THORACIC INCISIONS
PRESENTER: DR ANEFU, N. E
MODERATOR:DR S. EDAIGBINI
AHMADU BELLO UNIVERSITY TEACHING
HOSPITAL,ZARIA,NIGERIA
OUTLINE
• INTRODUCTION
• HISTORICAL PERSPECTIVES
• ANATOMY OF THE CHEST
• BASIS
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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
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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 on
Bony anatomy
Location & extent of pathology
Location of the hilum
Objective 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 notchxyphoid process
–Cosmetically appealing type of incision
e.g inframammary (bikini type) incision
Median sternotomy incision
Sternal spreader applied
Median sternotomy
Indications
exposure of ant. & middle mediast
lower cervical procedures
Tracheal resection& reconstruction
Indications
• Excision of thyroid masses &
parathyroid adenomas
• Excision of cervical oesophageal
tumours
• Exposure of heart & great vessels
• In cardiopulmonary bypass
Advantages
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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
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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
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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
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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
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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
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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
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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 procedures
Thoracic- VATS (video asst thoracoscopic
surgery) e.g TEF LIGATION
Cardiac- 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