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Cardiothoracic surgical approaches: Understanding the incision line for cardiac and lung operations
For cardiothoracic operations individual surgeons develop preferences for particular incisional approaches based on their particular experiences and training. This article has been written keeping physiotherapy management in regards as they need to know the medical and surgical approaches in order to plan out cardiopulmonary rehabilitation.
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Posterolateral thoracotomyPatient's positionOne quarter turn from prone (operative side elevated) with the uppermost arm elevated forward, flexed at the elbow, and placed beside the head. Incision lineThe typical posterolateral thoracotomy incision extends downwards from a point midway between the spine of the fourth thoracic vertebra and the scapula in a gently curving arch around the tip of the scapula to the fifth or sixth intercostals space at the anterior axillary line.
The serratus anterior is divided close to its muscular attachment in an effort to preserve its function and to avoid the long thoracic nerve. The pleural space is most often entered via an incision through the intercostals muscles at the fifth intercostals space, although a specific pathologic condition may dictate entry via another intercostals space.
Anterolateral thoracotomyPatient's positionPatients are positioned one quarter turn from supine (operative side elevated) with the uppermost arm flexed at the elbow and placed beneath the back in preparation for an anterolateral thoracotomy. Incision line Anterolateral thoracotomy or "sub-mammary incision" curves from the fourth or fifth intercostals space at the midaxillary line to the midclavicular or parasternal region. the pectoralis major is incised, and fibers of the serratus anterior are separated (with female patients, it is sometimes necessary for the surgeon to reflect the breast superiorly).
Lateral thoracotomyPatient's positionPatient is placed side lying position, operative side up, with the arm abducted, flexed at elbow, and rotated in preparation for a lateral thoracotomy.Incision lineIt is generally begins near nipple line and extends towards the scapula.
The latissimus is not incised; instead it is retracted either anteriorly or posteriorly . postoperative winging of scapula is avoided by careful preservation of long thoracic nerve. This incisional approach Provides access for pneumonectomy, lobectomy, and Diaphragmatic procedures.
Axillary thoracotomyPatient's positionPatients are place in side lying position with the arm flexed at the elbow, abducted 90 degrees at the shoulder, and rotated as for a lateral thoracotomy.Incision lineFrom the edge of the pectoralis major, anteriorly, the incision extends posteriorly within the second intercostals space to the edge of the latissimus dorsi.
Median sternotomy
It is the most frequent used incision for cardio-thoracic operationsPatient's positionThe patient is placed in the supine position.Incision lineThe initial skin incision usually begins in the midline inferior to the suprasternal notch and extends below the xiphoid process. The sternum is divided along its midline in a series of steps, and a sternal retractor is used to hold the incision open.
Thoraco-abdominal incisionsA thoraco-abdominal incision permits procedures on the diaphragm, esophagus, liver, spleen, adrenal glands, and kidney.Patient's positionPatients are positioned supine with the operative side rotated upwards 30- 40 degrees, the buttocks and back elevated and the arm on the operative side extended anteriorly as in a posterolateral thoracotomy.Incision lineThe incision is usually extends from the 8th or 9th intercostalspace at the posterior axillary line to the mid-line of the abdomen, transecting the latissimus dorsi, serratus anterior, external oblique, and rectus abdominis muscles.
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