Thoracic

Muscle-sparing Thoracotomy
Sarah M. Elswick, MD, MBA,* Shanda H. Blackmon, MD, MPH,† and Basel Sharaf, MD, DDS*

Surgical access to the thoracic cavity can be performed through a variety of approaches. Tradi-
tional surgical approaches focused on optimizing exposure, often times at the expense of sparing
adjacent truncal muscles, such as the latissimus dorsi or serratus anterior, which can serve as
lifeboats in thoracic reconstruction. Numerous studies have evaluated the differences in these
techniques, focusing on surgical access, postoperative pain, shoulder strength and mobility, and
lung function. We advocate, whenever possible, the routine use of a muscle-sparing thora-
cotomy to preserve vital local flap options for reconstruction of postresection complications. These
flaps can assist in the management of postoperative wound healing complications, such as em-
pyemas and bronchopleural fistulae. When local flap options are unavailable, other flap options
are often more morbid and can be challenging. Herein, we describe the technique for a muscle-
sparing thoracotomy at our institution.
Operative Techniques in Thoracic and Cardiovasculary Surgery 22:110–121 © 2017 Elsevier Inc.
All rights reserved.

KEYWORDS thoracotomy, muscle-sparing thoracotomy, latissimus dorsi, serratus anterior, muscle

flap

Introduction that differences in outcomes are not clinically significant or

can be attributed to advancements in surgical techniques and
S urgical access to the thoracic cavity can be performed
through a variety of approaches. Traditionally, the choice
of technique has focused on optimizing exposure, often at
anesthesia.1,10,13,14,17 Most studies concur that there is no dif-
ference in operating time between the 2 techniques; opening
time is longer in MST but the closing time is shorter com-
the expense of sparing adjacent truncal muscles. The muscle-
pared with the PLT approach, so the overall operating time
sparing thoracotomy (MST) has been advocated as an
is equal with either of the techniques.1,10,17,18
alternative to the posterolateral thoracotomy (PLT) because
In an attempt to clarify this controversy, several meta-
of its reduced rate of complications or to preserve recon-
analyses have been performed. A meta-analysis by Uzzaman
structive options.1,2 Although there are numerous thoracotomy
et al of 12 different studies comparing MST (n = 571) and
techniques, the basic difference between the MST and the PLT
PLT (n = 512) revealed better shoulder internal rotation in
is the preservation of the latissimus dorsi (LD) muscle. The
the muscle-sparing group (although there were no differ-
first published description of an MST in the United States was
ences in shoulder abduction, flexion, or external rotation),
by Bethencourt and Holmes in 1988,3 but the technique was
decreased postoperative pain on day 7 (but not on days one
initially described by Noirclerc et al in 1973.4,5
or 30), and no difference in lung function at 30 days after
Since then, numerous studies have evaluated the differ-
operation. Secondary outcomes including incision length, op-
ences in these 2 techniques, with emphasis on postoperative
erative time, length of hospital stay, and total number of
complications. Many of the studies advocating the MST ap-
complications were not significantly different between the 2
proach have shown that compared with a PLT, patients
groups with the exception of a higher rate of seroma forma-
experienced less postoperative pain, improved shoulder
tion in the MST group (4.0% vs 0%).19 These results are in
strength and mobility, and demonstrated better preserva-
concordance with another meta-analysis by Li et al that in-
tion of lung function.6-12 However, other studies showed no
cluded many of the same studies but did show less
significant differences in these outcomes when comparing the
postoperative pain on postoperative day 1, week 1, and at 1
2 surgical techniques.1,13-17 Critics of the MST technique imply
month in the MST group.20
This research did not receive any specific grant from funding agencies in
These studies, however, overlook one of the most impor-
the public, commercial, or not-for-profit sectors. tant considerations for performing an MST: the ability to use
*Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, the LD muscle as a lifeboat for managing postoperative com-
MN plications. This muscle can be used as a flap for both chest
†
Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester,
wall and intrathoracic reconstruction, including the manage-
MN
Address reprint requests to Basel Sharaf, MD, DDS, FACS, Division of Plastic ment of wounds, postoperative infections, empyemas,
Surgery, Department of Surgery, Mayo Clinic, 200 1st St SW, Rochester, bronchopleural fistulae, and to fill the empty space in the
MN 55905. E-mail: Sharaf.Basel@mayo.edu; elswick.sarah@mayo.edu pleural cavity when necessary.21-28 Some studies even advocate
110 1522-2942/$-see front matter © 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1053/j.optechstcvs.2017.12.001
Muscle-sparing thoracotomy
its use to prevent complications in high-risk patients.29-33 The
LD muscle, when preserved, can solely provide adequate reach
and bulk of vascularized tissue to address most postlobectomy
complications. Although the importance of preservation of
the extrathoracic chest muscles for rotational flaps in the event
of a postresectional complication has been emphasized in nu-
merous other studies,1,2,11,12,14,17,34,35 the MST is still not widely
utilized. When the LD muscle has been divided, another re-
constructive flap option is the serratus anterior muscle.
However, the use of this muscle often results in scapular
winging and may lead to shoulder weakness, decreased
111
range of motion, and pain. Furthermore, the serratus ante-
rior is often atrophied in this patient population and usually
provides less bulk for empty space obliteration than the LD
muscle.
Hence, we recommend the routine adoption of MST to
preserve local muscles for chest wall and intrathoracic re-
construction. These flaps can be potentially lifesaving, are
technically simpler to elevate, and can achieve the recon-
structive goals of postresectional complications at lower
morbidity than other reconstructive methods. The tech-
nique is detailed on the following pages (Figs.1-8).
112 S.M. Elswick et al.

Figure 1 The initial steps of an MST are identical to those of a PLT. The patient is placed in the lateral decubitus position with the operated
side up. The umbilicus is placed at the break in the table to allow flexion at the waist, thereby increasing the intercostal space and enhanc-
ing intrathoracic exposure. An axillary roll is placed under the lower axilla to protect the brachial plexus. The patient is immobilized with
sandbags or a beanbag that supports the back and abdomen. The legs are separated with a pillow; the lower leg is flexed gently at the knee,
whereas the upper leg is straight. The lower arm is placed on an arm board, which is situated 90 degrees from the OR table and separated
from the upper arm with pillows or an additional arm board. The patient is secured to the table with safety straps or tape across the hips.
Muscle-sparing thoracotomy 113

Figure 2 Once the patient is prepped and draped, the incision is marked in the form of a lazy S. The essential landmarks are identified in the
same manner as the PLT incision, including the tip of the scapula, anterior superior iliac spine (ASIS), posterior axillary line, and inframammary
fold. Posteriorly, the incision lies halfway between the scapula and the spine. It then courses anteriorly, lying 2 finger breadths inferior to
the tip of the scapula. It continues along the ribs onto the anterior chest, curving toward the inframammary fold and ending at the level of
the posterior axillary line and ASIS.
114 S.M. Elswick et al.

Figure 3 After skin incision, the subcutaneous tissue is dissected with electrocautery to the level of the LD fascia. Subcutaneous flaps over-
lying the LD muscle are raised. The posterior border of the LD is identified. Rather than transecting the muscle, as is done in a PLT, the
muscle is elevated off the chest wall through a combination of blunt dissection and electrocautery proceeding from the posterior to anterior
direction. There are multiple perforators entering the deep surface of the muscle, which are carefully divided via ligation or cauterization.
The superior edge of the muscle is then retracted anteriorly, exposing the underlying serratus anterior muscle. The serratus anterior muscle
is also preserved via a similar technique, by freeing the deep attachments of the inferior slip to the chest wall and retracting the muscle
cephalad if necessary.
Muscle-sparing thoracotomy 115

Figure 4 If more exposure is required, a small 3-4-cm segment of the most posterior and cephalic muscle origin can be divided off the T7 to
T10 spinous processes along a line parallel to the back midline. This preserves the bulk of LD muscle belly and does not disrupt the domi-
nant thoracodorsal vascular pedicle. However, this maneuver is rarely needed.
116 S.M. Elswick et al.

Figure 5 Next, the appropriate intercostal space is identified. This is accomplished via the development of the subscapular plane. A scapular
retractor is used to elevate the scapula, and the underlying connections to the chest wall are freed with a combination of blunt dissection
with the hand and electrocautery dissection. The surgeon then places his or her hand in this plane to identify the first rib and then count
to identify the desired intercostal space to be entered, which is usually the fourth or fifth intercostal space.
Muscle-sparing thoracotomy 117

Figure 6 The rib is then exposed along the appropriate intercostal space. A limited portion of the intercostal muscles are dissected from the
cephalad portion of the rib with electrocautery. Dissection is performed in the posterior to anterior direction, which facilitates the release of
the muscle attachments to the rib as the cautery is running along the muscle fibers. Posteriorly, the paraspinal muscle can be freed from the
underlying rib with electrocautery and retracted toward the midline to allow better access. The rib periosteum is then incised. A periosteal
elevator is introduced along the caudad portion of the rib and is used to strip the periosteum from the deep surface of the rib while pre-
serving the neurovascular bundle. A doyen rib elevator is slid along the deep surface of the ribs to further free the attachments, clearing
enough space to allow the introduction of the rib cutters. The rib cutters are used to make 2 small osteotomies approximately 1 cm apart.
This small intervening fragment of rib is dissected free from the soft tissue and removed. This rib ostectomy enhances intrathoracic expo-
sure, prevents inadvertent fractures, and stops the 2 ends of bone from rubbing together and causing postoperative pain. The remainder of
the intercostal muscles are divided and the dissection is continued anteriorly. Care is taken when dividing the parietal pleura and entering
the pleural cavity so as to not injure the underlying lung.
118 S.M. Elswick et al.

Figure 7 Once the pleural cavity is accessed, 2 retractors can then be placed. The first retractor is a rib spreader and is placed parallel to the
ribs. A second retractor is placed perpendicular to the ribs, retracting the preserved LD muscle anteriorly and inferiorly to enhance expo-
sure. The retractors are sequentially opened to provide adequate visualization.
Muscle-sparing thoracotomy 119

Figure 8 If a pedicled LD muscle flap reconstruction is required, the muscle is elevated by the thoracic or plastic surgical team. This can be
done at the beginning of the case if a muscle flap is needed or after the thoracic surgical portion is completed (A). When the muscle is
elevated earlier, the flap is then mobilized, protected, and retracted to allow optimization of exposure (B). It is imperative to avoid injury or
compression to the thoracodorsal vessels during retraction. The thoracic surgery portion of the procedure can then be completed (C, de-
cortication for a complex empyema). Thoracostomy tubes are placed as necessary before flap inset so they do not interfere with wound
closure. If chest wall reconstruction is needed, the flap can be sutured to the surrounding chest wall tissues to cover the mesh. If intratho-
racic reconstruction is required, a window is made in the chest wall to allow transposition of the flap (D, E).
120
Closure
The thoracotomy incision can be closed in the standard fashion.
Depending on the spacing, 2 or 3 holes are drilled into the
inferior rib along the thoracotomy. A blunt tip 1 Vicryl
(Ethicon, Somerville, NJ) suture is used to place inter-
rupted paracostal sutures through these holes to the intercostal
muscles above the superior rib along the thoracotomy. A 3-0
interrupted Vicryl or PDS suture is used to approximate the
deep subcutaneous tissue. The skin is closed with 3-0
Monocryl (Ethicon) for deep dermal sutures and 4-0 Monocryl
in a running subcuticular fashion. Alternatively, 3-0 nylon
(Ethicon) vertical mattress sutures can be used for skin closure,
depending on the amount of tension and quality of the skin.
An incisional wound vac may be placed in selected cases if
necessary.
Conclusion
Surgical access to the thoracic cavity can be performed through
a variety of approaches. Studies have shown that the MST
may offer limited advantages over the PLT approach, includ-
ing better shoulder range of motion and decreased
postoperative pain. However, the most important reason to
perform MST is the ability to use the LD muscle for chest
wall or intrathoracic reconstruction, should a postoperative
complication arise after the thoracotomy. Hence, we recom-
mend the routine teaching and adoption of MST technique
whenever possible to preserve this valuable reconstructive
option. These flaps are potentially lifesaving and are techni-
cally simpler to perform with lower morbidity than other
reconstructive methods using abdominal or intraabdominal
tissue. The surgical access, when performed properly, offers
adequate exposure without relevant downsides compared with
a traditional posterolateral thoracotomy.
Acknowledgments
We would like to acknowledge Carl Clingman for his assis-
tance with illustrations and Tim Seelinger for his assistance
with video editing.
Supplementary Material
Supplementary data are available in the online version of this
article at doi:10.1053/j.optechstcvs.2017.12.001.
References
1. Athanassiadi K, Kakaris S, Theakos N, et al: Muscle-sparing versus
posterolateral thoracotomy: A prospective study. Eur J Cardiothorac Surg
31:496-499, 2007
2. Shipkov C, Mojallal A, Uchikov A. The importance of muscle-sparing
thoracotomy for the treatment of postresectional complications after
thoracotomy. Eur J Cardiothorac Surg 32:551-552, 2007
3. Bethencourt DM, Holmes EC. Muscle-sparing posterolateral thoracotomy.
Ann Thorac Surg 45:337-339, 1998
4. Noirclerc M, Dor V, Chauvin G, et al: Extensive lateral thoracotomy
without muscle section. Ann Chir Thorac Cardiovasc 12:181-184,
1973
5. Noirclerc M. Muscle-sparing thoracotomy. Ann Thorac Surg 47:330,
1989
S.M. Elswick et al.
6. Sugi K, Nawata S, Kaneda Y, et al: Disadvantages of muscle-sparing
thoracotomy in patients with lung cancer. World J Surg 20:551-555,
1996
7. Miyata K, Fukaya M, Itatsu K, et al: Muscle sparing thoracotomy for
esophageal cancer: A comparison with posterolateral thoracotomy. Surg
Today 46:807-814, 2016
8. Nosotti M, Baisi A, Mendogni P, et al: Muscle sparing versus posterolateral
thoracotomy for pulmonary lobectomy: Randomised controlled trial.
Interact Cardiovasc Thorac Surg 11:415-419, 2010
9. Kutlu CA, Akin H, Olcmen A, et al: Shoulder-girdle strength after
standard and lateral muscle-sparing thoracotomy. Thorac Cardiovasc
Surg 49:112-114, 2001
10. Hazelrigg SR, Landreneau RJ, Boley TM, et al: The effect of muscle-
sparing versus standard posterolateral thoracotomy on pulmonary
function, muscle strength, and postoperative pain. J Thorac Cardiovasc
Surg 101:394-400, 1991
11. Kucukarslan N, Kirilmaz A, Arslan Y, et al: Muscle sparing thoracotomy
in pediatric age: A comparative study with standard posterolateral
thoracotomy. Pediatr Surg Int 22:779-783, 2006
12. Ziyade S, Baskent A, Tanju S, et al: Isokinetic muscle strength after
thoracotomy: Standard vs. muscle-sparing posterolateral thoracotomy.
Thorac Cardiovasc Surg 58:295-298, 2010
13. Ponn RB, Ferneini A, D’Agostino RS, et al: Comparison of late pulmonary
function after posterolateral and muscle-sparing thoracotomy. Ann Thorac
Surg 53:675-679, 1992
14. Landreneau RJ, Pigula F, Luketich JD, et al: Acute and chronic morbidity
differences between muscle-sparing and standard lateral thoracotomies.
J Thorac Cardiovasc Surg 112:1346-1350, 1996
15. Lemmer JH Jr, Gomez MN, Symreng T, et al: Limited lateral thoracotomy.
Improved postoperative pulmonary function. Arch Surg 125:873-877,
1990
16. Khan IH, McManus KG, McCraith A, et al: Muscle sparing thoracotomy:
A biomechanical analysis confirms preservation of muscle strength but
no improvement in wound discomfort. Eur J Cardiothorac Surg
18:656-661, 2000
17. Akcali Y, Demir H, Tezcan B. The effect of standard posterolateral versus
muscle-sparing thoracotomy on multiple parameters. Ann Thorac Surg
76:1050-1054, 2003
18. Akcali Y, Demir H, Tezcan B. A technique facilitating muscle-sparing
thoracotomy. Asian Cardiovasc Thorac Ann 10:194-195, 2002
19. Uzzaman MM, Robb JD, Mhandu PC, et al: A meta-analysis comparing
muscle-sparing and posterolateral thoracotomy. Ann Thorac Surg
97:1093-1102, 2014
20. Li S, Feng Z, Wu L, et al: Analysis of 11 trials comparing muscle-sparing
with posterolateral thoracotomy. Thorac Cardiovasc Surg 62:344-352,
2014
21. Meyer AJ, Krueger T, Lepori D, et al: Closure of large intrathoracic airway
defects using extrathoracic muscle flaps. Ann Thorac Surg 77:397-404,
2004
22. Botianu PV, Dobrica AC, Butiurca A, et al: Complex space-filling
procedures for intrathoracic infections—Personal experience with 76
consecutive cases. Eur J Cardiothorac Surg 37:478-481, 2010
23. Michaels BM, Orgill DP, Decamp MM, et al: Flap closure of
postpneumonectomy empyema. Plast Reconstr Surg 99:437-442,
1997
24. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account of their
use in the management of 100 consecutive patients. Ann Surg 211:656-
660, 1990
25. Garcia-Yuste M, Ramos G, Duque JL, et al: Open-window thoracostomy
and thoracomyoplasty to manage chronic pleural empyema. Ann Thorac
Surg 65:818-822, 1998
26. Seify H, Mansour K, Miller J, et al: Single-stage muscle flap reconstruction
of the postpneumonectomy empyema space: The Emory experience. Plast
Reconstr Surg 120:2007, 1886-1891
27. Stamatis G, Freitag L, Wencker M, et al: Omentopexy and muscle
transposition: Two alternative methods in the treatment of pleural
empyema and mediastinitis. Thorac Cardiovasc Surg 42:225-232, 1994
28. Botianu PV, Botianu AM, Bacarea V, et al: Thoracodorsal versus reversed
mobilisation of the latissimus dorsi muscle for intrathoracic transposition.
Eur J Cardiothorac Surg 38:461-465, 2010
29. Abolhoda A, Bui TD, Milliken JC, et al: Pedicled latissimus dorsi muscle
flap: Routine use in high-risk thoracic surgery. Tex Heart Inst J
36:298-302, 2009
Muscle-sparing thoracotomy
30. Shiraishi Y, Katsuragi N, Nakajima Y, et al: Pneumonectomy for complex
aspergilloma: Is it still dangerous? Eur J Cardiothorac Surg 29:9-13,
2006
31. Shiraishi Y, Nakajima Y, Katsuragi N, et al: Pneumonectomy for
nontuberculous mycobacterial infections. Ann Thorac Surg 78:399-403,
2004
32. Hata Y, Otsuka H, Makino T, et al: Surgical treatment of chronic
pulmonary aspergillosis using preventive latissimus dorsi muscle flaps.
J Cardiothorac Surg 10:151, 2015
121
33. Botianu PV, Botianu AM. Thoracomyoplasty in the treatment of
empyema: Current indications, basic principles, and results. Pulm Med
2012:418514, 2012
34. Malczewski MC, Colony L, Cobb LM. Latissimus-sparing thoracotomy
in the pediatric patient: A valuable asset for thoracic reconstruction.
J Pediatr Surg 29:396-398, 1994
35. Anderson TM, Miller JI Jr: Use of pleura, azygos vein, pericardium, and
muscle flaps in tracheobronchial surgery. Ann Thorac Surg 60:729-733,
1995