Thoracic Incisions Technique

The first principle in making a thoracic incision is that adequate exposure must be achieved, especially during the most technically challenging part of the operation. The choice of incision is aided by a thorough understanding of the surface anatomy and a comprehensive review of the radiographic images that are obtained preoperatively.

The next principle is that chest-wall function and appearance should be preserved to the extent possible. Measures aimed at following this principle include nonspreading video-assisted thoracoscopic surgery (VATS) procedures, muscle-sparing techniques, avoidance of excessive rib retraction, and rib preservation when possible.

The third principle is that closure must be meticulous and appropriate. Strict layered closure is the rule for thoracic surgical incisions. Every effort should be made to approximate the individual divided chest-wall muscles in appropriate layers; otherwise, a significant delay in the recovery of range of motion (ROM) may result. Care must be taken to avoid overapproximating the ribs and to prevent an override; this will help minimze postoperative pain.

Similarly, divided bony tissue, especially the sternum (as in a median sternotomy), should be rigidly approximated. Excess rib or sternal motion decreases the efficiency of chest-wall movements and increases the work of breathing, especially in the setting of postoperative pain.

Median sternotomy

For most cardiac surgical operations, the median sternotomy is the incision of choice. It offers excellent exposure of the heart, pericardium, great vessels, thymus, anterior mediastinal structures, lower trachea, and carina and is well suited for bilateral pulmonary procedures such as resection of bilateral pulmonary metastasis. Left-lower-lobe pulmonary resection is quite challenging from this approach, and access to posterior mediastinal structures (eg, esophagus and distal descending thoracic aorta) is not possible.

The advantages of this incision are that it is quick to perform, especially in hemodynamic emergencies, and that it produces less pain than a traditional thoracotomy. The main drawback is cosmetic, and a risk of sternal malunion exists, which is usually associated with a postoperative infection.

The patient is placed supine with both arms padded and draped at the sides. A vertical midline incision is made from below the sternal notch up to the tip of the xiphoid process. The pectoral fascia (with muscles if present) is divided, and the periosteum is scored with a cautery. Palpating the lateral margins of the sternum facilitates identification of the midline.

The sternum is divided in the midline with a power saw. Periosteal bleeding must be meticulously controlled. Occasionally, the marrow bleeding necessitates the use of bone wax or one of the newer commercially available water-soluble absorbable agents to tamponade marrow oozing.

The retractor should be placed lower in the incision and should be spread slowly to avoid tearing of tissue, with particular attention paid to the innominate vein. Minimal spreading minimizes traction on the upper ribs and reduces occult fractures and neurologic insult on the brachial plexus.

Simple sternal wire closure or a figure-eight wire closure is the common method of closing the sternum. No. 6 and No. 7 stainless steel wires are commonly used in adults. Polyester ribbon and, occasionally, nonabsorbable sutures are used, commonly in children. Robicsek et al described a lateral sternal wire weave that reinforces the lateral sternal edges for a more secure closure. ^[3]  At least two wires in the manubrium and four or more wires in the body of the sternum are required for a tight secure closure.

Alternatively, various techniques that use plates and screws can also be used to close the sternum.

If bleeding from an internal thoracic vessel occurs, it is controlled with a figure-eight stitch. It is also very important to ensure that the mediastinal drain is not entrapped in the wound closure. The pectoralis fascia is then closed so that the wires are not visible, and the rest of the incision is closed in layers in the standard fashion.

Reoperative sternotomy

Reoperative sternotomy carries an increased mortality over the initial sternotomy, and each additional reparative entry increases mortality further. This is directly related to the increased operative mortality during the performance of a repeat sternotomy. Exposing the femoral artery and vein before opening the sternum for urgent access to institute cardiopulmonary bypass (CPB) is prudent.

If excessive difficulty is anticipated during repeat sternotomy, on the basis of the preoperative evaluation of the patient (including previous operative reports and preoperative chest radiographs, especially the lateral view), instituting femorofemoral CPB before performing the repeat sternotomy is safe.

The use of an oscillating saw facilitates sternal reopening. Appreciating the depth of penetration with the oscillating saw is the key to a successful sternal reopening. Elevating the previous sternal wires to provide upward retraction of the sternum is well described and is a useful technique to know.

Mediastinitis is the most serious complication following median sternotomy. The reported incidence is 0.6-5%, with an associated mortality of 0-36%. ^[4] Chronic obstructive pulmonary disease (COPD), prolonged stay in the intensive care unit (ICU), respiratory failure, connective-tissue disease, male sex, morbid obesity, uncontrolled diabetes mellitus, and possibly the use of bilateral mammary arteries as conduits have all been associated with a higher incidence of sternal wound complications.

Treatment includes intravenous (IV) antibiotic therapy, operative debridement, and either delayed primary closure or closure after transposition of muscle flaps or omentum.

Partial sternotomy

A common variation of the median sternotomy is the partial sternal split, which provides adequate access to the anterior superior mediastinum.

This incision is often combined with a transverse collar neck incision to provide wide cervicomediastinal exposure. The sternotomy can be extended supraclavicularly, usually on the right side for exposure of the innominate, subclavian, and carotid vessels. The partial sternotomy is also an integral part of the trapdoor incision, which includes a supraclavicular incision as well as a transverse anterior thoracotomy, most commonly on the right side, affording excellent exposure of the superior mediastinum and the superior sulcus region and large anterior mediastinal masses.

The patient is placed in the supine position, and the sternal saw is used to divide the manubrium. Depending on the extent of exposure required, the sternal split ends at the level of the manubrial-sternal junction or below it. Often, a J-type incision in the sternum is extended into the third or fourth interspace as a controlled cut (see the image below). Rarely, a T-junction is created at the end of the partial sternotomy. If excessive spreading of the sternal edges is performed, it results in a fracture of the lower end of the sternal incision.

The most popular thoracic incision, with which most thoracic surgeons are familiar, is the thoracotomy (see the image below). ^{[5, 6]}

A standard posterolateral thoracotomy transects the latissimus dorsi; an anterolateral thoracotomy transects the serratus anterior. No specific written definitions for each type of thoracotomy exist, but it still is probably useful to define the standard thoracotomies according to their relation to the latissimus dorsi, which is arbitrarily considered lateral. Incisions completely anterior to the latissimus dorsi are referred to as anterior thoracotomies; those posterior to it are referred to as posterior thoracotomies. (See the image below.)

The advantage of a thoracotomy is that it is extremely versatile and flexible and provides excellent exposure of the entire ipsilateral hemithorax, including the lung, esophagus, mediastinum, and cardiac structures. Its major disadvantages are related to the division of main muscle groups, with the attendant postoperative pain (especially ipsilateral shoulder pain ^{[7, 8]} ) and detrimental effect on pulmonary function. ^[9] Also, a significant potential exists for poor exposure if the wrong interspace is chosen to enter the thorax and if single-lung anesthesia is not possible.

Posterolateral thoracotomy

Historically, the posterolateral thoracotomy has been the standard thoracotomy for most procedures; however, in current practice, there is a preference for using smaller incisions that result in less functional disability and postoperative pain.

The patient is placed in a full lateral decubitus position with appropriate pressure-point padding. Soft rolls, bean bags, and straps of 2-in. (5-cm) adhesive tape are used to secure the patient to the table. The lower leg is flexed at the hip and knee, while the upper leg is kept straight with pillows in between the legs.

The dependent arm is flexed, as is the superior arm, to yield the so-called praying position. Safely preventing the upper arm from hanging over onto the chest is important because such overhang can limit the space within which the surgeon is maneuvering instruments within the bony thorax.

Widely preparing and draping the patient and marking the incision and significant anatomic landmarks with a felt-tip pen prior to skin incision are also important.

The skin incision is designed to allow upward retraction of the scapula. The incision starts in front of the anterior axillary line at the anterior border of the latissimus dorsi and passes 3-6 cm below the scapula tip, extending posteriorly and cephalad midway between the posterior midline over the vertebral bodies and the medial border of the scapula. The latissimus dorsi is identified and divided with the electrocautery in line with the incision; some muscular vessels are likely to require individual ligation.

The serratus anterior is in a deeper plane, and it is divided as low as possible, close to the muscular attachment, to minimize the amount of distal denervated muscle. In this same plane, posteriorly, a small portion of the trapezius or (higher up) the rhomboid muscles may have to be divided if necessary for additional exposure.

The interspace to be entered is located by positioning the hand up along the paraspinal muscles and by lifting the scapula with a large broad retractor. Sometimes, the first rib is difficult to palpate, but the attachment of the serratus posterior superior to the second rib is almost always discernible. Also, the second intercostal space is usually the widest intercostal space that is palpable and thus can serves as an added guide to correctly counting the ribs.

More than one way of entering the pleural space exists. The easiest and most common method is the intercostal approach, which enters along the superior border of the rib to avoid injury to the underlying intercostal neurovascular bundle. Another common method is the approach through the periosteal bed. The periosteum is raised off the superior border of the rib after it is scored with an electrocautery, and the pleural cavity is then entered through the periosteal bed, preferably with the anesthesiologist holding ventilation at the time of entry into the pleural cavity.

Before the pleural incision is extended, it is important to ensure that the lung is not directly adherent to the chest wall. Many surgeons advocate a short-segment rib resection in elderly patients and those with brittle bones to reduce the incidence of rib fractures and improve exposure. This method of "shingling" involves excising a 1- to 2-cm segment of rib at the costovertebral angle posteriorly.

For repeat thoracotomies, resecting a long segment of rib subperiosteally and entering the pleural space through the resected rib bed is often prudent. Extensive adhesions may exist at the time of reoperation, and this wider entry facilitates safe pleural entry.

A large Finochietto-type rib retractor is used to open the incision, with the large blade inserted superiorly to ensure that the scapula is retracted. Sometimes, a smaller Tuffier-type rib spreader can also be used anteriorly to widen the exposure. Opening the rib spreader slowly and gradually to avoid rib fractures is important.

At least four pericostal sutures of heavy absorbable material (eg, No. 2 polyglycolic acid) are placed. If a rib is resected, wider sutures are placed around the remaining ribs. Sometimes, a rib reapproximator (Bailey type) or towel clips are required to support the ribs while the sutures are tied, with care taken not to overapproximate the space. The muscular layers are approximated with a continuous suture; ideally, the latissimus dorsi is closed in two layers, with the anterior and posterior fascial layers separately reapproximated and care taken to minimize muscular bunching.

Anterior (anterolateral) thoracotomy

With the ongoing trend toward minimally invasive cardiac and thoracic surgical techniques, the anterior thoracotomy has seen a resurgence. ^{[10, 11]} In the emergency setting, it allows rapid access to the left chest, the pericardium, and also the aorta. It is the incision of choice for open lung biopsy, especially in sick patients who would not be able to tolerate single-lung anesthesia.

The patient is positioned supine with the arm padded and tucked to the side or placed over the body on an arm rest. The skin incision begins just lateral to the sternal edge and follows the inframammary crease up to the anterior axillary line. The angle of Louis and hence the second rib are used as a reference point for counting the ribs.

The dissection is carried down to the chest wall dividing the pectoralis major and minor and the medial edge of the serratus anterior. Entry into the higher intercostal space requires control of the anterior perforating arterial branches to the pectoralis muscles.

Extended medial exposure can be achieved by controlling and dividing the internal thoracic vessels and extending the incision transsternally. One or both costal cartilages may be divided with an angled rib cutter to gain wider exposure.

During closure, it is difficult to achieve rib reapproximation anteriorly; accordingly, it is important to perform a multilayered closure of the muscle and soft tissue to prevent local wound dehiscence.

Axillary thoracotomy

The original axillary thoracotomy was developed for operations on the thoracic sympathetic nervous system. It is a useful incision for first-rib resection, apical bullous lung disease, management of spontaneous pneumothorax with apical pleurectomy, and wedge resections. Currently, however, most of these procedures are routinely performed thoracoscopically.

The main advantages of the axillary thoracotomy are that muscle transection is minimal, that the incision is easy to perform, and that the scar is largely hidden under the arm. The main drawbacks of this incision are that the exposure is primarily limited to the upper half of the chest and that there is the potential for injury to the intercostobrachial nerve and the long thoracic nerve.

The patient is placed in the lateral decubitus position with the ipsilateral arm flexed at the elbow and rotated superiorly, where it is suspended vertically and secured to a strand so as to open up the axilla, with care taken not to overextend the arm.

A 6-cm curvilinear incision is made at the base of the axillary hairline from the anterior margin of the latissimus dorsi to the posterior margin of the pectoralis major. These muscles are retracted, and the third intercostal space is identified.

Care is taken to preserve the long thoracic neurovascular bundle that courses in the posterior aspect of the incision over the ribs. If the incision is used for first-rib resection, blunt dissection is carried upwards to develop the plane, with care taken not to injure the intercostobrachial nerve that exits the second intercostal space.

During closure, the retracted muscles are allowed to fall back in place after the pericostal sutures are placed. In certain situations, when no significant thoracic drainage is expected, no pleural drain is placed, and the inevitable small postoperative pneumothorax is usually well tolerated.

Muscle-sparing thoracotomy

Muscle-sparing variants of standard thoracotomy incisions have become standard choices for most thoracic surgeons. The advantages of reduced postoperative pain, decreased narcotic usage, and improved shoulder-girdle muscle strength have been well documented. The minor drawbacks include postoperative seroma formation and the potential for compromised exposure during the procedure.

Various terms (eg, limited lateral, muscle-sparing posterolateral, extensive lateral, and vertical axillary) are used to describe the different muscle-sparing approaches to thoracotomy. Most of the variations have to do with the dimensions, location, and course of the specific skin incision used and the degree of muscle-sparing involved with or without the development of extensive flaps.

The modified muscle-sparing posterolateral thoracotomy raises extensive skin flaps over the latissimus dorsi and the trapezius. The two are then separated, and the latissimus is detached posteriorly by an incision in the thoracolumbar fascia. The serratus anterior is detached from its rib insertion inferiorly and retracted anteriorly along with the latissimus dorsi. Most commonly, however, the latissimus dorsi is divided as in a standard thoracotomy, and the serratus anterior is preserved after being mobilized and retracted anteriorly.

A useful option is to make an incision from the tip of the scapula posteriorly and inferiorly, extending it forward for about 10 cm as in a standard lateral thoracotomy. Flaps are raised, the anterior edge of the latissimus dorsi is incised vertically, and the plane between the latissimus dorsi and the serratus anterior is developed. Similarly, the posterolateral edge of the serratus anterior is incised, the muscle is elevated, and the plane is developed. The latissimus dorsi is retracted posteriorly, and the serratus anterior is retracted anteriorly to expose the intercostal space.

Often, in this modified low thoracotomy, the ribs must be counted upward from below and the highest interspace that can be entered is the fifth interspace, because not enough space exists for inserting a hand to count the ribs from above.

The vertical axillary thoracotomy provides adequate muscle-sparing exposure for middle- and lower-lobe lung resection, but access to the upper chest can be problematic. ^{[12, 13, 11]}  The incision begins high in the axilla along the anterior border of the latissimus dorsi and extends vertically down the posterior axillary line. The latissimus dorsi is retracted posteriorly, and the serratus anterior is retracted anteriorly after appropriate planes are developed. This approach is probably not recommended if difficult hilar dissection is anticipated.

In 1966, Chamberlain and McNeill introduced anterior parasternal mediastinoscopy to stage and diagnose advanced upper-lobe lung cancers. ^[14] This approach affords access to level 5 (aortopulmonary window) and level 6 (preaortic) lymph nodes on the left and to level 3 (prevascular), level 4 (lower right paratracheal), and level 10 (tracheobronchial) lymph nodes on the right, as well as enabling biopsy of mediastinal masses. Accordingly, it is a useful diagnostic procedure in the armamentarium of the thoracic surgeon.

The patient is positioned supine with a small shoulder roll, the bed is in reverse Trendelenburg position to reduce central venous pressure, and the parts are widely prepared and draped in case an extended thoracotomy or sternotomy is required in the event of catastrophic bleeding. A 6-cm transverse incision is positioned over the second or third costal cartilage parasternally.

The pectoralis muscle fibers are retracted after division, and the costal cartilage is excised from its bed. The mediastinal space is entered through the perichondrial bed, and care is taken to control bleeding from the internal thoracic vessels. An alternate technique uses an intercostal incision preserving the costal cartilage and usually requires the pleura to be opened. In the original description, the pleura is swept laterally to access the mediastinal structures.

Use of a lighted mediastinoscope and deep narrow retractors can greatly facilitate exposure during the operation. Closure usually does not entail pleural drainage, and the incision is closed in multiple layers.

Significant disadvantages of this incision include the limited exposure afforded, the inability to visualize the posterior hilar structures, and the frequent sacrifice of the internal thoracic vessels. The incision can be extended as an anterior thoracotomy if needed, or the surgeon can adopt a thoracoscopic approach.

The transverse thoracosternotomy is probably the most morbid of all the thoracic incisions described in this article. However, it has seen a resurgence in carefully selected indications, including the following:

• Resection of large mediastinal masses
• Double-lung transplantation (though the median sternotomy is a viable alternative in this setting ^[15] )
• Bilateral pulmonary metastasectomy
• Extension of the emergency anterior thoracotomy performed by a trauma surgeon to resuscitate a patient in extremis

Although this incision provides excellent wide exposure of both lungs, the mediastinum, and great vessels, it causes increased postoperative pain, frequently requires the patient to be on postoperative ventilatory support, and carries a serious risk of sternal malunion and chest-wall dysfunction.

Bilateral clamshell incision

The patient is placed supine with both arms extended over the face and with the elbows flexed and secured to a stand. Bilateral anterior thoracotomies are performed along the inframammary crease, coursing upwards in the midline to the appropriate fourth or fifth intercostal space, where the transverse sternal incision is to be performed (see the image below).

After the pleurae are opened, the internal thoracic vessels are divided bilaterally, and the sternum is divided transversely with a power saw, a Gigli saw, or a Lebsche sternal knife. Rib spreaders are usually placed on both sides. To prevent traction injury of the phrenic nerves, care must be taken not to open the chest too widely.

Interrupted or figure-eight heavy-gauge wire sutures are used to close the sternum, and the thoracotomies are closed in the standard layered fashion as previously described. Multiple parallel vertical Kirschner wires (K-wires) are used in the reapproximated sternum to reduce override and shifting of the sternal ends.

Hemiclamshell incision

The hemiclamshell incision combines an anterior thoracotomy with a partial upper sternal split. Although it is rarely used, it provides excellent exposure for large central pulmonary lesions and large invasive mediastinal tumors and affords ready access to the brachiocephalic vessels and the intrapericardial pulmonary vessels.

The patient is placed supine, and an anterior thoracotomy is made in the inframammary crease up to the sternal midline. Exploration to confirm resectability should always be completed before a commitment is made to the sternal incision. The skin incision is extended vertically upwards to the sternal notch and then for a short distance along the ipsilateral sternocleidomastoid in the neck.

The fourth intercostal space is entered at the top of the fifth rib, and the internal thoracic vessels are controlled before the sternum is opened. The upper partial sternotomy is performed from above downward in the midline of the sternum and curved out to the fourth interspace in a J-type cut.

In the placement of the retractor, care should be taken to avoid undue traction on the brachial plexus. Meticulous closure involves perfect reapproximation of the sternum with wires and the use of pericostal sutures for the intercostal space incision; all of this is done in multiple layers.

The thoracoabdominal incision provides wide exposure of the lower thorax, the upper abdomen, and the retroperitoneal space. It offers excellent exposure for thoracoabdominal aneurysms, cancer of the esophagogastric junction, and pathology of the lower thoracic and upper lumbar spine. The left side is preferred because retraction and mobilization of the liver and inferior vena cava (IVC) on the right are more problematic than retraction and mobilization of the spleen or aorta on the left.

The patient is placed in the right lateral decubitus position with the hips rotated back at least 45º to increase abdominal exposure. Alternatively, the patient is placed supine with the left side elevated and rotated with a support extending from the hip to the chest on the ipsilateral side. If the supine position is used, the ipsilateral arm is padded and supported by the patient’s side, either extended outward 90º or suspended across the chest.

The skin incision is made from the anterior axillary line diagonally forward at the appropriate rib level to a point in the abdomen midway between the umbilicus and the xiphoid process. Depending on the structures to be approached, the incision can be extended toward the tip of the scapula or downward below the umbilicus. Also, the vertical abdominal portion of the incision can be placed in the midline, or a paramedian abdominal incisional approach can be chosen.

The latissimus dorsi and serratus anterior are divided, and the scapula is elevated. The chest-wall opening is determined by the specific operative procedure to be performed, but the seventh intercostal space approach is the one most commonly used. A short segment of costal cartilage at the transition to the abdominal incision is often removed to facilitate later rib and costal reapproximation during closure.

The abdomen is opened in layers with the electrocautery. The left hemidiaphragm can be opened radially to the esophageal hiatus or can be opened circumferentially, with a 2-3 cm rim of diaphragm left on the chest wall for later reapproximation. Care is taken to avoid injury to the main phrenic nerve and its large branches.

The diaphragm is closed with large nonabsorbable sutures. Chest drains are routine, and a standard thoracotomy closure is achieved. The retroperitoneum is not usually drained. The costal margin is closed with one or two heavy figure-eight sutures that incorporate the upper edge of the diaphragm to prevent postoperative hernia formation.

Of special interest is the open thoracoabdominal approach to lower thoracic and upper lumbar spine pathology. Once again, a left-side approach is preferred. The spinal levels to be exposed should be well marked and imaged fluoroscopically before preparation and draping. Usually, a posterolateral thoracotomy is required, and the 10th or 11th rib is resected subperiosteally.

The diaphragm is divided circumferentially, with care taken to leave a rim on the chest wall for later reapproximation. The peritoneum is left intact and is swept forward from lateral to medial, with care taken not to injure the spleen. A special effort must be made to avoid injury to the aorta at the diaphragmatic hiatus. The segmental intercostal vessels over the involved vertebral bodies are controlled, ligated, and divided.

Respiratory complications are worrisome after these thoracoabdominal approaches, and atelectasis of the left lower lobe of the lung is frequently reported.

Extrathoracic incisional approaches to the thorax include several special incisions that are sometimes used to expose intrathoracic structures without the need for a thoracotomy. The three extrathoracic approaches discussed here are as follows:

• Transcervical (collar) approach
• Subxiphoid approach
• Transdiaphragmatic approach

The main disadvantage shared by all these approaches is the limited intrathoracic exposure that they offer.

Transcervical

The transcervical approach is a standard transverse suprasternal (collar) neck incision that can be used to access anterior superior mediastinal pathology (eg, thymus, mediastinal parathyroid glands, substernal goiters, and anterior mediastinal cysts and tumors).

The substernal space is bluntly dissected, and special self retaining retractors, preferably with built-in lighting, are used to expose the anterior superior mediastinum. This incision can be extended into a T-incision with a vertical midline skin incision, and either a partial or a complete sternotomy can be added to achieve wider mediastinal and cardiac exposure.

Subxiphoid

The subxiphoid approach is a vertical midline incision centered over the xiphoid process. It is frequently used to drain a pericardial effusion.

The retroxiphoid space is developed, and the xiphoid can either be excised or split in the midline up to its junction with the lower end of the sternum. The retrosternal space can then be developed and the sternum elevated to allow access to the pericardium. The incision can easily be extended into a sternotomy (partial or complete) with a vertical midline superior extension.

Transdiaphragmatic

When Thirlby et al described the transdiaphragmatic approach to the lower esophagus, it was an alternative that provided excellent limited access via a laparotomy. ^[16]  It allows access to the posterior mediastinum at the level of T8.

As originally described, this incision is a semicircular incision in the central tendon of the diaphragm that gives excellent exposure to the lower esophagus. After the left hemiliver is mobilized up to the left hepatic vein and the greater or hepatic omentum is opened, the crus of the diaphragm is identified.

More commonly, an incision is made into the right crus of the diaphragm. This can be extended anteriorly for increased exposure. In the event of unexpected extension of the pathology at surgery, the laparotomy can be extended upwards into a partial or complete sternotomy. Alternatively, a separate thoracotomy can be added (either left or right, depending on the individual pathology).

Thoracic surgeons with a special interest in foregut procedures—specifically, those involving the esophagus and proximal stomach—should be familiar and comfortable with using laparoscopic techniques to perform operations such as myotomy (for esophageal mobility disorders) and fundoplication (for gastroesophageal reflux disease), among others.

In laparoscopy, as in thoracoscopy, appropriate port placement is the key to a smooth procedure. A thorough knowledge of the abdominal wall musculature and the surface anatomy aids the thoracic surgeon in choosing the optimal locations for the ports.

The access port is usually located in the left upper quadrant of the abdomen, about 2 in. (5 cm) from the umbilicus. The liver retractor port is placed in either the right subcostal or the subxiphoid position, depending on the specific type of retractor being used. Working ports are typically placed in the midline epigastrium and in the right subcostal region, especially if the surgeon stands between the patient’s legs for the procedure. Additional ports for retraction depend on the operation being done and the intra-abdominal findings at laparoscopy.

Unlike VATS, laparoscopy requires the establishment of pneumoperitoneum to prevent the abdominal wall from collapsing on the intra-abdominal contents during the procedure. Carbon dioxide is insufflated to a maximum pressure of 15 mm Hg. It is important to monitor the flow rate on the carbon dioxide insufflation; as low flow rates, especially during initial port placement, indicate obstruction of the Veress needle, a problem that should be promptly addressed.

The technique for initial port placement is usually dependent on the surgeon’s preference and on where the (intra-abdominal) adhesions are anticipated to be.

The safest and most commonly employed open technique is that of Hasson. ^[17]  The skin incision is deepened, and the anterior fascia is grasped with clamps and incised. A heavy suture is passed on each side to elevate the abdominal wall, and a hemostat is used to bluntly dissect the remaining layers of the abdominal wall down to the peritoneum. The surgeon usually sweeps the inside of the peritoneal cavity with a finger to ensure a free peritoneal space, and only then is the blunt-tip trocar inserted and pneumoperitoneum established.

For more routine procedures in which adhesions are unlikely to be encountered, a closed technique is used. The skin incision is made, and the entire abdominal wall is lifted up. A Veress needle is passed bluntly into the abdomen, with the three separate clicks (anterior rectus fascia, posterior rectus fascia, and transversus abdominis/peritoneum layer) appreciated along the way. The pneumoperitoneum is established as previously described, maintaining carbon dioxide flow and pressure.

Once the pneumoperitoneum is established, the spring-loaded retractable trocar-type port is quickly inserted into the peritoneal cavity with a twisting motion. Some surgeons use the clear plastic-tipped retractors that allow a 0º telescope to view the fascial layers as they are encountered during entry into the peritoneum; this appears to be a safe compromise alternative to the Hasson technique.

Closure of the laparoscopic port sites is usually straightforward, though various innovative fascial closure techniques have been developed with the aim of reducing the incidence of herniation (typically in the range of 1-5% but higher if large ports are used). Ports should be removed under direct vision to confirm that hemostasis is achieved.

Thoracoscopy was first described in 1910 by the Swedish physician Jacobeus, who used a cystoscope to examine the pleural space. ^[18]  In 1991, the application of video technology to thoracoscopy revolutionized the procedure by allowing the entire operating team to see the operative field as they would in an open procedure. Improvements in optics, lighting systems, and endoscopic instruments, including staplers, have had a profound impact on the evolution of VATS. Patient demand has become the main force driving thoracic surgeons to perform VATS procedures.

A rigid bony thorax and collapsible lungs provide an excellent closed space within which video surgery can be performed without the need for positive-pressure insufflation. The benefits of thoracoscopy include reduced pain in the early postoperative period, enhanced ability to view some operative regions, better cosmetics, and improved shoulder-girdle function. Thoracoscopy has yet to be proved beneficial in the long term with  regard to pulmonary function.

For most VATS procedures involving the lungs, pleura, esophagus, or posterior or middle mediastinum, the patient is placed in the lateral decubitus position, which permits easy conversion to thoracotomy if necessary. Flexing the distal half of the table is important for ensuring that instruments have adequate range of motion within the rigid thoracic cavity. A few procedures (eg, bilateral procedures for metastasectomy, sympathectomy, bleb resection, and anterior mediastinal procedures such as thymectomy) require the patient to be in the supine position with the arms extended.

VATS procedures are performed with general anesthesia and single-lung ventilation. In approximately 20% of patients undergoing VATS, intraoperative conversion to thoracotomy is required for any of several reasons (eg, extensive adhesions, intraoperative complications, inability to locate small lesions, or the need for a more extensive procedure). The instruments needed for an open thoracotomy should always be readily available and possibly opened and ready on the back table, in case an emergency thoracotomy is required.

VATS is conventionally performed through several small incisions. However, single-incision approaches have also been developed. ^{[19, 20]} A systematic review and meta-analysis by Abouarab et al found that single-incision VATS yielded better postoperative outcomes than conventional VATS in the treatment of thoracic disorders: postoperative pain, blood loss, drainage time, and length of postoperative hospital stay were all substantially reduced. ^[21]

The basic strategy in standard VATS techniques derives from the triangulation concept, in which the camera and the operating ports are at the base of the triangle and the area of interest is at the apex, so that all of the tools are oriented in the same direction, facing the target disease within a 180º area. The camera port is usually located between the working ports. The smallest ports that will permit safe performance of an operation are selected.

For most procedures, the scope is inserted through a port placed between the midaxillary line and the posterior axillary line at the seventh or eighth intercostal space; a more posterior location is chosen on the left side because the heart hinders visualization from the more anterior location. One working port is placed at the fifth intercostal space in the anterior midaxillary line, and the other is placed at the fifth space parallel to and about 2-3 cm away from the posterior border of the scapula. (See the image below.)

In some tall individuals with hyperinflated lungs and patients with apical lesions, the port sites are all moved superiorly by one or two intercostal spaces.

Accessory incisions are frequently required, especially when lesions must be directly visualized or palpated and when complex assisted procedures are performed to manipulate regions of interest using standard instruments for dissection and vessel width.

The accessory or utility thoracotomy is made just posterior to the pectoralis muscle, usually in the midaxillary line, and is 4-8 cm in length. The delineation between a VATS procedure and a small thoracotomy is theoretically breached if rib-spreading is required. For lower-lobe lung lesions, the accessory incision is made at the fifth space; for upper or middle lobectomies, the fourth space is used, with the appropriate pulmonary vein serving as the guide.

These basic concepts of port placement and incisions are modified as necessary to accommodate the procedures being performed and the location of the lesion being removed.

A 1- to 2-cm incision is made at the appropriate site, and a hemostat is used to dissect the subcutaneous tissue and intercostal muscles at the upper border of the rib. Electrocauterization under direct vision or blunt dissection is employed to dissect through the muscles and the pleura. Care is taken to identify a free pleural space, and only when this is done should a port be inserted. If any doubt exists, the incision is enlarged so that the surgeon can explore the pleural space with a finger and sweep away flimsy adhesions sufficiently to permit placement of the videothoracoscope.

A few surgeons use initial carbon dioxide insufflation to hasten the lung collapse. If this is done, the patient's cardiovascular status should be monitored during the maneuver.

The entire thoracic cavity is explored systematically. Additional port sites are placed under direct vision by using the telescope and camera. It is easier to insert larger ports through the anterior chest, where the intercostal spaces are wider.

At the conclusion of the operative procedure, one or more chest drains may be placed through the existing port sites. Ports are removed under direct vision to confirm hemostasis, and the port-site incisions are closed in layers, with care taken to close the muscular-fascial layer separately.

A few issues are specific to the performance of a VATS procedure. Intercostal neuralgia is usually caused by pressure on an adjacent intercostal nerve by a trocar. The incidence of this problem can be reduced by using smaller trocars and making an adequate incision. Treatment involves the use of nerve blocks and anti-inflammatory agents. In rare cases, major vascular injuries occur. If this happens, the vessel should be tamponaded with a sponge stick and an urgent thoracotomy performed to control the hemorrhage.

The data on tumor seeding in the chest wall at the trocar sites are not conclusive. All lung nodules and potentially malignant tissue can be removed in a retrieval sac without intraoperative spillage, even if that means extending the incision at the end of a difficult procedure.

Considerable interest has been generated from early case reports suggesting that uniportal (subxiphoid and transthoracic) VATS can be used as an additional tool to make these procedures even less invasive for patients. ^[20]

Incisions for robotic-assisted thoracic surgery (RATS) are similar to those for VATS and are likewise based on the triangulation concept described above, with one very important caveat: Sufficient space must be left around the incisions to allow free movement of the robotic arms. There is an additional "assistant incision" to facilitate active retraction, suctioning of the cavity, passage of gauze sponges, and other tasks, while the surgeon sits comfortably and operates remotely from the main console.

The port positions chosen and the number of robotic arms used depend upon the individual operation being performed. The patient is often in the supine position for anterior mediastinal surgery and in the prone postion for posterior mediastinal procedures rather than the standard lateral decubitus position. 

Advantages of RATS include high-definition optics with three-dimensional vision that allow a greater precision of movement while greatly reducing the surgeon's inherent hand tremors. Potential drawbacks include the lack of adequate tactile feedback, the lack of time and cost savings, and the additional steep learning curve associated with this procedure.

In 2014, Sedrakyan et al, published the results of a study that compared 2489 RATS lobectomies with 37,595 thoracoscopic lobectomies performed in the United States between 2008 and 2011. ^[22] Intraoperative bleeding and injury, as well as costs, were significantly higher in the RATS group. These findings probably were a reflection of the steep initial learning curve, in that subsequent studies have reported comparable results with the two techniques.

Chest-wall reconstruction techniques have been used since the 1940s, when Watson and James described the use of fascia lata grafts for closure of chest-wall defects. ^[23]  The most common indications for chest-wall resection include the following:

• Primary or metastatic chest-wall neoplasms
• Contiguous tumors from the breast and lung
• Traumatic lesions
• Radiation necrosis
• Osteomyelitis

These produce partial- or full-thickness defects. The location and size of the defect are of the utmost importance in planning the operation.

The three main principles in this surgical procedure are as follows:

• Removal of devitalized tissue
• Restoration of a rigid chest wall to prevent physiologic failure
• Healthy soft-tissue coverage to seal the pleural space, protect the underlying viscera and vessels, and prevent infection

For large  (>5 cm) chest wall defects, synthetic or alloplastic materials can be used. Synthetic mesh (eg, knitted polypropylene), a thick 2-mm polytetrafluoroethylene (PTFE) soft-tissue patch, or a polymethylmethacrylate (PMMA) sandwich can be used to achieve sternal or rib stability. If the wound is contaminated, the use of prosthetic material generally is not advised.

Muscle is the tissue of choice for soft-tissue coverage and also in contaminated wounds. Commonly used muscle transposition flaps include the following:

• Latissimus dorsi flap based on the thoracodorsal neurovascular pedicle
• Pectoralis major flap based on the thoracoacromial bundle
• Rectus abdominis flap based on the internal mammary neurovascular bundle

Omental transposition is usually reserved for use in a partial-thickness reconstruction or as a backup for muscle transposition that has failed.

In 1932, Henry Pancoast, a radiologist from Philadelphia, described what he termed a "superior pulmonary sulcus tumor" that was associated with Horner syndrome, rib destruction, and atrophy of the hand muscles. ^[24]  These tumors are now described as entering the apex of the lung at or above the level of the second rib with involvement of extrathoracic structures of the apical chest wall (eg, ribs, vertebral bodies, brachial plexus roots, sympathetic nerves, and subclavian vessels).

With the extension of the definition of resectability and the use of induction chemoradiotherapy followed by resection, surgery has now become an integral part of the multimodality approach to this complex tumor. In North American Southwest Oncology Group (SWOG) Trial 9416, the 5-year survival was 41% for all patients and 53% for complete resection. ^[25]

Posterior approach

The posterior approach was the initial one, and it remained the mainstay in exposing most Pancoast tumors with the patient in the lateral decubitus position. The posterolateral thoracotomy is extended superiorly parallel to the scapula up to C7 at the base of the neck. A safe interspace (the fourth or fifth) is entered, and a thorough exploration is performed to confirm resectability before the incision is extended and the trapezius and rhomboids divided posteriorly to dislocate and elevate the scapula and expose the first rib.

The scalene muscles are divided and the subclavian vessels assessed and dissected. (Resection of the subclavian vessels is very difficult via the posterior approach.) Resection of the chest wall en bloc is begun with anterior division of the ribs. Posterior disarticulation of the ribs to be resected requires solid understanding of the neurovascular anatomy of the spine.

Attention is then turned to resecting the first rib and appropriately managing the T1 nerve root. Other structures that sometimes must be addressed include the superior stellate ganglion of the sympathetic nervous system, the vertebral arteries, and, on the left, the thoracic duct and esophagus.

Once all of the aforementioned structures at the base of the neck have been addressed and dissected, a standard upper lobectomy is performed to complete the en-bloc resection of the tumor. As always, a mediastinal lymph node dissection should be performed to complete the procedure.

Anterior approach

The anterior approach, popularized by Dartevelle et al, is better suited to Pancoast tumors that invade more anteriorly (as opposed to the classic Pancoast tumors that invade posteriorly), in that it allows better control of the subclavian vessels. ^[26]

Dartevelle’s technique involved a transclavicular approach, with the incision following the anterior border of the sternocleidomastoid in the neck and then extending laterally along the clavicle (see the image below). Masaoka et al used a hemiclamshell-type incision with a partial sternotomy into the fourth intercostal space and a supraclavicular transverse extension. ^[27]

Historically, two chest tubes have been used to drain the thoracic cavity postoperatively. The anterior tube (A-tube) is directed apically and is expected to drain air, whereas the posterior (back) tube (B-tube) is placed basally and is expected to drain fluids (blood). However, with the ongoing tendency toward minimally invasive approaches, it is increasingly common to use only one tube. Tubes smaller than 20 French tend to kink and are not recommended.

Tubes are usually removed when drainage is less than 250 mL/24 hr, when no air leakage is noted, and when their function is no longer required.