Transcript Incisions in cardiothoracic surgery

IN THE NAME OF GOD
Dr.mehdi hadadzadeh
Assistant professore of cardiovascular surgery
 A surgical incision opens an aperture into the thorax to
permit the work of the planned operation to proceed
 If an operation is difficult, you are not doing it
properly," applies directly to the incision used
The choice of incision:
 underlying pathology
 the site (e.g. lung, chest wall, oesophagus)
 experience of the surgeon
Types of incisions
 Median Sternotomy
 Posterolateral thoracotomy
 Anterolateral thoracotomy
 Lateral thoracotomy
 Bilateral thoracosternotomy
 Subxiphoid(pericardial window)
Posterolateral thoracotomy
 gold standard of thoracic incisions
 excellent exposure for most general thoracic
procedures including the lung, heart, aorta, the lower
esophagus, and diaphragm
 This approach is also used for spinal operations
Preoperative preparation
 Assessment of pulmonary function
 given a dose of antibiotics preoperatively
 preoperative education and incentive spirometry
training as to the importance of adequate inspiration
postoperatively to prevent atelectasis (lung collapse
Position
 complete lateral decubitus position
 use of sandbags, rolled sheets front and back or bean
bags supporting the back and the abdomen
 The lower leg is flexed at the knee and hip while the
upper leg lies straight on the top of the pillow
 to avoid post operative complications ;
 cutaneous necrosis,
 venous thrombosis
 or nerve compression.
 arm placed on an angle pad
 free from any fixation.
Incision
 The position of the vertebral spines and the nipple is
notified.
 The standard incision follows between scapula and
mid-spinal line to the anterior axillary line
 passing 3cm below the tip of the scapula.
 The skin incision :No. 10 scalpel
 latissimus dorsi and serratus anterior muscles : No. 10
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scalpel or cautery
Posteriorly, the muscle layers of the rhomboid and
trapezius are incised
The pleural space :incising the musculature between
the ribs or via an osteotomy
transect the muscles on the superior border of the ribs
to avoid injuring the neurovascular bundle.
ribs may be transected or resected
 at the level of the 5th rib for exposure of the upper
thoracic area :COA
 level of the 6th or 7th rib for lower thoracic area (e.g.,
lower esophageal or diaphragmatic surgery)
 After operation drainage tubes must be placed
 The rib approximator is closed and No.1 chromic or No. 1 vicryl
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sutures are placed to encircle the bone along the length of the
incision.
Silk sutures are to be avoided as it increases postoperative pain
The cut ends of the trapezius and latissimus dorsi muscles are
then approximated and sutured
subcutaneous tissue is closed using an interrupted 3-0
absorbable sutures.
The skin is closed using surgical clips or a running 4-0
subcuticular stitch such as Monocryl.
disadvantages of this incision
 increased potential for blood loss and moderate time
requirement for opening and closing the incision
 prolonged ipsilateral shoulder and arm dysfunctions
 compromised pulmonary function and chronic post
thoracotomy pain syndromes
 scolioses have been described in children
Median sternotomy
 Most common thoracic incision
 Indications:cardiac operations-anterior mediastinal
lesions-bilateral lung procedures
 Speed in opening and closing
 Supine position and arms in patient,s side
Incision
 Incision from below the suprasternal notch toa point
between the xyphoid and umblicus
 An electric saw with a vertical blade is used
 An oscillating saw is used for repeated sternotpmy
 Bone wax is a useful tool to control bleeding from
sternum
 sterile mixture of beeswax and isopropyl palmitate
 Sternal retractor is used in lower thired of the sternum
and gradually opened
 Stainless steel wire is at present the standard suture in
median sternotomy
Disadvantage of this incision
 Scar formation
 Brachial plexus injury
 Chronic chest pain
Axillary(lateral)thoracotomy
 Advantages:muscle sparing-ease and speed-good cosmetic
 Disadvantages:limited exposure
 Choice in majority of pulmonary resections ,PDA
ligation,PA banding and….
 Lateral decubitus position homolateral arm is abducted at
90° at the shoulder level, flexed at the elbow
 Incision Between posterior border of pectoralis major and
anterior border of latisimus dorsi
 through the 4th or 5th intercostal space;
Bilateral
thoracosternotomy(clamshell)
 Previously choice for bilateral lung transplant
 Incision along the inframammary creases and across
the sternum
 4 or 5th intercostal space
 Poor healing of wound
Anterolateral thoracotomy
 Useful in variety of operation on heart,pulmonary
resection and esophagus
 Supine and operation site elevated30 degree
 Incision from lateral border of sternum to midaxillary
at 4or5interspace
 Pectoralis major and seratus anterior is divided
Subxiphoid incision(pericardial
window)
 Indications:pericardial effusion,pericardial
biopsy,epicardial pacemaker
 Supine posision,midline incision over the xiphoid
Intrapleural(chest) tubes
 Whenever thoracotomy has been done
 exit of fluids and air and monitors of bloodloss
 Separate incision