Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 29  |  Issue : 3  |  Page : 646--650

Vertical thoracotomy versus conventional posterolateral thoracotomy


Ahmed L Dokhan1, Alaa A ElSesy2, Medhat R Nashy1, Ahmed H Onsi1,  
1 Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Menoufia governorate, Egypt
2 Department of Surgery, Faculty of Medicine, Menoufia University, Menoufia governorate, Egypt

Correspondence Address:
Ahmed H Onsi
Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Shebin El kom, Menoufia Governorate, 32511
Egypt

Abstract

Objective The aim of the study was to evaluate the use of vertical thoracotomy as a thoracic approach. Background A carefully planned thoracic incision should provide effortless and excellent exposure, preservation of the underlying anatomy and function, and a cosmetically acceptable result. Materials and methods We conducted a prospective, cohort study in which 30 consecutive patients were exposed to two types of thoracotomies performed by the surgeons of the cardiothoracic surgery Department in Menoufia University Hospital from October 2012 to October 2014. The patients were classified randomly into two groups: group A (n = 15) in which vertical thoracotomy was performed and group B (n = 15) in which standard posterolateral thoracotomy was performed. Operative data were collected from all patients in both groups as regards indication of operation, type of operation, intraoperative complications such as bleeding, need of extension of the incision, total operative time, and time of opening and closure of the thoracotomy. Results Results showed that vertical thoracotomy can be used for a wide range of procedures in different age groups and in both sexes. Shoulder joint movement was significantly better when vertical thoracotomy was used (P = 0.044), and cosmetic results are better. Conclusion Vertical thoracotomy offers specific advantages of minimum trauma and maximum preservation of chest wall function with a cosmetically acceptable scar.



How to cite this article:
Dokhan AL, ElSesy AA, Nashy MR, Onsi AH. Vertical thoracotomy versus conventional posterolateral thoracotomy.Menoufia Med J 2016;29:646-650


How to cite this URL:
Dokhan AL, ElSesy AA, Nashy MR, Onsi AH. Vertical thoracotomy versus conventional posterolateral thoracotomy. Menoufia Med J [serial online] 2016 [cited 2020 Jul 15 ];29:646-650
Available from: http://www.mmj.eg.net/text.asp?2016/29/3/646/198748


Full Text

 Introduction



The key to successful thoracic surgery is adequate and proper exposure. Over the years, various incisions have been used to approach organs within the thoracic cavity. The decision regarding which incision to use is based on the problem at hand and the surgeon's experience. A well-chosen incision should provide excellent and effortless exposure, preservation of the underlying anatomy and function, and a cosmetically acceptable result. By using a vertical skin incision and sparing the underlying musculature, these criteria are adequately met. The technique is simple and easily learned, and it can be performed without complications [1] .

Location of the incision must permit rapid extension when circumstances dictate. This mandates a wide sterile prep for most thoracic procedures. Options to widen the existing incision need not be restricted to the linear axis, as counter-incisions or perpendicular incisions can be used for greater surgical exposure. Retractors have been developed to improve exposure from otherwise less than adequate incisions [2] .

The selection of the surgical incision is also based on the surgeon's experience and familiarity with the exposure that a particular incision provides [3] .

The aim of this study was to evaluate the use of vertical thoracotomy as a thoracic approach and compare it with standard posterolateral thoracotomy.

 Materials and methods



After obtaining guidance and approval from the Department of Ethics Committee, we conducted a prospective, cohort study in which 30 consecutive patients were exposed to two types of thoracotomies performed by the surgeons of the cardiothoracic surgery department in Menoufia University Hospital from October 2012 to October 2014. The patients were classified randomly into two groups: group A (n = 15) in which vertical thoracotomy was performed and group B (n = 15) in which standard posterolateral thoracotomy was performed. Operative data were collected from all patients in both groups as regards indication for operation, type of operation, intraoperative complications such as bleeding, need of extension of the incision, total operative time, and time of opening and closure of the thoracotomy.

Surgical technique

The patient was turned on the unaffected side in the lateral decubitus with hips secured to the table by means of wide adhesive tapes. The lower leg was flexed at the knee with a pillow between the upper and lower legs. The upper leg was extended. The shoulder and upper thorax were supported by a rolled sheet or blanket placed under the axilla. Table supports were used to maintain the position, and additional strapping was used at the hip for stability. The upper arm was supported by a bracket at a position of 90° flexion.

Fifteen patients were subjected to vertical thoracotomy incision (group A). An incision was made parallel to the anterior border of the latissimus dorsi. The anterior aspect of the latissimus was identified and mobilized in a cephalad and caudad manner, freeing it from the loose areolar attachments of the underlying serratus anterior. It is extended from the axillary hairline down to a distance of 10-15 cm. The latissimus was then retracted posteriorly, and the posterior aspect of the serratus anterior was identified. The serratus was then mobilized and retracted anteriorly, exposing the chest wall. The appropriate intercostal space to enter was determined by passing a hand under the scapula and counting the ribs. Exposure was obtained by placing a standard chest retractor to spread the ribs. Gentle intermittent rib spreading will prevent fractures. The latissimus and serratus muscles were retracted with a self-retaining retractor placed at a right angle within the chest spreader. In case of higher rib space entry (i.e., fifth or sixth space) several serratus rib insertions were disinserted to prevent avulsion. The chest was closed after chest tubes were placed, and the ribs were reapproximated with absorbable pericostal sutures, and the skin was approximated in a subcuticular manner. Suction drains were planned to be avoided but were used in obese patients.

Another group of 15 patients were subjected to posterolateral thoracotomy (group B). The incision is started at the mid-axillary line and continued posteriorly for 2-3 cm below the scapular tip. The incision then follows the contour of the posterior border of the scapula superiorly along a line midway between the posterior border of the scapula and the spine. The dissection was carried down to the latissimus muscle, which was divided with cautery. The serratus muscle can often be spared. If this muscle is to be divided in case of higher rib space entry, several serratus rib insertions must be disinserted to prevent avulsion. Division of the serratus slips close to rib insertions ensures that the majority of the muscle will remain innervated. All patients were followed up for postoperative complications and wound complications, movement of the shoulder girdle, and for cosmetic satisfaction.

 Results



In group A (vertical thoracotomy), the time of opening of the thoracotomy was 38.0 ± 3.0 min, whereas in group B (posterolateral thoracotomy) the time of opening of the thoracotomy was 23.06 ± 4.35 min. There was a significant statistical difference between the two groups (P = ±4.35). In group A (vertical thoracotomy) the time of closure of the thoracotomy was 25.13 ± 2.38 min, whereas in group B (posterolateral thoracotomy) the time of closure of the thoracotomy was 26.26 ± 3.01 min.

There was no significant statistical difference between the two groups with respect to operative, wound, and postoperative complications. Intraoperative bleeding occurred in seven cases of group A (vertical thoracotomy) and only in three cases of group B (posterolateral thoracotomy). Wound complications occurred in seven cases of group A in the form of seroma (two cases) and infection (two cases) and in six cases of group B in the form of seroma in five and infection in one patient. Nine patients in group A (60%) suffered postoperative complications: six patients had postoperative air leak, one had postoperative empyema, one had pneumonia, and one had deep vein thrombosis (DVT). In group B (posterolateral thoracotomy), only four  patients (20%) had postoperative complications.

There was a significant statistical difference between the two groups with respect to the degree of movement of the shoulder joint. The mean degree of movement of the shoulder joint in group A (vertical thoracotomy) was 166.67 ± 6.17°, whereas the mean degree of movement of the shoulder joint in group B (posterolateral thoracotomy) was 148.67 ± 13.02° (P = 0.044). There was no significant statistical difference  between the two groups in terms of cosmetic satisfaction of the patients (P = 0.148) ([Table 1], [Table 2], [Table 3] and [Table 4]).{Table 1}{Table 2}{Table 3}{Table 4}

 Discussion



The standard posterolateral muscle-splitting incision remains the thoracic incision of choice of most thoracic surgeons and has withstood the test of time. This incision provides excellent exposure for almost any intrathoracic procedure, and the functional and cosmetic results are acceptable. Its main disadvantages are due to the division of major chest wall muscles and include severe post-thoracotomy pain, ineffective coughing, and poor performance of chest exercise, limited shoulder mobility, and delayed ambulation. These increase postoperative morbidity. Lung herniation has also been reported after this procedure [4] .

In group A (vertical thoracotomy) the time of opening of the thoracotomy was 38.0 ± 3.0 min, whereas in group B (posterolateral thoracotomy) the time of opening of the thoracotomy was 23.06 ± 4.35 min. There was a significant statistical difference between the two groups (P = ±4.35). In group A (vertical thoracotomy) the time of closure of the thoracotomy was 25.13 ± 2.38 min, whereas in group B (posterolateral thoracotomy) the time of closure of the thoracotomy was 26.26 ± 3.01 min. There was no significant statistical difference between the two groups (P = 0.263).

In group A (vertical thoracotomy) the operative time was 184.27 ± 85.91 min, whereas in group B (posterolateral thoracotomy) the operative time was 176.40 ± 88.61 min. There was no significant statistical difference between the two groups (P = 0.663). This coincides with the results of Ashour [4] on 54 patients who underwent vertical muscle-sparing thoracotomy who revealed that the time taken to enter the pleural cavity was 35 min but closure time was less than 10 min.

Baeza and Foster [5] recorded that slightly more time is necessary to enter the chest with this incision; however, the time is regained because closure requires much less time than does closure of a muscle-splitting thoracotomy. These results are similar to that recorded in our study. Thus, they prefered this approach for most of the routine elective thoracotomies but preferred to avoid it in emergent or urgent cases because of the long time taken to enter the chest. However, the time to open has reduced markedly with experience. In the study by Wang et al. [6] there was no statistical difference in aortic clamp time, cardiopulmonary bypass time, or total operation time between the two groups. The time to establish cardiopulmonary bypass in group 1 (mitral valve replacement through right vertical infra-axillary thoracotomy) was significantly longer than that in group 2 (mitral valve replacement through standard median sternotomy).

There was no significant statistical difference between the two groups in terms of operative and postoperative complications. Intraoperative bleeding occurred in seven cases of group A and only in three cases of group B. Nine patients in group A (60%) had postoperative complications. Six patients had postoperative air leak, one had postoperative empyema, one had pneumonia, and one had DVT. In group B, only three patients (20%) suffered postoperative complications. Our results are markedly different from that obtained by Kim and Park [7] who reported only three cases of bleeding among 174 patients. We saw six cases of intraoperative bleeding among 15 cases due to pleural adhesions and lung tears, and one case due to intraoperative vascular injury, whereas intraoperative bleeding occurred only in three cases of group B. We had found that the exposure permitted by this incision, although slightly smaller than that afforded by a posterolateral thoracotomy, is quite adequate for most work. We had not used it when chest wall resections or extremely difficult hilar dissections were anticipated. However, we had performed lobectomies, pneumonectomies, and various other procedures using it. The study by Lemmer et al. [8] also showed better exposure with muscle-cutting incisions than with muscle-sparing ones. Ashour [4] , by using a muscle-sparing thoracotomy for a wide range of procedures, noted that exposure was inadequate in 4% of cases.

Wound complications occurred in four patients of group A in the form of seroma (two cases) and infection (two cases) and in six patients of group B: five patients had seroma and one patient had infection. In our study, in the standard posterolateral thoracotomy, skin flaps must be created superiorly and inferiorly to preserve the muscles and to allow for adequate retraction. With the elevation of skin flaps, problems with seromas arise, necessitating the prophylactic placement of subcutaneous drains. However, by the use of a 'vertical' skin incision, in combination with a muscle-sparing approach, this problem decreased because the incision was made parallel to the latissimus, the creation of skin flaps was unnecessary, and seroma formation rarely occurred.

Hazelrigg et al. [9] reported the development of  seroma in nearly a quarter of patients who underwent muscle-sparing thoracotomy despite the use of subcutaneous drains, and no incidence of seroma with standard posterolateral thoracotomy. Ashour [4] noted that wound seroma occurred in 2% of cases with muscle-sparing thoracotomy for various procedures. Lemmer et al. [8] opted to use vertical skin incision in combination with the muscle-sparing approach. Because the incision was made parallel to the latissimus, the creation of skin flaps was unnecessary, and seroma formation did not occur.

In our study there was a significant statistical difference between the two groups in terms of the degree of movement of the shoulder joint. The mean degree of movement of the shoulder joint in group A was 166.67 ± 6.17°, whereas the mean degree of movement of the shoulder joint in group B was 148.67 ± 13.02° (P = 0.044). This result coincides with that of Hazelrigg et al. [9] , who noticed that the decrease in shoulder range of motion occurred 1 week postoperatively with the standard posterolateral thoracotomy. They also noticed that preservation of shoulder girdle strength was significantly better when the muscle-sparing technique was used than with standard posterolateral thoracotomy. Landreneau et al. [10] demonstrated that there was no difference in shoulder function between both thoracotomy approaches. Ginsberg [11] reported that in vertical muscle-sparing thoracotomy the patient was able to raise the ipsilateral arm over the head on the first postoperative day with a total pain-free mobility of the shoulder girdle.

There was no significant statistical difference between the two groups in terms of cosmetic satisfaction of the patients (P = 0.148). The number of patients who were unsatisfied with their thoracotomy wound in group A was three (20%). In group B, six patients were unsatisfied with their thoracotomy wound (40%). Rothenberg and Porkorny [12] reported that the cosmetic results of vertical thoracotomy were esthetically superior to that of conventional posterolateral thoracotomy. The scar was not seen when the arm was by the side of the body.

There are two local anatomic conditions that must be taken into consideration when surgical correction is intended: the amount of scarring of the folds and adjacent skin, and the involvement of the hair-bearing area [13] .

 Conclusion



Vertical thoracotomy offers the specific advantages of minimum trauma and maximum preservation of chest wall function, cosmetically acceptable scar results, and full shoulder girdle movement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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