Plate 196

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 gutter along the spine and the other directed anteriorly. The posterolateral chest tube is brought out through stab wounds in the skin as low as possible in a posterolateral position (Figure 12). The chest tubes are to be placed prior to the closure of the thoracotomy and should ideally be anterior to the midaxillary line for patient comfort and ease of drainage. Single, untied skin nonabsorbable sutures may be placed through the stab wound before the tube is inserted to aid in closing when the chest tubes are withdrawn. In placing the chest tube, the surgeon first grasps the lower cut edges of the latissimus dorsi and the serratus anterior, and the assistant retracts them superiorly. The surgeon forms a tunnel through the chest wall with Kelly forceps, grasps the chest tube, and draws it out through the wall. The catheter serves two main purposes: to remove air escaping from lung parenchymal injury. The chest tubes are usually attached with underwater seal with or without sutures for as long as there is drainage from the pleural space or persistence of an air leak (Figure 13). Should excessive air leakage be present, another chest tube is placed in the second or third interspace anteriorly at the level of the midclavicular line (Figure 13). A smaller Silastic catheter will suffice and will be the last chest tube to be removed. The catheters allow expansion of the lung with approximation of pleural surfaces and thus prevent postoperative atelectasis and fluid accumulation with infection. The catheters are usually attached to an underwater-seal device with or without negative suction (Figure 14).

The preoperative insertion of a thoracic epidural should help postoperative pain control. If an epidural is not possible due to coagulation defects or anesthesia preference, intercostal blocks above and below the incision using a long-acting local anesthetic can be placed at the end of surgery. Intercostal blocks combined with the use of a patient-controlled analgesic device are known to provide adequate pain control.

The patient should be encouraged to cough vigorously and use incentive spirometry. The patient should be helped in coughing by supporting his operative side with a pillow. The patient should be encouraged to change positions frequently. Ambulation should be early, and active exercise should be encouraged.

The chest tubes are usually removed when they have served their purpose, as evidenced by normal breathing sounds on the operative side and x-ray films showing complete expansion of the lung and the absence of air leak and fluid accumulation. This is usually on the second or third postoperative day. Persistent air leakage may indicate improper position of the catheter, leakage around the entrance of the thoracotomy tube, or large bronchial air leaks. In these circumstances, early bronchoscopy and radiologic imaging with plain films or computed tomography are encouraged.