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254 Thoracic incisions
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Once the procedure has been completed, thoracos-
3d
mated with sternal wires, and the fascia overlying the sternum
is closed with a running absorbable suture. One should be
aware of the location of the internal mammary vessels to
avoid their inadvertent injury at the time of chest closure.
tomy tubes are placed. The sternum is reapproxi-
4a
3d
Bilateral thoracosternotomy
This approach to the chest has been used most
4a
tion. It provides excellent exposure of the hilum as well as the
heart and great vessels. Initially, a bilateral submammary
incision is made. The subcutaneous tissues and pectoralis
muscles are divided exposing the ribs. The fourth intercostal
space is opened lateral to medial. The mammary vessels are
located approximately 1 cm lateral to the sternal edge. They
are identified and ligated.
frequently for bilateral sequential lung transplanta-
Blunt dissection is used to free the sternum from
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4b,c
knife is used to divide the sternum horizontally. The anterior
chest wall is lifted superiorly and anteriorly by placing two
Finnichietto retractors in each intercostal space.
the underlying mediastinum, and a Lebsche
Operation 255
4c
4b
Once the procedure has been performed, bilateral pleural
thoracostomy tubes are placed with additional mediastinal
tubes as needed. The ribs are reapproximated with heavy
paracostal sutures. These sutures are placed but not tied. Two
sternal wires are used to bring the sternal edges together, and
then the paracostal sutures are tied. The muscles and soft tissues are reapproximated.
Thoracosternotomy
A thoracosternotomy is usually performed in the opera-
5
tive management of anterior mediastinal tumors. The
incision is carried along the ipsilateral sternocleidomastoid to
the sternal notch down to the level of the inframammary fold.
It then follows the contour of the inframammary fold across
to the anterior axillary line. The incision is then deepened
with cautery through the fascia down to the middle of the
sternum. Inferiorly, the fascia is divided below the breast. The
pectoralis muscle overlying the fourth ICS is divided exposing
the underlying chest wall. The fourth intercostal space is
entered laterally and the incision continued medially.
Usually, it is necessary to divide the mammary vessels. Next,
the sternal saw is used to divide the sternum to the level of the
fourth intercostal space and is then brought across the
remaining sternum. A Ruhltract retractor is used to elevate
the chest wall and provide exposure of the anterior mediastinum and thoracic cavity.
5
256 Thoracic incisions
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After performing the procedure, the sternum is reapproximated with number 5 wires, and the ribs are reapproximated
with a large absorbable suture. Again, the paracostal sutures
are placed but not tied. The sternal wires are placed. The muscle and soft tissues are closed in the usual fashion.
Anterior mediastinotomy
This incision is used to biopsy nodes or masses in the
6
superior mediastinum. A 2-cm incision is made overlying the second costal cartilage, and the subcutaneous tissues
are divided. The muscle fibers of the pectoralis major are
divided exposing the periosteum overlying the second rib.
The periosteum is incised and dissected away from the rib.
Once it has been circumferentially dissected, a portion of the
costal margin is resected. The posterior perichondrium is
divided, and the underlying pleura is reflected laterally if not
previously displaced. The mammary vessels may be retracted
medially or ligated if hindering exposure.
6
The mass is palpated, and biopsies are taken. We usually
use a biopsy forceps. During this procedure, one must work
closely with the pathologist in order to determine when an
adequate amount of tissue has been taken to obtain a diagnosis. For lymphomas, at times at least a gram of tissue may be
necessary. If a mass is not readily palpable, the deeper space
can be explored with the aid of a mediastinoscope.
This procedure may also be performed through the second
intercostal space. One must work medially to stay out of the
pleural space. If the pleural space is inadvertently entered, the
residual air may be evacuated at the time of closure by reapproximating the tissues over a red rubber catheter.
Transcervical approach
This incision is used for a transcervical thymectomy or to
biopsy or resect small anterior mediastinal masses. The
patient is placed on an inflatable pillow, and the head is fully
extended as if performing a mediastinoscopy. The chest is
prepped and draped from the chin to the umbilicus in case of
the need for a sternotomy. Initially, a curvilinear incision is
made just above the heads of the clavicle. The platysma
is divided with electrocautery. The strap muscles are incised
along the midline and retracted laterally. The sternal ligament
is divided, and the substernal space is bluntly dissected.
Details of the transcervical thymectomy are found in
Chapter 5 on thymectomy. If proceeding with a biopsy, the
polytrac retractor is positioned under the sternum, and the
inflatable pillow is decompressed. Anterior mediastinal
masses can be palpated and biopsied or resected. After performing the procedure, the strap muscles and platysma are
reapproximated. The skin is closed with a running subcuticular suture.
Cervicothoracic approach to the apex
Currently, this incision is preferred for the operative management of apical lung tumors. It can also be used for high posterior neurogenic tumors, as well as exposure to the upper
thoracic vertebrae or arterial reconstructions.
The patient is placed in the supine position with a
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7
shoulder roll behind the scapulae and the head turned to
the contralateral side. An “L” shaped skin incision is made,
coursing along the edge of the inferior border of the sternocleidomastoid, to the sternal notch, and then gently curving
infraclavicularly out to the deltopectoral groove. The subcutaneous tissues are divided. The pectoralis and subclavius are
dissected away from the clavicle. The superior border of the
medial clavicle is dissected by dividing its attachment to the
sternocleidomastoid. The head of the clavicle is divided in a
horizontal fashion with the oscillating saw. This maneuver
allows for a more stable reapproximation of the clavicle at the
end of the procedure. The Ruhltract retractor is inserted to
elevate the clavicle, and the sternocleidomastoid is further
mobilized. This step exposes the distal brachiocephalic, internal jugular, and subclavian veins. Once this has been done,
the chest is entered by incising the intercostal muscle along
the superior aspect of the rib, one rib below the level of chest
wall involvement. After the procedure, the clavicle is reapproximated with number 5 sternal wires, and the soft tissues
and skin are closed.
Further reading 257
If this approach is being used for operations where one
does not anticipate resection of chest wall, as in neurogenic
tumors, approaches to the upper thoracic spine, or vascular
reconstructions, then we usually lower the inferior border of
the skin incision and use the Lebsche knife to divide the
manubrium into the second intercostal space. We then
elevate this segment of chest wall with a Ruhltract
retractor.
Reoperative thoracotomy
For reoperative procedures in the chest, we tend to either vary
the approach, i.e perform an anterior muscle-sparing thoracotomy though the fourth ICS when a posterolateral thoracotomy has previously been performed, and vice versa. This
approach can facilitate lysis of adhesions which are usually
7
most dense at the site of previous thoracotomy. If using the
same thoracotomy, resecting a rib facilitates exposure.
FURTHER READING
Ginsberg RJ. Alternative (muscle-sparing) incisions in thoracic surgery.
Annals of Thoracic Surgery 1993; 56: 752–4.
Heitmiller RF. The left thoracoabdominal incision. Annals of Thoracic
Surgery 1988; 46: 250–3.
Mitchell RL. The lateral limited thoracotomy incision: standard for
pulmonary operations. Journal of Thoracic and Cardiovascular
Surgery 1990; 91: 1259–64.
Pasque ML, Cooper JD, Kaiser LR, et al. Improved technique for bilateral
lung transplantation: rationale and initial clinical experience. Annals
of Thoracic Surgery 1990; 49: 785–91.
Urschel HC Jr, Razzuk MA. Median sternotomy as a standard approach
for pulmonary resection. Annals of Thoracic Surgery 1986; 41: 130–4.
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Bronchoplastic procedures
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LARRY R. KAISER, MD
The John Rhea Barton Professor and Chairman, Department of Surgery, University of Pennsylvania; Surgeon-in-Chief,
University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
24
HISTORY
The first sleeve lobectomy was performed by Price-Thomas
in 1947 for an endobronchial adenoma. Five years later,
Allison reported a sleeve lobectomy for carcinoma.
Shaw and Paulson, however, popularized sleeve resection
with their 1955 paper entitled “Bronchial anastomosis and bronchoplastic procedures in the interest of
preservation of lung tissue.” The use of their techniques
allows the modern thoracic surgeon to perform parenchymal sparing procedures on patients who would not
tolerate a pneumonectomy. In the case of malignancy,
sleeve resections are performed without compromise of oncological principles.
PRINCIPLES AND JUSTIFICATION
Pneumonectomy is associated with an increased morbidity
and mortality when compared to lobectomy and sleeve lobectomy. Thus, in our practice, we make every effort to avoid
pneumonectomy. This strategy includes complex bronchoplastic and bronchovascular reconstructions when
required. The justification of this approach is simply that by
avoiding pneumonectomy we avoid its attendant risks while
providing an equivalent cancer operation. In addition, lungsparing procedures allow us to offer curative operations to
patients with poor pulmonary function who would otherwise
not tolerate an operation.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Our preoperative evaluation includes a complete history and
physical examination. Special attention is focused on previous
thoracic procedures and chest irradiation. Systemic illnesses or
use of high-dose steroids which might interfere with bronchial
anastomotic healing are noted. All patients have a chest X-ray,
a chest computerized tomographic (CT) scan, and pulmonary
function testing with diffusion capacity. Patients with a diagnosis or suspicion of malignancy also have an extent of disease
workup which includes a bone scan and magnetic resonance
imaging (MRI) of the brain when indicated.
We perform selected mediastinoscopy in patients with
malignant disease. Patients who have mediastinal adenopathy
of greater than 1.0 cm on CT scan undergo mediastinoscopy
prior to thoracotomy. If the mediastinoscopy is negative, we
proceed with the thoracotomy. If the mediastinoscopy reveals
ipsilateral N2 disease, the patient is referred for preoperative
chemo/radiation therapy and returns later for resection.
Those patients with contralateral N3 disease are referred
for chemo/radiation therapy and are not offered surgical
resection.
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ANESTHESIA
Following the induction of general anesthesia, all
1
patients undergoing sleeve resection require bronchoscopy by the operating surgeon. This procedure can be
done with either a rigid or flexible bronchoscope.
Bronchoscopy allows visualization of the lesion and planning
of the resection. Following bronchoscopy, the surgeon should
have a complete discussion with the anesthesiologist regarding the operative plan. If a right-sided sleeve is being performed, a left-sided double lumen tube should be placed. If a
left-sided sleeve is being entertained, a right-sided tube is
placed. For sleeve pneumonectomy or a carinal sleeve resection, a sterile anesthesia circuit is required to allow direct ventilation from the surgical field.
OPERATIONS
We have performed sleeve resections through standard posterior lateral incisions, serratus muscle-sparing posterior lateral
incisions, and vertically oriented serratus and latissimus muscle-sparing incisions. The surgeon should choose an incision
which provides complete exposure and he/she is comfortable
working through; for most this choice will likely be the posterior lateral approach.
Following entry into the chest, complete exploration is
made to rule out disseminated disease. On both the right and
1
left side we begin our dissection in the anterior hilum and
completely dissect out the main pulmonary artery. Special
care must be taken on the left side to avoid damage to the
short left main pulmonary artery. If bulky disease exists or
any difficulty is encountered with dissection, we do not hesitate to open the pericardium on either side to obtain proximal control. Next, we encircle the main pulmonary artery
with an umbilical tape and snare it with a Rumel tourniquet
in the event that proximal arterial control is needed. The
remaining steps are specific to the sleeve being performed,
and each will be described independently below.
Operations 261
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Right-sided resections
RIGHT UPPER LOBECTOMY SLEEVE RESECTION – THE
PROTOTYPE BRONCHOPLASTIC PROCEDURE
After proximal arterial control has been obtained, we
2
continue our dissection superiorly and enter the plane of
the right upper lobe bronchus. The lung is retracted anteriorly, and we continue our dissection in the crotch between
the right upper lobe bronchus and the bronchus intermedius.
A “crotch” lymph node is a consistent finding in this location.
This node is elevated away from the crotch to reveal the pulmonary arterial branch to the superior segment of the right
lower lobe. Once this branch is identified, the posterior portion of the fissure is completed with a linear stapler. This
approach avoids extensive parenchymal dissection in the fissure. Up to this point, we have not made any irreversible
maneuvers. A complete inspection is carried out to ensure
that all disease including nodal disease can be removed. Once
complete resectability is confirmed, we begin by ligating and
dividing the pulmonary arterial branches to the right upper
lobe.
Proximal
bronchial
line of
division
Superior
segmental
bronchus
Distal
bronchial
line of division
RML
RLL
Suture line
RML
RLL
Right upper lobe
Tumor
Azygos vein
Right main
bronchus
Bronchus
intermedius
2
Likewise, the venous drainage is divided with a vascular
3
stapler taking care to preserve the middle lobe venous
drainage. The anterior portion of the fissure is completed
with a linear stapler. At this juncture, the only point of attachment is the bronchus. We divide the mainstem bronchus with
a fresh number 15 blade just proximal to the right upper lobe
take off. Similarly, the bronchus intermedius is divided just
distal to the right upper lobe take off. For upper lobe sleeve
resections, these cuts must be perpendicular to the long axis
of the airway; a “sciving” cut is to be avoided. The proximal
and distal airway margins are cut from the specimen and
inked by the surgeon. They are then taken to the pathologist
for a frozen section examination. Once the margins have been
cleared, the reconstruction is started. A positive margin
requires additional resection of the involved area. We perform our bronchial sleeve anastomosis in either a running or
interrupted fashion. The key to a successful bronchial sleeve
anastomosis is a precise tension-free repair which is pneumostatic. When required, tension can be relieved by incising the
inferior pulmonary ligament or performing other release
maneuvers.
3
262 Bronchoplastic procedures
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When performing an interrupted anastomosis, we use
4
4.0 oiled vicryl suture. The first suture is placed in an
“outside to in” fashion at the junction of the cartilaginous
and membranous bronchi. The suture is not tied but is
secured to a suture guide. Additional sutures are placed at 2mm intervals to complete the first half of the cartilaginous
anastomosis. Once the midpoint of the cartilaginous bronchi
is reached, we begin tying the sutures starting at the corner.
The surgeon “crosses” the next suture in the series to relieve
tension while the assistant ties. The cartilaginous anastomosis
is completed from the midpoint down to the opposite corner
in a similar fashion. The lung is retracted anteriorly to reveal
the membranous portion of the bronchus. The membranous
portion of the anastomosis is completed with interrupted
sutures. The chest is filled with saline, and the anastomosis is
tested to 20 cm water pressure. Needle hole air leaks are
ignored; however, air leaks between the cut edges of the
bronchus are reinforced with simple interrupted sutures.
Suture guide
5
4
We wrap all anastomoses with either a pleural flap or
5
pericardial fat. We avoid the use of intercostal muscle
which has been reported to calcify and cause anastomotic
stricture. When performing a running anastomosis, we use a
4.0 absorbable monofilament suture (Maxon). The anastomosis is started at the midpoint of the cartilaginous bronchi
with the knot placed on the outside. The suture is brought
inside on the mainstem bronchus, and the surgeon runs the
first half of the cartilaginous anastomosis away from himself
up to the corner, at the junction of the cartilaginous and
membranous portion of the bronchi. The suture is brought to
the outside, and tension is kept on the suture by securing it to
the drape with a rubber-shodded clamp. The surgeon now
sews from the midpoint towards himself to the opposite corner. The assistant follows the suture to maintain tension.
Sutures are placed with precision so that alignment is perfect
at the corner. The lung is retracted anteriorly, and the membranous portion of the anastomosis is completed by running
each suture from the corner to the midpoint of the membranous bronchus. The suture is tied, and the anastomosis
checked for pneumostasis and wrapped with pericardial fat.
MIDDLE LOBE SLEEVE RESECTION
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The middle lobe sleeve resection is an infrequently
6
performed operation. Following proximal arterial control, the middle lobe vein is identified, isolated, and divided.
The bronchus to the middle lobe lies immediately posterior
to the middle lobe vein. The bronchus is followed back to its
origin. A right angled clamp is placed around the bronchus
intermedius, and it is divided at a location proximal to the
middle lobe orifice. The division is slightly angled. The distal
division is also angled to preserve the orifice to the superior
segment of the lower lobe. The pulmonary artery lies directly
behind the bronchus, and care must be taken to avoid injury
when dividing the bronchus. After division of the airway, the
middle lobe arterial branch is easily visualized. The branch is
ligated and divided. Next, the fissures are completed with firings of a linear stapler.
Following confirmation of negative margins, the airway
anastomosis is performed. This step can be done in either a
running or interrupted manner as described above for the
right upper lobectomy sleeve resection. Special considerations in performing a middle lobe sleeve resection must be
given to the superior segmental orifice of the lower lobe. This
orifice should not be narrowed or occluded when creating an
anastomosis. Pericardial fat is used to wrap the anastomosis
and separate it from the pulmonary artery.
Operations 263
6
Distal
bronchial
line of division
Superior
segmental
bronchus
Suture line
RML
RLL
Proximal
bronchial
line of division
RUL
BILOBECTOMY SLEEVE RESECTION
Bilobectomy sleeve resection is performed for endo-
7
bronchial lesions in the bronchus intermedius. The basic
principles of proximal arterial control, microscopic negative
margins, and a precise tension free anastomosis apply. Due to
the reorientation of the upper lobe bronchus after removal of
the middle and lower lobe, special care must be taken to avoid
torsion of the bronchus at the anastomosis.
7
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