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4 - Access to the chest cavity: safeguards and pitfalls

from Section I - Diagnostic work-up of the thoracic surgery patient

Published online by Cambridge University Press:  05 September 2016

By
Laura Socci  and
Antonio E. Martin-Ucar
Edited by
Marco Scarci ,
Aman Coonar ,
Tom Routledge  and
Francis Wells
Laura Socci
Affiliation:
Cardiothoracic Surgery Unit, Northern General Hospital, Sheffield, UK
Antonio E. Martin-Ucar
Affiliation:
Department of Thoracic Surgery, Nottingham City Hospital, Nottingham, UK
Marco Scarci
Affiliation:
University College London Hospital
Aman Coonar
Affiliation:
Papworth Hospital
Tom Routledge
Affiliation:
Guy’s Hospital
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Summary

Introduction

The choice of incision is vital for procedures in the thoracic cavity. The main principle should always be adequate exposure in order to perform a safe and effective procedure without compromise. However, the trauma of entering the chest cavity is particularly severe with impact on pain, muscle performance and respiratory function. As with surgical access in any region of the body, surgeons have always tried to minimize the impact of this trauma in the thoracic wall. As a result, we have at our disposal a myriad of incisions to choose from when facing thoracic procedures, with their own indications and pitfalls. As a general rule, in order to decide our approach, we have to take into account the indication for surgery, the anatomical location of the pathology, the likelihood of encountering difficulties (such as previous surgeries or locally invasive tumours), the pre-operative assessment of the patient, the predicted extent of side effects and also the patient's views in term of cosmesis and recovery.

Common to all techniques are the basic principles: correct positioning of the patient on the operating table, anatomical landmarks to place the incision, correct tissue handling and haemostasis and gradual spread of ribs/sternum to minimize trauma. For the purpose of this chapter, we will divide the incisions into three main groups: open approaches in lateral decubitus position (muscle and non-muscle sparing), open approaches in supine position (sternotomy, anterior thoracotomy, clamshell and their variations) and minimally invasive approaches (VATS and hybrid). We will describe the techniques with points regarding their main indications and their potential pitfalls.

Techniques

Open approaches in lateral decubitus

The majority of the chest wall approaches for thoracic surgery procedures are still performed in the lateral decubitus position. It is crucial that multiple pressure points are padded, with the dependent leg flexed with a pillow between the legs. Ideally, both arms should be flexed ‘in the prayer position’, although this can vary depending on the surgeon's preference. It is important to widen the intercostal spaces to be entered by hyperextending the chest cavity with a roll positioned under the dependent chest at the level of the tip of the scapula or by ‘breaking’ the operating table mechanism.

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Type
Chapter
Information
Core Topics in Thoracic Surgery , pp. 25 - 38
Publisher: Cambridge University Press
Print publication year: 2016

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References

1 Mitchell, R, Angel, W, Wuerflein, R, Dor, V. Simplified lateral chest incision for most thoracotomies other than sternotomy. Ann Thorac Surg 1976; 22:284–6.Google Scholar
2 Bethencourt, DM, Holmes, EC. Muscle-sparing posterolateral thoracotomy. Ann Thorac Surg 1988; 45:337–9.Google Scholar
3 Horowitz, MD, Ancalmo, N, Ochsner, JL. Thoracotomy through the ausculatory triangle. Ann Thorac Surg 1989; 47:782–3.Google Scholar
4 Ziyade, S, Baskent, A, Tanju, S, et al. Isokinetic muscle strength after thoracotomy: standard vs. muscle-sparing posterolateral thoracotomy. Thorac Cardiovasc Surg 2010; 58(5):295–8.Google Scholar
5 Hazelrigg, SR, Landreneau, RJ, Boley, TM, 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(3):394–400; discussion 400–1.Google Scholar
6 Athanassiadi, K, Kakaris, S, Theakos, N, Skottis, I. Muscle-sparing versus posterolateral thoracotomy: a prospective study. Eur J Cardiothorac Surg 2007; 31(3):496–9; discussion 499–500. Epub 2007 Jan 22.Google Scholar
7 Nazarian, I, Down, G, Lau, OJ. Pleurectomy through the triangle of auscultation for treatment of recurrent pneumothorax in younger patients. Arch Surg 1988; 123:11.Google Scholar
8 Li, S, Feng, Z, Wu, L, et al. Analysis of 11 trials comparing muscle-sparing with posterolateral thoracotomy. Thorac Cardiovasc Surg 2014 Jun; 62(4):344–52. doi: 10.1055/s-0033-1337445. Epub 2013 Apr 1. Review.CrossRefGoogle Scholar
9 Becker, RM, Munro, DD. Transaxillary minithoracotomy: the optimal approach for certain pulmonary and mediastinal lesions. Ann Thorac Surg 1976; 22:254–9.Google Scholar
10 Ochroch, EA, Gottschalk, A, Augoustides, JG, et al. Pain and physical function are similar following axillary, muscle-sparing vs posterolateral thoracotomy. Chest 2005; 128(4):2664–70.Google Scholar
11 Freixinet, JL, Canalís, E, Juliá, G, et al. Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax. Ann Thorac Surg 2004; 78(2):417–20.Google Scholar
12 Han, S, Yildirim, E, Dural, K, et al. Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib. Eur J Cardiothorac Surg 2003; 24(3):428–33.Google Scholar
13 Meng, RL, Jensik, RJ, Kittle, CF, Faber, LP. Median sternotomy for synchronous bilateral pulmonary operations. J Thorac Cardiovasc Surg 1980; 80(1):1–7.Google Scholar
14 Urschel, HC Jr, Razzuk, MA. Median sternotomy as a standard approach for pulmonary resection. Ann Thorac Surg 1986; 41(2):130–4.Google Scholar
15 Martin-Ucar, AE, Stewart, DJ, West, KJ, Waller, DA. A median sternotomy approach to right extrapleural pneumonectomy for mesothelioma. Ann Thorac Surg 2005; 80(3):1143–5.Google Scholar
16 Edwards, JG, Martin-Ucar, AE, Stewart, DJ, Waller, DA. Right extrapleural pneumonectomy for malignant mesothelioma via median sternotomy or thoracotomy? Short- and long-term results. Eur J Cardiothorac Surg 2007; 31(5):759–64.Google Scholar
17 Asaph, JW, Handy, JR Jr, Grunkemeier, GL, et al. Median sternotomy versus thoracotomy to resect primary lung cancer: analysis of 815 cases Ann Thorac Surg 2000; 70(2):373–9.Google Scholar
18 Welti, H. Upper median sternotomy in the treatment of mediastinal tumors; 7 personal cases. Mem Acad Chir (Paris) 1950 14–21; 76(22–23):638–54.Google Scholar
19 Zacharias, A, Habib, RH. Factors predisposing to median sternotomy complications. Deep vs superficial infection. Chest 1996; 110(5):1173–8.Google Scholar
20 Robicsek, F, Daugherty, HK, Cook, JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977; 73:267.Google Scholar
21 Bains, MS, Ginsberg, RJ, Jones, WG 2nd, et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994; 58(1):30–2; discussion 33.Google Scholar
22 Germain, A, Monod, R. Bilateral transversal anterior thoracotomy with sternotomy; indications and technics. J Chir (Paris) 1956; 72(8–9):593–611.Google Scholar
23 Bains, MS, Ginsberg, RJ, Jones, WG II, et al. The Clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994; 58:30–3.Google Scholar
24 Sarkaria, IS, Bains, MS, Sood, S, et al. Resection of primary mediastinal non-seminomatous germ cell tumors: a 28-year experience at Memorial Sloan-Kettering Cancer Center. J Thorac Oncol 2011; 6(7):1236–41.Google Scholar
25 Macchiarini, P, Ladurie, FL, Cerrina, J, et al. Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg 1999; 15(3):333–9.Google Scholar
26 Dartevelle, Fg, Chapelier, AR, Macchiarini, P. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993; 105:1025.Google Scholar
27 Lucà, F, Garsse, L van, Rao, CM, et al. Minimally invasive mitral valve surgery: a systematic review. Minim Invasive Surg 2013; 179569. Epub 2013 Mar 27.
28 Schuchert, MJ, Souza, AP, Abbas, G, et al. Extended Chamberlain minithoracotomy: a safe and versatile approach for difficult lung resections. Ann Thorac Surg 2012; 93(5):1641–5; discussion 1646.Google Scholar
29 Rocco, G, Internullo, E, Cassivi, SD, et al. The variability of practice in minimally invasive thoracic surgery for pulmonary resections. Thorac Surg Clin 2008; 18(3):235–47.Google Scholar
30 Onaitis, MW, Petersen, RP, Balderson, SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006; 244:420–5.Google Scholar
31 Nwogu, CE, Yendamuri, S, Demmy, TL. Does thoracoscopic pneumonectomy for lung cancer affect survival? Ann Thorac Surg 2010; 89:S2102–6.Google Scholar
32 McKenna, RJ Jr, Houck, W, Fuller, CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81:421–5.Google Scholar
33 Nagahiro, I, Andou, A, Aoe, M, et al. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001; 72:362–5.Google Scholar
34 Demmy, TL, Curtis, JJ Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg 1999; 68:194–200.Google Scholar
35 Atkins, B, Harpole, D, Mangum, J, et al. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg 2007; 84:1107–13.Google Scholar
36 Nakas, A, Klimatsidas, MN, Entwisle, J, et al. Video-assisted versus open pulmonary metastasectomy: the surgeon's finger or the radiologist's eye? Eur J Cardiothorac Surg 2009; 36(3):469–74.Google Scholar
37 Lin, JC, Wiechmann, RJ, Szwerc, MF, et al. Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases. Surgery 1999; 126(4):636–41; discussion 641–2.Google Scholar
38 Gaunt, A, Martin-Ucar, AE, Beggs, L, et al. Residual apical space following surgery for pneumothorax increases the risk of recurrence. Eur J Cardiothorac Surg 2008; 34(1):169–73.Google Scholar
39 Nakas, A, Ucar, AE Martin, Edwards, JG, Waller, DA. The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2008; 33(1):83–8.Google Scholar
40 Tong, BC, Hanna, J, Toloza, EM, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg 2010; 89(1):220–5.Google Scholar
41 Loscertales, J, Congregado, M, Merchán, R Jiménez. First rib resection using videothorascopy for the treatment of thoracic outlet syndrome. Arch Bronconeumol 2011; 47(4):204–7.Google Scholar
42 Zahid, I, Sharif, S, Routledge, T, Scarci, M. Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis? Interact Cardiovasc Thorac Surg 2011; 12(1):40–6.Google Scholar
43 Li, WW, Lee, RL, Lee, TW, et al. The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy. Eur J Cardiothorac Surg 2003; 23:390–6.Google Scholar
44 Paul, S, Altorki, NK, Sheng, S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010; 139(2):366–78.Google Scholar
45 Richards, JMJ, Dunning, J, Oparka, J, et al. Video-assisted thoracoscopic lobectomy: the Edinburgh posterior approach. Ann Cardiothorac Surg 2012; 1(1):61–9.Google Scholar
46 Hansen, HJ, Petersen, RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach: the Copenhagen experience. Ann Cardiothorac Surg 2012; 1(1):70–6.Google Scholar
47 Burfeind, WR, D'Amico, TA. Thoracoscopic lobectomy – operative techniques. Thorac Cardiovasc Surg 2004; 9:98–114.Google Scholar
48 Rocco, G, Martin-Ucar, A, Passera, E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004; 77(2):726–8.Google Scholar
49 Gonzalez-Rivas, D, Fernandez, R, Torre, M de la, Martin-Ucar, AE. Thoracoscopic lobectomy through a single incision. MMCTS 2012; mms007.
50 Rocco, G. Single-port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice. Op Techn Thorac Cardiovasc Surg 2009; 14:326–35.Google Scholar
51 Jin, CH, Liu, K, Yu, KZ, et al. The use of single incision thoracoscopic surgery in diagnostic and therapeutic thoracic surgical procedures. Thorac Cardiovasc Surg 2014 Aug; 62(5):439–44. doi: 10.1055/s-0032-1327764. Epub 2013 Mar 8.CrossRefGoogle Scholar
52 Marra, A, Huenermann, C, Ross, B, Hillejan, L. Management of pleural empyema with single-port video-assisted thoracoscopy. Innovations (Phila) 2012; 7(5):338–45.Google Scholar
53 Kilic, D, Dursun, P, Ayhan, A. Single port video-assisted thoracoscopy for the management of pleural effusion in ovarian carcinoma. J Obstet Gynaecol 2013; 33(1):98–9.Google Scholar
54 Ng, CS, Lau, KK, Wong, RH, et al. Single port video-assisted thoracoscopic lobectomy for early stage non-small cell lung carcinoma. Surgical Practice 2013; 17:35–6.Google Scholar
55 Chen, CH, Lee, SY, Chang, H, et al. Technical aspects of single-port thoracoscopic surgery for lobectomy. J Cardiothorac Surg 2012; 7:50.Google Scholar
56 Apiliogullari, B, Esme, H, Yoldas, B, et al. Early and midterm results of single-port video-assisted thoracoscopic sympathectomy. Thorac Cardiovasc Surg 2012; 60:285–9.Google Scholar
57 do, K Kang, Min, HK, Jun, HJ, et al. Single-port video-assisted thoracic surgery for lung cancer. Korean J Thorac Cardiovasc Surg 2013; 46(4):299–301.Google Scholar
58 Wang, BY, Tu, CC, Liu, CY, et al. Single-incision thoracoscopic lobectomy and segmentectomy with radical lymph node dissection. Ann Thorac Surg 2013; 96(3):977–82.Google Scholar
59 Rocco, G, Martucci, N, Manna, C La, et al. Ten-year experience on 644 patients undergoing single-port (uniportal) video-assisted thoracoscopic surgery. Ann Thorac Surg 2013; 96(2):434–8.Google Scholar
60 Jutley, RS, Khalil, MW, Rocco, G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005; 28:43–6.Google Scholar
61 Tamura, M, Shimizu, Y, Hashizume, Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg 2013; 12(8):153.Google Scholar
62 Gonzalez-Rivas, D, Fernandez, R, Fieira, E, Rellan, L. Uniportal video-assisted thoracoscopic bronchial sleeve lobectomy: first report. J Thorac Cardiovasc Surg 2013; 145:1676–7.Google Scholar
63 Bertolaccini, L, Rocco, G, Viti, A, Terzi, A. Geometrical characteristics of uniportal VATS. J Thorac Dis 2013; 5(Suppl 3):S214–6.Google Scholar
64 Giudicelli, R, Thomas, P, Lonjon, T, et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994; 58: 712–717; discussion 717–718.Google Scholar
65 Berry, MF, Onaitis, MW, Tong, BC, et al. Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection. Eur J Cardiothorac Surg 2012; 41(4):888–92.Google Scholar
66 Demmy, TL, Nwogu, CE, Yendamuri, S. Thoracoscopic chest wall resection: what is its role? Ann Thorac Surg 2010; 89(6):S2142–5.Google Scholar
67 Shikuma, K, Miyahara, R, Osako, T. Transmanubrial approach combined with video-assisted approach for superior sulcus tumors. Ann Thorac Surg 2012; 94(1):e29–30.Google Scholar
68 Bayarri, CI, Guevara, AC de, Martin-Ucar, AE. Initial single-port thoracoscopy to reduce surgical trauma during open en bloc chest wall and pulmonary resection for locally invasive cancer. Interact Cardiovasc Thorac Surg 2013; 17(1):32–5.Google Scholar
69 Zieliński, M, Kuzdzał, J, Szlubowski, A, Soja, J. Transcervical-subxiphoid-videothoracoscopic ‘maximal’ thymectomy–operative technique and early results. Ann Thorac Surg 2004; 78(2):404–9; discussion 409–10.Google Scholar
70 Chamberlain, MH, Fareed, K, Nakas, A, et al. Video-assisted cervical thoracoscopy: a novel approach for diagnosis, staging and pleurodesis of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2008; 34(1):200–3.Google Scholar
71 Zieliński, M. Video-assisted mediastinoscopic lymphadenectomy and transcervical extended mediastinal lymphadenectomy. Thorac Surg Clin 2012; 22(2):219–25.Google Scholar
72 Leschber, G, Holinka, G, Linder, A. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) – a method for systematic mediastinal lymphnode dissection. Eur J Cardiothorac Surg 2003; 24(2):192–5.Google Scholar

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