Full text of DOI:10.1177/021849230201000229

Muscle-Sparing Thoracotomy
HOW TO DO IT
Akçali
A Technique Facilitating
Muscle-Sparing Thoracotomy
TURKEY
Yig˘it Akçali, MD, Hasan Demir, MD,
Bekir Tezcan, MD
Department of Thoracic and Cardiovascular Surgery
Erciyes University Medical Faculty
Kayseri, Turkey
ABSTRACT
The muscle-sparing thoracotomy technique preserves the latissimus dorsi and
serratus anterior muscles and provides excellent exposure for most thoracic and
mediastinal operations. It also reduces postoperative pain and complications, and
preserves pulmonary function. The technique has been developed further to facilitate
subcutaneous dissection by insufflation of air from a syringe connected to a
large-bore needle via a 3-way tap.
(Asian Cardiovasc Thorac Ann 2002;10:194–5)
fascia. The entire anterior border is freed from its superior
aspect in the axilla to its inferior insertion at the iliac
crest. After freeing the deep aspect of the latissimus dorsi,
it is retracted posteriorly to expose the serratus anterior
muscle. The serratus anterior is freed superiorly beyond
the tip of the scapula, and inferiorly to its attachment on
the anterior aspect of the 6th rib. The deep aspect of the
serratus is mobilized with cautery and retracted forward.
After incision of the intercostal muscles, the chest is
entered, and two rib retractors are positioned; one to
retract the ribs, and the other oriented perpendicular to
the first retractor to separate the serratus anterior and
latissimus dorsi muscles. In patients over 40 years old, a
INTRODUCTION
The muscle-sparing thoracotomy, regarded as “a
reasonable alternative to the standard posterolateral
approach,” is associated with reduced shoulder girdle
disability, less postoperative pain, and improved respira-
tory function.1 The time from incision to retractor place-
ment (opening time) in this procedure can be lessened
by insufflation of air into the areas where subcutaneous
dissection is planned.
TECHNIQUE
After intubation with a double-lumen endotracheal tube,
the patient is positioned in a lateral decubitus position
with pillows between the knees and padding under the 1-cm segment of the lower rib at the intercostal incision
elbows. Before starting the skin incision, the incision line is resected at the costovertebral angle, to decrease the
and the areas scheduled for dissection are insufflated incidence of costal fracture.
subcutaneously with air from a 60-mL syringe connected
On completion of the pulmonary operation, a single
intercostal dose of 0.25% bupivacaine is administered to
anesthetize the two nerves above and below the intercostal
space. The thoracotomy is closed by approximating the
to a large-bore needle via a 3-way tap (Figure 1). The skin
is incised in an S-shape, beginning in front of the anterior
axillary line, curving 2 cm under the tip of the scapula,
and continuing a further 2 cm posteriorly. The subcu-
taneous attachments of the latissimus dorsi are mobilized ribs with pericostal heavy absorbable sutures. Two soft
with electrocautery by dissecting just superficial to the closed-suction drains are placed in the subcutaneous space.
For reprint information contact:
Yig˘it Akçali, MD Tel: 90 352 437 3511 Fax: 90 352 437 5285 email: yigit.akcali@isbank.net.tr
Mustafa Kemal Pas¸a Bulvarı, No. 131/20, Kayseri 38090, Turkey.
A
SIAN
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ARDIOVASCULAR & THORACIC
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NNALS
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2002, VOL. 10, NO. 2
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Akçali
Muscle-Sparing Thoracotomy
The muscle-sparing thoracotomy described by Bethencourt
and Holmes2 in 1988 does not involve transection of the
major thoracic muscles, but the subcutaneous tissue should
be dissected thoroughly so that extrathoracic muscles can
be dissected easily. The addition of subcutaneous
insufflation was based on two observations. The first was
the method that has been used for centuries by the Turks
to skin slaughtered sheep in accordance with Islamic
rites. A small skin incision is made in one of the back legs
of the sheep, and the whole carcass is insufflated to allow
quick and easy skinning. Secondly, in patients with
subcutaneous emphysema due to chest injury, the
subcutaneous tissue and vasculature are easily seen, and
this aids manipulation during a thoracotomy.
Syringe plus
three-way tap
(“spacemaker”)
Subcutaneous
dissection
area
Skin
incision
Subcutaneous air helped the creation of subcutaneous
and muscular planes prior to the skin incision. Hemostasis
was achieved using less cautery and fewer miniclips
because the courses of perforating vessels within these
layers were clearly visualized. It was considered that this
allowed subcutaneous and muscular dissection to be
performed faster and more safely. Although the duration
of surgery has been reported to be either longer or the
same with the muscle-sparing procedure compared to the
standard posterolateral thoracotomy, in this study, the
Iliac crest
Figure 1. Illustration of subcutaneous air insufflation through a 60-mL
syringe connected to a large-bore needle via a 3-way tap.
The drains are removed on the 3rd postoperative day or total operating time for the standard technique was
when drainage is less than 50 mL per day. To prevent approximately 9 minutes longer.1,3 It can be seen that the
seroma along the wound, the patient’s chest is wrapped time from incision to retractor placement in the muscle-
with an elastic bandage, so as not to impede ventilation. sparing thoracotomy, called a “time-eater” by supporters
of the standard posterolateral thoracotomy, may be
DISCUSSION
shortened by the insufflation technique described herein.
A prospective randomized blinded study of 60 consecutive
patients was carried out to compare the standard
posterolateral technique (30 patients, group 1) with the
muscle-sparing thoracotomy (30 patients, group 2). The
patients were undergoing surgery for bronchiectasis,
empyema, spontaneous pneumothorax, hydatid cyst, lung
cancer, solitary pulmonary nodule, or bronchogenic cyst.
Those with a history of previous thoracotomy were
excluded. There was no difference statistically between
the groups in terms of surgical approach time. Although
it took on average 9 minutes longer to open the chest in
group 2 (42.03 ± 5.59 minutes) than group 1 (33.9 ± 6.58
minutes), closure was much quicker in group 2 (30.23 ±
5.78 minutes) than group 1 (49.9 ± 3.83 minutes) where
suture approximation of the thoracic musculature was
required. Total operating times were 83.8 ± 7.21 minutes
in group 1 and 72.26 ± 10.64 minutes in group 2.
ACKNOWLEDGMENT
The authors wish to thank Mr. Metin Tatlı for his excellent
technical assistance.
REFERENCES
1. Hazelrigg SR, Landreneau RJ, Boley TM, Priesmeyer M,
Schmaltz RA, Nawarawong W, et al. The effect of muscle-
sparing versus standard posterolateral thoracotomy on
pulmonary function, muscle strength, and postoperative
pain. J Thorac Cardiovasc Surg 1991;101:394–400.
2. Bethencourt DM, Holmes EC. Muscle-sparing postero-
lateral thoracotomy. Ann Thorac Surg 1988;45:337–9.
3. Sugi K, Nawata S, Kaneda Y, Nawata K, Ueda K, Esato
K. Disadvantages of muscle-sparing thoracotomy in
patients with lung cancer. World J Surg 1996;20:551–5.
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