have shown similar postoperative outcomes in patients undergoing muscle-sparing thoracotomy compared to VATS procedures.

      Conclusions

      Today, the muscle-sparing axillary thoracotomy is the incision of choice for many thoracic surgeons. Improvements in technology and experience have overcome initial limitations of exposure, and this approach can now be used for most major thoracic operations.
      The posterolateral thoracotomy undoubtedly still affords the greatest exposure, and should be used for the most complex cases, or in cases where anatomical considerations necessitate a more posterior approach. However, muscle-sparing incisions can be used in the majority of patients, as an initial approach or in conjunction with VATS technology. We believe this approach is beneficial for most patients due to a better cosmetic result, improvement in postoperative pain, quicker recovery of function, and decreased morbidity postoperatively.

      References

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        Thoracic incisions.
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        Thoracic approaches.
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