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.
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.
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.
*Personal communication with W. Hardy Hendren on the origin of Dr. Gross' sign, September 20, 2007: “The sign was made by Dr. Robert E. Gross. He was the William E. Ladd Professor and surgeon-in-chief of Children's Hospital in Boston from 1947 to 1967, when he was succeeded by Dr. Judah Folkman. Dr. Gross was then appointed cardiovascular surgeon-in-chief until he retired in 1972. The sign hung in OR 3, which, sadly, became an anesthesia workroom when the OR suite was enlarged. Dr. Folkman saved the sign, which was an important relic of the past. In 1982, Dr. Folkman elected to spend full time in his burgeoning laboratory. He was succeeded by W. Hardy Hendren, who had been for 22 years head of pediatric surgery at the Massachusetts General Hospital. When Dr. Hendren was appointed chief of surgery at Children's Hospital in 1982, Dr. Folkman presented the sign to him. It hung in OR 7 until the operating suite was once again enlarged, and the room was changed into a nursing administrative office. Alas, planners have no appreciation of historical places. Only the original Ida Smith ward, where the surgical neonates were housed back to the Ladd era, has thus far escaped the wrecker's ball. When Bob Shamberger became chief of surgery, I passed on to him ‘The Sign.’ It is now in his office. Perhaps it will find its way back to the OR. I hope the above will correct the record on the famous sign. Best regards, Hardy.”
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.
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 incision curves around the tip to lie along the top margin of the sixth rib (fifth intercostal space). In general, it extends to the anterior axillary line (Fig. 2-1). The soft tissue and Scarpa's fascia are divided. The latissimus dorsi muscle is divided. The auscultatory triangle, the space bounded by the lower border of the trapezius, the serratus anterior, and the medial margin of the scapula can be identified at this time. The serratus anterior muscle can be spared by freeing it from the soft tissue of the auscultatory triangle and the muscle rotated forward. Preservation of the serratus anterior muscle helps to preserve the motion of the shoulder girdle and quickens recovery time. An intact serratus anterior muscle can limit the spread of the fifth and sixth ribs. This can be overcome by detaching the lower slips of attachment of the muscle from the eighth, seventh, and sixth ribs (Fig. 2-2).
Standard posterolateral thoracotomy incision, with extrathoracic musculature and surface landmarks. The incision wraps around the tip of the scapula and parallels the course of the sixth rib.
Posterolateral thoracotomy divides the latissimus dorsi muscle and rotates the serratus anterior muscle forward. The incision appears centered on the greater fissure of the lung, providing access to the pulmonary artery at the base of the fissure.