Plate 195

This incision is ideal for a wide variety of elective as well as emergency procedures. Through the left side, the left lung, the heart, descending aorta, lower esophagus, vagus nerves, and diaphragmatic hiatus are well exposed, whereas both vena cavas, the right lung, the superior exposure of the hepatic veins, and the upper esophagus are approached through the right chest.

The height of the incision on the chest wall varies with the nature of the procedure to obtain optimum exposure of either the apex, the middle, or the basal portions of the chest cavity. One or more ribs may be divided posteriorly and occasionally removed, depending on the mobility of the chest wall and the exposure required. For optimum exposure of the upper portion of the chest cavity, such as in closure of a patent ductus or resection of a coarctation, the chest is entered at the level of the fifth rib. This may be divided posteriorly, along with the fourth rib, if necessary. For procedures on the diaphragm and lower esophagus, the thoracic cavity should be entered at the level of the sixth or seventh rib. If still wider exposure is desired, one or two ribs above and below may be transected at the neck.

Except in acute emergencies, the patient must be prepared for optimal pulmonary function by cleaning the tracheobronchial tree with postural drainage, expectorants, and antibiotics, which may be given both systemically and by inhalation. Preventative spirometry is preferably started preoperatively to improve compliance postoperatively. Patients should be advised not to smoke for several weeks before an elective operation. Pulmonary function studies a room air blood gas should be performed on all patients being considered for thoracotomy. A further evaluation can be obtained by noting the patient's tolerance to climbing stairs. For practical purposes, any patient able to walk up three flights of stairs will tolerate a thoracotomy. When a patient has borderline pulmonary function, aggressive preoperative pulmonary rehabilitation may be appropriate. Because technical difficulties may arise necessitating more extensive resection than planned, the surgeon must be thoroughly familiar with the patient's respiratory reserve.

Prior to undergoing a thoracotomy, all patients should undergo fibro-optic bronchoscopy at the beginning of the case via a single-lumen endotrachial tube to remove any secretions, verify the endobronchial anatomy, and survey for endobronchial masses. All thoracotomies require thoracic anesthetic expertise and include the insertion of a thoracic epidural for adequate pain control, an arterial line, and the capacity to perform single lung ventilation. Single lung ventilation can normally be achieved by way of a double-lumen endotracheal tube appropriately positioned or an endobronchial blocker. The position of the double-lumen tube or the endobronchial blocker must be verified prior to positioning with a fibro-optic bronchoscope.

The patient is placed in a lateral decubitus position with the hips secured to the table by wide adhesive tape (Figure 1). The lower leg is flexed at the knee, and a pillow is placed between it and the upper leg, which is extended. A rolled sheet or blanket is placed under the axilla, referred to as an “axillary roll” to support the shoulder and upper thorax. The arm on the side of the thoracotomy is extended forward and upward and placed in a padded grooved arm holder in line with the head, permitting access to the veins. The lower arm is extended forward and rested on an arm board perpendicular to the operating table.

The skin is cleaned with antiseptic, and the area of incision is either draped with towels and covered with an adhesive plastic drape, followed by the large sterile thoracotomy sheet.

The surgeon makes the incision while standing posterior to the patient, with the first assistant on the other side of the table across from the surgeon. The incision begins midway between the medial border of the scapula and the spine, proceeding downward parallel to these two structures for the first few inches and then curving in a gentle S one fingerbreadth below the tip of the scapula, and finally extending down into or just below the submammary crease, if necessary. In exposures of the fourth or fifth interspace, the medial end of the incision is extended transversely toward the sternum. For lower openings of the seventh or eighth interspace, or ones involving transection of the costal cartilages for maximum exposure, the medial end of this incision curves gently toward or into the epigastrium. The surgeon then carries the incision directly down through the latissimus dorsi and the serratus anterior muscles (Figure 2). During this process, each of the muscles may be elevated individually by the surgeon's index and middle fingers. This is accomplished by entering the auscultatory triangle formed by the superior border of the latissimus dorsi, the inferior border of the trapezius, and the medial border of the scapula.

The incision is extended anteriorly and posteriorly through the borders of the trapezius and rhomboid muscles. Care must be taken to make this posterior incision parallel to the spinal column and thus lessen the chance of dividing the spinal accessory nerve, which innervates the trapezius. Bleeders are cauterized as they appear. By palpating the widened interspace between the first and second ribs and the insertion of the posterior scalene muscle on the first rib, the surgeon may count down to the appropriate rib level (Figure 3). The pleural space should be entered just over the superior part of the rib to eliminate the potential for injury to the neurovascular bundle (Figure 4). The periosteum is incised directly over the midportion of the rib (Figure 4). The sacrospinalis muscle and fascia are elevated by a periosteal elevator, and a retractor is inserted in this space. A Coryllos periosteal elevator is swept anteriorly along the upper half of the rib (Figure 5).The Hedblom periosteal elevator is then inserted under the bared portion of the rib and slipped upward along the rib, stripping the remaining periosteum from the upper half of the rib in a posterior-to-anterior direction (Figure 6). After ensuring that the patient is on single lung ventilation (i.e., no ventilation to the side being operated upon), a small incision is made entering the pleura (Figure 7). The lung drops away, thus allowing the incision to be extended for the desired length.

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