THORACIC INCISIONS

PRESENTER: DR ANEFU, N. EMODERATOR:DR S. EDAIGBINI

AHMADU BELLO UNIVERSITY TEACHING HOSPITAL,ZARIA,NIGERIA

OUTLINE

• INTRODUCTION• HISTORICAL PERSPECTIVES• ANATOMY OF THE CHEST

• BASIS• GENERAL PRINCIPLE• TYPES OF THORACIC INCISIONS• CURRENT TREND• FUTURE TREND• CONCLUTION

INTRODUCTION

• Incision;- 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 incision

Historical perspective

• Development evolution thoracic incision is closely related to the development of thoracic surgery

• Used in ancient time for draining abscesses in the chest

Anatomy of the chest

CHEST WALL

• Bony rib cage;- manubrum, sternum, 12 pair of rib, coastal cartilage & thoracic vertebrae

• Soft tissue covering:- muscles, neurovascular bundles, other connective tissues

• Two aperture• Superior=root of the neck• Inferiorly=separated from abdominal cavity by

diaphragm

Lungs surface markings in the ribcage

• In spite of the large intra-thoracic space, separate pleural spaces &rigid- ribbed chest wall, its anatomy makes specific incision selection crucial to the ease & safety of a given thoracic procedure

• Respiration is still possible; due to the nature of the joint & muscular attachments

General principles

• Patient evaluation & clinical assessment– History, P.E, Lab & Radiological investigations-LFT,

Spirometric measurement,SPO2,CXR,– Performance score rating

• Patient education/counseling/consent• Start Chest physiotherapy• Peri-op monitoring/medications

Gen. principles

• Anaesthesia(G.A,double lumen ETT or single lung intubation)

• Analgesia( epidural catheters,intercostal nerve block)

• Surgery• Antibiotics prophylaxis• Follow-up

Analgesia CTU-ABUTH

• Taken very seriously• Intra-op =I.V pentazoxine• Post-op =Triple px– Opioid; pentazoxine– NSAIDs;diclofenac– Acetaminophen;PCM

Prophylactic Antibiotics-CTU

• Intra-op =3rd generation cephalosporin e.g ceftriaxone + metronidazole, repeated after 8hrs,

• Post-op =same extended X 2-3/7

Surgical principles

• To allow a successful surgical outcome• Adequate exposure • Preserve chest-wall function & appearance• Incision along langers line or positioned to

minimize visibility• Closure-rigid approximation & strict layered

closure

• Optimal approach depends onBony anatomyLocation & extent of pathologyLocation of the hilumObjective of the procedure

Chest drainage

Types of thoracic incisions

• Sternotomy• Thoracotomy• Axillary thoracotomy• Anterior mediastinotomy• Thoracoabdominal incision

Types cont…

• Bilateral Trans-sternal thoracotomy( clam-shell incision)• Extra-thoracic approaches to the

thorax

Sternotomy incisions

• Partial–Hemisternotomy (spares 6-8cm skin)

• Complete–Suprasternal notchxyphoid process–Cosmetically appealing type of incision

e.g inframammary (bikini type) incision

Median sternotomy incision

Sternal spreader applied

Median sternotomy

Indicationsexposure of ant. & middle mediastlower cervical proceduresTracheal resection& reconstruction

Indications

• Excision of thyroid masses & parathyroid adenomas• Excision of cervical oesophageal

tumours• Exposure of heart & great vessels• In cardiopulmonary bypass

Advantages• Quick to perform• Excellent exposure• Safe• Heals quickly• Less incisional pain

Disadvantages

• Many 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 sternotomy• Partial sternal split

CLOSURE:Interlucking wire suture technique

Less invasive sternotomy incisions

• Hemisternotomy- suprasternal notch,tee-off to the R at interspace 4 or xyphoid,tee-off,R, at interspace 2

• Full sternotomy with skin sparing• Bikini-type (inframammary) incision- cosmesis

Less invasive sternotomy incisions

Post-op care

• ICU MANAGEMENT/MONITORING

• O2 DELIVERY VIA NEBULIZER

• PAIN MANAGEMENT( I.Vanalgesics,Eidural nr block)

• PHYSIOTHERAPY

COMPLICATIONS

• Anaesthetic:- arrhythmias, laryngeal spasm

Specific :- Early;haemorrhage,injury to contiguous

structures, pneumothorax, haemothorax, Late;infection, empyema thoracis, post

surgery pain

Complications

• Mediastinitis (S.aureu31%,E.coli3%,enterococcus 2%)

• Sternal osteomyelitis• Brachial 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 wall

Types of thoracotomy incisions

• Lateral • Anterior • Anterolateral• Posterolateral• Posterior• others

The numenclature for std thoracotomy incisions

Indications for posterolateral incision

• Standard thoracotomy incisions can be used for a wide range of surgical procedures involving;

• The Heart• Oesophagus• Mediastinum• Ipsilateral lung

Advantages

• Flexibility of the incision

• Wide range of intra-thoracic exposure

• Proven experience with these incisions has made them the standard thoracic incisional approach

Disadvantages

• Has potential for poor exposure ,if wrong interspace is chosen

• Unilateral hemithorax exposure• Incisional pain• Disability related to division of chest wall

muscles• Detrimental effect on pulmonary function

Technique (posterolateral)

• Induction using single/double lumen tube

• Appropriate monitoring• Anaesthesia-G.A+ETT

• Positioning –lateral decubitus position

• Cleaning/drapping

• Crescent or “lazy-S”incision, transversely• Dissected down & scapular retracted• Pleural space entered• Pleural/mediastinal drainage• Thoracotomy 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 ribs

• To resect a rib, enter through its periosteal bed

Anterior & anterolateral thoracotomy

• Indications• Has greater use historically• Used for pulmonary resection• Cardiac procedures• Management of mediastinal masses• Oesophageal pathology

Technique

• Monittoring

• Anaesthesia are same as posterolatral

• Supine position• Chest elevated at 30-45• Curved submammary incision, extended

laterally(anterolateral)

Anterolateral thoracotomy incisions

Lateral thoracotomy

• Within confines of latissimus dorsi

• Transverse incision

• 1-2cm inferior to the scapular

Complications

• Post thoracotomy incision pain• Wound infection• Wound dehiscence• Bronchopleural fistula-8%• Empyema thoracis-2.2%

Muscle-sparing thoracotomy

• Indications –As in std thoracotomy–Variant of std thoracotomy–Well established–Has less complications

Muscle sparing anterolateral thoracotomy incision

Advantages

• Less early post-op pains• Greater shoulder girdle strength• Most result in quick closure• Preserve chest wall muscle• Prevent chest wall deformity

Axillary thoracotomy

• Indications–1st rib disection–Apical bleb Dx–Mgt of spontaneous pneumothorax

with apical pleurectomy or pleurodesis–Staging of lung cancer

Patient positioning & incision for a vertical axillary incision

ADVANTAGES

• Small incision• Quickly performed• Muscle sparing• Cosmetically appealing• Ideal for pt with poor pulmonary

function

Disadv

• Limited exposure• Intercostobrachial nerve injury• Proximal 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 incision

• provides excellent exposures for procedures involving

• the spleen• Stomach• L hemidiaphragm • Aorta• lower oesophagus

Current trend

Towards 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

Conclusion• Great achievement has been made in

cardiothorcic surgery• Emphasy now is on minimally

invasive/thoracoscopic procedures• We still use thorcic incisions due to

our own limitations• There is great hope for the future.

Thank you for listening