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