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4 - Access to the chest cavity: safeguards and pitfalls

from Section I - Diagnostic work-up of the thoracic surgery patient

Published online by Cambridge University Press:  05 September 2016

Laura Socci
Cardiothoracic Surgery Unit, Northern General Hospital, Sheffield, UK
Antonio E. Martin-Ucar
Department of Thoracic Surgery, Nottingham City Hospital, Nottingham, UK
Marco Scarci
University College London Hospital
Aman Coonar
Papworth Hospital
Tom Routledge
Guy’s Hospital
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The choice of incision is vital for procedures in the thoracic cavity. The main principle should always be adequate exposure in order to perform a safe and effective procedure without compromise. However, the trauma of entering the chest cavity is particularly severe with impact on pain, muscle performance and respiratory function. As with surgical access in any region of the body, surgeons have always tried to minimize the impact of this trauma in the thoracic wall. As a result, we have at our disposal a myriad of incisions to choose from when facing thoracic procedures, with their own indications and pitfalls. As a general rule, in order to decide our approach, we have to take into account the indication for surgery, the anatomical location of the pathology, the likelihood of encountering difficulties (such as previous surgeries or locally invasive tumours), the pre-operative assessment of the patient, the predicted extent of side effects and also the patient's views in term of cosmesis and recovery.

Common to all techniques are the basic principles: correct positioning of the patient on the operating table, anatomical landmarks to place the incision, correct tissue handling and haemostasis and gradual spread of ribs/sternum to minimize trauma. For the purpose of this chapter, we will divide the incisions into three main groups: open approaches in lateral decubitus position (muscle and non-muscle sparing), open approaches in supine position (sternotomy, anterior thoracotomy, clamshell and their variations) and minimally invasive approaches (VATS and hybrid). We will describe the techniques with points regarding their main indications and their potential pitfalls.


Open approaches in lateral decubitus

The majority of the chest wall approaches for thoracic surgery procedures are still performed in the lateral decubitus position. It is crucial that multiple pressure points are padded, with the dependent leg flexed with a pillow between the legs. Ideally, both arms should be flexed ‘in the prayer position’, although this can vary depending on the surgeon's preference. It is important to widen the intercostal spaces to be entered by hyperextending the chest cavity with a roll positioned under the dependent chest at the level of the tip of the scapula or by ‘breaking’ the operating table mechanism.

Publisher: Cambridge University Press
Print publication year: 2016

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