DISCUSS THORACIC INCISIONS
THORACIC INCISIONSINTRODUCTIONIncision;- Is a surgical wound made by a surgeon on the skin, with intension of gaining access to a lesion beneath or cavity.Such wounds created anywhere on the chest (thoracic) wall is thoracic incisionAnatomy of the chest
CHEST WALLBony rib cage;- manubrum, sternum, 12 pair of rib, coastal cartilage & thoracic vertebraeSoft tissue covering:- muscles, neurovascular bundles, other connective tissuesTwo apertureSuperior=root of the neckInferiorly=separated from abdominal cavity by diaphragm
Types of thoracic incisionsSternotomyThoracotomyAxillary thoracotomyAnterior mediastinotomyThoracoabdominal incisionBilateral Trans-sternal thoracotomy( clam-shell incision)Extra-thoracic approaches to the thorax
Sternotomy incisionsPartialHemisternotomy (spares 6-8cm skin)CompleteSuprasternal notchxyphoid processCosmetically appealing type of incision e.g inframammary (bikini type) incisionMedian sternotomy incision
Sternal spreader applied
Median sternotomyIndicationsexposure of ant. & middle mediastlower cervical proceduresTracheal resection& reconstruction
Indications Excision of thyroid masses & parathyroid adenomasExcision of cervical oesophageal tumoursExposure of heart & great vesselsIn cardiopulmonary bypassAdvantagesQuick to performExcellent exposureSafeHeals quicklyLess incisional painDisadvantagesMany finds the vertical incision unsighty
Gives limited exposure of the lower chest & posterior mediastinum
May lead to post-op complications-unsteable sternum, infections
Technique Standard sternotomy
Open sternotomy
Re-operative sternotomyPartial sternal splitCLOSURE:Interlucking wire suture technique
Less invasive sternotomy incisionsHemisternotomy- suprasternal notch,tee-off to the R at interspace 4 or xyphoid,tee-off,R, at interspace 2Full sternotomy with skin sparingBikini-type (inframammary) incision- cosmesis Less invasive sternotomy incisions
COMPLICATIONSAnaesthetic:- arrhythmias, laryngeal spasm
Specific :- Early;haemorrhage,injury to contiguous structures, pneumothorax, haemothorax, Late;infection, empyema thoracis, post surgery painComplications Mediastinitis (S.aureu31%,E.coli3%,enterococcus 2%)Sternal osteomyelitisBrachial plexus injury,incidence:1.4-6.5%
Thoracotomy Standard thoracotomy incisions
Defined arbitrarily in relation to the position of Latissismus dorsi muscle,which is laterally sited on the chest wallTypes of thoracotomy incisionsLateral Anterior AnterolateralPosterolateralPosteriorothers
The numenclature for std thoracotomy incisions
Indications for posterolateral incisionStandard thoracotomy incisions can be used for a wide range of surgical procedures involving;The HeartOesophagusMediastinumIpsilateral lungAdvantages Flexibility of the incision
Wide range of intra-thoracic exposure
Proven experience with these incisions has made them the standard thoracic incisional approachDisadvantages Has potential for poor exposure ,if wrong interspace is chosenUnilateral hemithorax exposureIncisional painDisability related to division of chest wall musclesDetrimental effect on pulmonary functionTechnique (posterolateral)Induction using single/double lumen tube
Appropriate monitoringAnaesthesia-G.A+ETT
Positioning lateral decubitus position
Cleaning/drapping
Crescent or lazy-Sincision, transverselyDissected down & scapular retractedPleural space enteredPleural/mediastinal drainageThoracotomy closure
Option for entering the pleural space after posterolateral thoracotomy
Intercostal approach-incising i.c muscles
Utilizing intercostal incision but to divide one or more ribsTo resect a rib, enter through its periosteal bed
Anterior & anterolateral thoracotomyIndicationsHas greater use historicallyUsed for pulmonary resectionCardiac proceduresManagement of mediastinal massesOesophageal pathologyTechnique Monittoring
Anaesthesia are same as posterolatral
Supine positionChest elevated at 30-45Curved submammary incision, extended laterally(anterolateral) Anterolateral thoracotomy incisions
Lateral thoracotomyWithin confines of latissimus dorsi
Transverse incision
1-2cm inferior to the scapularComplications Post thoracotomy incision painWound infectionWound dehiscenceBronchopleural fistula-8%Empyema thoracis-2.2%Muscle-sparing thoracotomyIndications As in std thoracotomyVariant of std thoracotomyWell establishedHas less complicationsMuscle sparing anterolateral thoracotomy incision
Advantages Less early post-op painsGreater shoulder girdle strengthMost result in quick closurePreserve chest wall musclePrevent chest wall deformityAxillary thoracotomyIndications1st rib disectionApical bleb DxMgt of spontaneous pneumothorax with apical pleurectomy or pleurodesisStaging of lung cancer
Patient positioning & incision for a vertical axillary incision
ADVANTAGES Small incisionQuickly performedMuscle sparingCosmetically appealingIdeal for pt with poor pulmonary functionDisadv Limited exposureIntercostobrachial nerve injuryProximal lung thorcic nerve injury
Complications Very minimal
Infection-0.7%
Limited shoulder mobility-0.5%Anterior mediastinotomy (chamberlain procedure)Used in scalene lymph node biopsy
Exploratory thoracotomy
In cases of lung cancer( inoperable)Anterior mediastinotomy(Chamberlain)
Thoracosternotomy(Clam shell)
Left thoracoabdominal incisionprovides excellent exposures for procedures involving the spleenStomach L hemidiaphragm Aorta lower oesophagusCurrent trendTowards minimally invasive proceduresThoracic- VATS (video asst thoracoscopic surgery) e.g TEF LIGATIONCardiac- OPCAB (off-pump coronary art. Bypass)MIDCAB (mini invas dir coron art. Bypass)
Endoscopic aortic/mitral valve replacement