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An alternative method is direct incision into the intercostal space. The incision is made through the intercostal muscles along the superior border of the rib. Simple ligation of these is sufficient. Dissection is carried directly down and into the pleura. The incision in the pleura is extended anteriorly and posteriorly with cautery. The internal mammary vessels, which join the intercostals at the sternum, lie medial and deep to the costal cartilages, and should not be injured during this incision (Figure 8). If additional exposure is required, a rib may be divided or resected. The periosteum along the lower border of the rib is stripped to isolate the neurovascular bundle, which is grasped between right-angle forceps, ligated, and divided. The rib is then transected at the costal cartilage of the neck with rib shears (Figure 9). A self-retaining retractor is inserted (Figure 10) and opened gradually.

The closure of the thoracotomy incision requires stabilization of the thorax for the entire length of the incision. Encircling No. 1 absorbable sutures (A) are placed and can be tied with or without a rib approximator to aid in the process (Figure 11A). If any ribs were transected or fractured during spreading, sutures (B) must encircle both ribs and immobilize all rib fragments (Figure 11A). Further hemostasis and stabilization of the transected rib are accomplished by placing a suture (C) through the sacrospinalis muscle, fixing it to the neck of the transected rib and the rib above (Figure 11A). The chest muscles are approximated using a running or interrupted absorbable sutures as shown in Figure 12. Care must be taken to approximate each of the layers separately—i.e., rhomboids and the serratus anterior above the trapezius and latissimus dorsi. Subcutaneous 000 nonabsorbable sutures will prevent disruption of the incision when the skin staples are removed in 7 or 8 days.

All patients undergoing thoracotomy should have postoperative drainage of the pleural space. The chest tube used must be of adequate size, and anything less than a 32 French catheter will obstruct with blood clots. It is often advantageous to have two chest tubes in the postoperative chest—one lying over the diaphragm muscle in the posterior ...

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