Pneumonectomy - Different Types of Incisions Used

(20 Marks - Clinical Cardiopulmonary Conditions)

Definition and Introduction

Patient Positioning

Types of Incisions Used for Pneumonectomy

1. Standard Posterolateral Thoracotomy (Most Common - Gold Standard)

• Begins anteriorly below the level of the nipple (or inframammary fold in females)
• Passes 1-2 cm below the tip of the scapula
• Extends posteriorly and superiorly between the medial border of the scapula and the spine

1. Skin and subcutaneous tissue
2. Latissimus dorsi muscle - divided in line with the skin incision using coagulating diathermy
3. Serratus anterior muscle - if divided, it should be cut close to its attachment to ribs 6, 7, and 8; alternatively it can be mobilized along its inferior border and left intact
4. Trapezius and rhomboid fibers (partially)
5. Sixth rib periosteum - scored near its upper border with diathermy; periosteal elevator is used to lift the periosteum off the superior border of the rib
6. Intercostal muscles - cut just above the rib upper border
7. Pleura - entered by blunt dissection

• Excellent exposure of the entire lung, hilum, and mediastinal structures
• Best access for lymph node dissection (stations 7, 10, 11)
• Optimal control of pulmonary vessels and main bronchus
• Allows conversion to more extensive procedures if needed

• Requires division of major chest wall muscles (latissimus dorsi, serratus anterior)
• Significant postoperative pain
• Total respiratory compliance may fall by up to 75%; work of breathing increases; lung volumes decline dramatically due to chest wall trauma, rib retraction/resection, and muscle transection (Fishman's Pulmonary Diseases and Disorders, 2-Volume Set)
• Longer recovery time

2. Anterolateral Thoracotomy

• Curvilinear incision underneath the inferior border of the pectoralis major muscle at the inframammary fold
• In females, follows the inframammary crease
• Extends from the lateral edge of the sternum to the posterior axillary line over the fourth or fifth intercostal space

• Subcutaneous tissue
• Pectoralis major and minor muscles
• Intercostal muscles
• Pleura

• Rapid access - does not require major muscle division posteriorly
• Used for emergency thoracotomy (e.g., penetrating chest wounds, cardiac arrest, massive hemothorax)
• Can be quickly converted to a clamshell incision by extending to the contralateral side
• Good access to the left ventricle, anterolateral walls of the right ventricle, both atria, and allows aortic cross-clamping

• Limited posterior and mediastinal exposure compared to posterolateral approach
• Not ideal for elective pneumonectomy unless combined with other approaches
• Posterolateral wall of the right ventricle and posterior walls of both ventricles are harder to access

3. Muscle-Sparing Thoracotomy (Axillary / Muscle-Sparing Variant)

• Vertical axillary (muscle-sparing) incision: Made anterior to the latissimus dorsi muscle; enters the chest through the fourth intercostal space; the latissimus dorsi is retracted rather than divided
• Lateral muscle-sparing thoracotomy: The latissimus dorsi is retracted posteriorly; serratus anterior is split (not transected) along its fiber direction

• Significantly less postoperative pain
• Preservation of shoulder girdle function
• Faster recovery
• Less respiratory dysfunction postoperatively (less reduction in vital capacity and FEV1)
• Cosmetically superior scar

• Exposure may be more limited, particularly for large tumors or extensive hilar dissection
• Requires a skilled surgical team to optimize retraction for adequate visualization

4. Median Sternotomy

• Vertical midline skin incision from the suprasternal notch to just below the tip of the xiphoid process
• Sternum divided in the midline using an oscillating/sternal saw
• Sternal retractor spreads the sternum approximately 8-10 cm

• Skin and subcutaneous tissue
• Periosteum
• Sternum (divided by saw)
• Pericardium can be opened; pleura on either side can be opened to access the hemithorax

• Excellent exposure of the heart, superior vena cava, aortic root, pulmonary vessels, and pulmonary hilae bilaterally
• Incision can be extended into the anterior cervical region or supraclavicular fossa to enhance exposure of the great vessels
• Avoids major chest wall muscles
• Good access to the mediastinum
• Traditionally used for bilateral pulmonary metastasectomy, mediastinal tumors, and cardiac surgery

• Takes longer to open than anterolateral thoracotomy
• Access to the left and right lung is more limited than posterolateral thoracotomy
• Descending aorta, trachea, and esophagus cannot be reached through a sternotomy
• Risk of sternal dehiscence and mediastinitis

5. Clamshell (Bilateral Anterior Thoracotomy + Transverse Sternotomy)

• Two anterior thoracotomy incisions made bilaterally in the inframammary fold
• Connected by a transverse division of the sternum at the fourth intercostal space
• Both internal mammary arteries (LIMA and RIMA) are ligated

• Largest single incision for thoracic access - provides excellent bilateral exposure
• Ideal for accessing both lung hila, the entire heart, and great vessels
• Preferred for bilateral lung transplantation in many centers
• Allows management of large mediastinal tumors or bilateral hilar dissections
• Can be rapidly created from a left anterolateral thoracotomy by extending to the right

• Larger than median sternotomy - typically more painful postoperatively
• Requires ligation of both internal mammary arteries
• Higher wound morbidity and postoperative complications
• Reserved for specific indications

6. Video-Assisted Thoracoscopic Surgery (VATS) Approach

• A utility incision (approximately 3-4 cm) placed at one intercostal space
• 2-3 additional port sites (each 1-2 cm) for camera and instruments
• Careful placement is relative to the patient's ribs, arm, diaphragm, and scapula
• Ribs are NOT spread

• A high-definition camera and long thoracoscopic instruments are used
• Improved lighting and optics create excellent visualization, often superior to open approaches

• Reduced postoperative pain
• Shorter length of hospitalization
• Faster recovery and return to activity
• Less chest wall trauma - no major muscle division
• Better cosmetic outcome

• Technically demanding - requires specialized training and equipment
• Limited access in cases of dense adhesions or difficult hilar anatomy
• Conversion to open thoracotomy may be required

Comparative Summary Table

Bronchial Stump Management Post-Incision

• Right main bronchus: divided at approximately the third cartilage counted from the carina
• Left main bronchus: also divided at the third cartilage; a longer bronchial stump must be avoided as it creates a pocket for secretion accumulation
• A TA stapler is placed in the "Sweet direction" and fired orthogonally to the longitudinal axis of the bronchus
• Bronchial stump is tested for air leaks at 20 cmH2O positive pressure (Fischer's Mastery of Surgery, 8e)

Key Postoperative Consideration Related to Incision

• The standard posterolateral thoracotomy causes up to 75% fall in total respiratory compliance
• Work of breathing increases substantially
• Lung volumes (FRC, VC, FEV1) decline dramatically
• Muscle-sparing and VATS approaches significantly reduce this morbidity
• Post-pneumonectomy space management (mediastinal balancing, drainage systems) is mandatory regardless of incision type (Miller's Anesthesia, 10e)

Conclusion

• Miller's Anesthesia, 10e - Pneumonectomy section
• Bailey and Love's Short Practice of Surgery, 28e - Thoracotomy chapter
• Fischer's Mastery of Surgery, 8e - Left Pneumonectomy and Surgical Technique: Incisions
• Sabiston Textbook of Surgery, The Biological Basis of Modern Surgical Practice - Thoracic Incisions
• Schwartz's Principles of Surgery, 11e - Operative Approaches and Exposure
• Fishman's Pulmonary Diseases and Disorders, 2-Volume Set - Lung Resection
• Harrison's Principles of Internal Medicine, 22e - Recipient Operation (transplant incisions)