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Introduction

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A surgical incision opens an aperture into the thorax to permit the work of the planned operation to proceed. If placed correctly, the operation proceeds with unimpeded visualization of the important anatomy. If placed incorrectly, it can lead to frustrating delays and difficulty in the operation. Dr. Robert E. Gross' admonition, “If an operation is difficult, you are not doing it properly,” applies directly to the incision used.* This chapter is designed for both the novice and those who have already gained some experience with thoracic incisions. The artwork is designed to explain important relationships for the inexperienced. We also have provided subtle pearls that will rekindle an appreciation of different incisions for the more experienced. More important, we have tried to explain the logic behind the incisions.

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Each incision is described in terms of its current general use, technical details, advantages, and disadvantages. We also provide details of chest wall anatomy, with particular attention to structures that can be injured while developing the incision. Finally, we provide surface anatomy landmarks that can be used to place the incision properly.

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As the thoracic surgeon gains experience, these incisions frequently will be modified to accommodate the primary surgical objective of a given operation. Furthermore, as technology progresses, these standard incisions may begin to change. For instance, in the modern era of video-assisted techniques, even classic open incisions are decreasing in length as surgeons become more comfortable with the concept of centering the incision on the anatomy that is critical for the operation to progress. In this regard, these standardized incisions can be thought of as building blocks, similar to the notes of a musical chord. It is our belief that the more the surgeon understands the strengths, weaknesses, and possibilities of each incision, the quicker he or she will learn to use the full variety of possible incisions tailored to the individual patient.

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Posterolateral Thoracotomy

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General Use
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Posterolateral thoracotomy is the standard workhorse for most thoracic surgeons. It offers excellent direct visualization of the entire thoracic cavity, including the posterior diaphragmatic sulcus and apex of the hemithorax. The incision generally is centered over the fifth intercostal space, which corresponds to the greater fissure of the lung. This provides an unobstructed view of the base of the fissure, the pulmonary artery, and the hilum. The incision generally is used for anatomic lung resections, including pneumonectomy and lobectomy. It offers the easiest access for radical lymphadenectomy. An extended posterolateral thoracotomy is used for Pancoast resection, extrapleural pneumonectomy, and aortic transection.

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Technique
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The patient is placed in a standard lateral decubitus position, with the ipsilateral arm extended forward. The inferior tip of the scapula is palpated and generally marked. The incision begins approximately 3 cm posterior to the scapula tip and approximately halfway between the scapula and the spinous process. The ...

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