Incisions in cardiothoracic surgery

Incisions in cardiothoracic surgeryDr.mehdi hadadzadehAssistant professore of cardiovascular surgery

IN THE NAME OF GODA surgical incision opens an aperture into the thorax to permit the work of the planned operation to proceed

If an operation is difficult, you are not doing it properly," applies directly to the incision used

The choice of incision: underlying pathology

the site (e.g. lung, chest wall, oesophagus)

experience of the surgeonTypes of incisionsMedian SternotomyPosterolateral thoracotomyAnterolateral thoracotomyLateral thoracotomyBilateral thoracosternotomySubxiphoid(pericardial window)

Posterolateral thoracotomygold standard of thoracic incisions

excellent exposure for most general thoracic procedures including the lung, heart, aorta, the lower esophagus, and diaphragm

This approach is also used for spinal operations

Preoperative preparationAssessment of pulmonary function

given a dose of antibiotics preoperatively

preoperative education and incentive spirometry training as to the importance of adequate inspiration postoperatively to prevent atelectasis (lung collapse

Position

complete lateral decubitus positionuse of sandbags, rolled sheets front and back or bean bags supporting the back and the abdomen

The lower leg is flexed at the knee and hip while the upper leg lies straight on the top of the pillow

to avoid post operative complications ; cutaneous necrosis, venous thrombosis or nerve compression. arm placed on an angle padfree from any fixation.

IncisionThe position of the vertebral spines and the nipple is notified. The standard incision follows between scapula and mid-spinal line to the anterior axillary line passing 3cm below the tip of the scapula.

The skin incision :No. 10 scalpel latissimus dorsi and serratus anterior muscles : No. 10 scalpel or cauteryPosteriorly, the muscle layers of the rhomboid and trapezius are incisedThe pleural space :incising the musculature between the ribs or via an osteotomytransect the muscles on the superior border of the ribs to avoid injuring the neurovascular bundle.ribs may be transected or resected

at the level of the 5th rib for exposure of the upper thoracic area :COA

level of the 6th or 7th rib for lower thoracic area (e.g., lower esophageal or diaphragmatic surgery)

After operation drainage tubes must be placed The rib approximator is closed and No.1 chromic or No. 1 vicryl sutures are placed to encircle the bone along the length of the incision. Silk sutures are to be avoided as it increases postoperative painThe cut ends of the trapezius and latissimus dorsi muscles are then approximated and sutured subcutaneous tissue is closed using an interrupted 3-0 absorbable sutures.The skin is closed using surgical clips or a running 4-0 subcuticular stitch such as Monocryl.

disadvantages of this incision increased potential for blood loss and moderate time requirement for opening and closing the incisionprolonged ipsilateral shoulder and arm dysfunctionscompromised pulmonary function and chronic post thoracotomy pain syndromesscolioses have been described in children

Median sternotomyMost common thoracic incisionIndications:cardiac operations-anterior mediastinal lesions-bilateral lung proceduresSpeed in opening and closingSupine position and arms in patient,s side

IncisionIncision from below the suprasternal notch toa point between the xyphoid and umblicusAn electric saw with a vertical blade is usedAn oscillating saw is used for repeated sternotpmy

Bone wax is a useful tool to control bleeding from sternumsterile mixture of beeswax and isopropyl palmitate

Sternal retractor is used in lower thired of the sternum and gradually opened

Stainless steel wire is at present the standard suture in median sternotomy

Disadvantage of this incisionScar formationBrachial plexus injuryChronic chest pain

Axillary(lateral)thoracotomyAdvantages:muscle sparing-ease and speed-good cosmeticDisadvantages:limited exposureChoice in majority of pulmonary resections ,PDA ligation,PA banding and.Lateral decubitus position homolateral arm is abducted at 90 at the shoulder level, flexed at the elbowIncision Between posterior border of pectoralis major and anterior border of latisimus dorsithrough the 4th or 5th intercostal space;

Bilateral thoracosternotomy(clamshell)Previously choice for bilateral lung transplantIncision along the inframammary creases and across the sternum4 or 5th intercostal spacePoor healing of wound

Anterolateral thoracotomyUseful in variety of operation on heart,pulmonary resection and esophagusSupine and operation site elevated30 degree

Incision from lateral border of sternum to midaxillary at 4or5interspace

Pectoralis major and seratus anterior is dividedIndications:pericardial effusion,pericardial biopsy,epicardial pacemakerSupine posision,midline incision over the xiphoidSubxiphoid incision(pericardial window)

Intrapleural(chest) tubesWhenever thoracotomy has been doneexit of fluids and air and monitors of bloodlossSeparate incision