SURGICAL ACCESS TO THE CHEST

Access for open surgery within the thorax may be anteriorly through the sternum,
laterally between the ribs, or from below through the diaphragm. There is also
limited access from the neck. In an emergency, most general surgeons will feel
more comfortable with a lateral thoracotomy than a median sternotomy, unless
they have had some exposure to cardiac surgery during their training.

Median sternotomy
This is the incision which is performed most frequently for elective cardiac surgery
and provides excellent access to the heart. It may also be the most appropriate
incision in an emergency when damage to the heart or to the great vessels of the
superior mediastinum is suspected. The incision can be extended up into the neck
along the anterior border of sternocleidomastoid for injuries of the carotid root,
or laterally above the clavicle for access to an injury to the subclavian roots.
A vertical midline skin incision is made from the suprasternal notch to
the xiphisternum, and deepened down to bone. The manubrium and sternum are
then divided in line with the skin incision, using an electric oscillating saw
designed specifically for this purpose. If this is not available, a longitudinal
substernal tunnel is made close to bone with long forceps and a Gigli saw is
passed underneath the sternum with the aid of a long artery forceps. There is
danger of injury to the underlying heart, and it is also easy to breach the right
pleura. Opening the sternum in repeat surgery is hazardous as the heart may be
adherent to the sternum. It should only be attempted with an oscillating saw,
which cuts through the outer table first, then the inner table without jeopardizing
adherent structures beneath the sternum. Bleeding from the sternal marrow is
reduced by the application of bone wax, and bleeding from the periosteal edges is
controlled with diathermy coagulation.
The sternum should be separated from underlying structures before
attempts are made to separate the edges widely with a self-retaining retractor.
The pleural sacs are swept off the pericardium, and no entry into either pleural
space is required. The thymus, lying on the pericardium in the superior
mediastinum, is divided in the plane between the lobes, avoiding the innominate
vein superiorly. The pericardium is then incised vertically.
 After surgery within the pericardium, drains should be left both inside
the pericardium and in the anterior mediastinum. The two halves of the sternum
are then drawn together. Stainless steel wire sutures can either be introduced
through the sternal bone with a heavy needle, or the sutures can be placed
further laterally through the intercostals fascia at the lateral sternal edge. The
latter are easier to insert, but there is a danger of injury to the internal mammary
artery.

Postero-lateral thoracotomy
This is the standard approach for elective surgery of the lung. A right thoracotomy also
affords excellent access to the thoracic oesophagus, and a left lateral thoracotomy to
the descending thoracic aorta. Access to the hilum of a lung and the mediastinal
structures is good, but only on the respective side. In an emergency it is the incision of
choice for a rapidly collecting unilateral haemothorax. In elective surgery, the level of
the incision may be dependent on the underlying pathology, but in an emergency the
5th intercostal space is the most satisfactory. The patient is positioned on his or her
side with pelvic and upper arm support to secure stability, and a posterolateral
thoracotomy incision is made (Fig. 7.8). The alternative semi-prone position affords
excellent stability for a posterolateral thoracotomy in an extreme emergency, but
adequate ventilation may be more difficult.

The incision is made through the skin and latissimus dorsi in the
same line (Fig. 7.9), and should be two finger breadths below the tip of the
scapula. Posteriorly, the skin incision may turn up to divide the angle between the
spine and the medial edge of the scapula. Anteriorly, it extends into the
submammary fold. It is then deepened through the latissimus dorsi, the fibres of
which are at about 90 degrees to the incision. The plane deep to latissimus dorsi
is then developed upwards, under the scapula. The ribs and intercostal muscles
are now exposed, so that it is possible to count the ribs, and plan the appropriate
level for the thoracotomy. The edge of the second rib is the highest rib which can
be felt under the scapula, and the flat surface of the third is then palpable below
it. Having identified the chosen space for the thoracotomy, the lower border of
serratus anterior is freed by coagulation diathermy from the fascial and fatty
plane and divided as low as is practical to preserve innervation. If more space is
needed the trapezius can be divided.

Entry into the chest may then be through the intercostals muscles,
directly along the upper border of the rib to avoid damage to the neurovascular
bundle, or it can be through the bed of a rib. The former route is quicker in an
emergency. If the incision is to be through the bed of a rib, the periosteum is
incised along the length of the rib with diathermy, and stripped off its upper
border (Fig. 7.10a). A periosteal elevator as shown in Figure 7.6(b) can be used for
this. Stripping should be from back to front as the fibres of the intercostal muscles
then keep the dissection on the upper border of the rib. The pleural cavity is then
entered through the posterior periosteum. Care must be taken to avoid injury to
the underlying lung, and a moments apnoea from the anaesthetist can be
helpful. Rib resection is unnecessary but division of the costo-transverse ligament
posteriorly allows greater mobility of the superior rib, reducing the risk of fracture
when the self-retaining retractor is introduced.
The pleura is incised, and with a double-lumen tube in place, the
anaesthetist can allow the lung to collapse out of the operating field. The chest
wall edges are protected by large swabs and a Finochetti, or other self-retaining
chest retractor, is inserted. Rib retraction puts the intercostal neurovascular
bundle on stretch. Prophylactic surgical division of the neuro-vascular bundle
should be performed if tearing appears likely.
One or two chest drains are commonly placed in the pleural cavity at
the end of surgery before closure, and are brought out through separate stab
incisions. Rib apposition can be held by four pericostal sutures spaced along the
incision (Fig. 7.10b), followed by a continuous suture approximating the upper
leaf of the divided periosteum to the fascia over the intercostal muscle in the
space below (Fig. 7.10c). The chest wall muscles are then repaired with
absorbable sutures.
Transaxillary lateral thoracotomy
This is a limited lateral thoracotomy, performed through the medial wall of the
axilla, which affords restricted access to the apex of the lung. It was a standard
approach for a thoracic sympathectomy but it has now generally been superseded
by VATS.
Antero-lateral thoracotomy
A left anterolateral thoracotomy is often the incision of choice for emergency
access to the heart. Access to the posterolateral aspect of the left ventricle is
superior to that obtained with a median sternotomy but, more importantly, it is a
faster and safer approach, especially in the absence of the necessary saws. The
patient is laid obliquely supine with the ipsilateral hip and shoulder raised. A left
5th space antero-lateral thoracotomy can be extended by a transverse or oblique
division of the sternal body to a 5th or 4th interspace right antero-lateral
thoracotomy if greater access is required. In this clam-shell thoracotomy both
internal mammary arteries must be ligated and divided.

Thoraco-abdominal incisions
These incisions, which allow simultaneous access to the upper abdomen and
chest, have lost popularity as both postoperative pain and respiratory
complications are common. In general they can be avoided. A left thoraco-
abdominal incision was routinely used for cancers of the gastric cardia and lower
oesophagus. With the advent of minimal access techniques and circular stapling
devices for anastomoses, it is now possible to perform both the dissection of the
thoracic oesophagus and the anastomosis by using a trans-hiatal approach from
below. When more extensive access to the intrathoracic oesophagus is necessary,
a separate right thoracotomy incision is employed. A right thoraco-abdominal
incision was used for liver surgery, but the alternative subcostal incision provides
good access to the mobilized liver, with less morbidity.

Lateral decubitus position= side lying position

1. Median sternotomy
2. Pacemaker scar
3. Posterolateral thoracotomy
4. Anterolateral thoracotomy
5. Axillary thoracotomy
Axillary thoracotomy
Sternal angle=angle of Louis

Clamshell incision
 Posterolateral thoracotomy

Median sternotomy

Partial sternotomy