Thoracic Incisions
David B. Campbell, MD
A ccess to chest contents and appreciation of the anatomy
of the chest wall and internal anatomy are practical req-
uisites for all general and trauma surgeons. The expediency of
a clinical situation and the scope of the patient’s problems
dictate the access options chosen. Although minimally inva-
sive options for elective operations within the chest are evolv-
ing, small chest incisions offer less flexible access than lapa-
roscopic surgery because of fixed intercostal positions,
postoperative pain from involvement of multiple intercostal
nerves, and immature instrumentation to address the variety
of pathologies encountered. The need for adequate ventila-
tion with endobronchial control is a unique concern for all
chest operations, but a generous open exposure is required
for rapid and uncompromised exposure of the heart, lung
hilum, or aorta. A collaborative effort with anesthesia pro-
vides lung isolation. A double lumen endotracheal tube, an
endobronchial blocker or mainstem bronchial intubation can
all be effective. Abdominal incisions through soft tissues have
inherent mobility, but most thoracic incisions provide lim-
ited flexibility because access is limited by the rigid chest wall
and overlapping muscles with different functions. A proper
thoracic incision provides adequate exposure while minimiz-
ing damage to ribs, cartilage, muscle, and intercostal nerves.
Options for extension should be anticipated. A limited inci-
sion provides limited exposure, and over-retraction may re-
sult in complex local rib fractures and muscle tears. The skin
incision may be minimized, but the internal intercostal inci-
sion should be relatively wide from front to back to allow the
ribs to separate by “hinging” like bucket handles. Optimal
pain management begins before thoracotomy, and a variety
of ancillary indwelling catheters can alleviate pain and expe-
dite recovery.
Chest Incision Closure
Hemostasis is achieved in the usual manner, but unipolar
electrocautery should be used with caution in the posterior
mediastinum near intervertebral foramina. After every thora-
cotomy, the chest should be flooded with warm saline and
Department of Cardiothoracic Surgery, Penn State Milton S. Hershey Med-
ical Center, Hershey, PA.
Address reprint requests to David B. Campbell, MD, Professor of Cardiotho-
racic Surgery, Penn State Milton S. Hershey Medical Center, MC H-165,
500 University Drive, Hershey, PA 17033. E-mail: dbc2@psu.edu
1524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2008.06.001
the lung re-inflated to check for air leaks. Direct suture, sta-
pling, and applied topical adhesives and hemostatic agents
should be used aggressively to minimize postoperative air
leaks. Infection risks are thereby minimized, chest tube
removal expedited and lengths of stay minimized. Inter-
rupted paracostal sutures of #1 braided Dacron provide
secure rib approximation. Intrathoracic dead space should
be minimized and routinely two 32°F chest tubes are used:
a straight tube in an apical anterior position for air evacu-
ation and a basal curved tube in the posterior recess to
recover blood and fluid. Tubes should exit the skin ante-
rior to the mid axillary line to minimize discomfort when
the patient lays supine. Incised muscles are re-approxi-
mated with strong running suture taking bites of fascia in
front and back. Large spaces around separated muscles
should be drained with soft flexible catheters to prevent se-
roma formation.
The risk of chest wall hernia after thoracotomy is low, and
most incision closures are straightforward. However, pain
control deserves special emphasis, as adequate analgesia al-
lows patients to maintain adequate pulmonary toilet and to
progress toward functional recovery. Epidural, paravertebral,
and intercostal catheters all have proper places in postoperative
management. Intercostal nerve blocks (bupivacaine 0.5% with
epinephrine 1/200,000) offer excellent supplemental pain relief.
Brief discussions of chest incisions useful to the general surgeon,
particularly with respect to trauma, follow.
Table 1 presents a summary comparison of four useful
incisions.
Anterior Thoracotomy
Emergent access to the heart for manual cardiopulmonary
resuscitation or tamponade can be achieved by left antero-
lateral thoracotomy. Access to both ventricles, the left hi-
lum, and the descending aorta is possible. A submammary
incision is made and extended down to the superior sur-
face of the underlying fifth or sixth rib (Fig 1A). This is at
the inferior margin of the pectoralis major muscle, and
intercostal incision is made over the top of the underlying
rib. Extension laterally follows the split fibers of the ser-
ratus. Medial extension to the sternum will divide the
internal mammary artery, which lies 1 cm lateral to the
sternum. Limiting the medial extent avoids this trouble-
77
78 D.B. Campbell

Figure 1 Anterior thoracotomy. (A) Line of incision, left chest rotated up 30 degrees. (B) Deep exposure with pectoralis
major incised medially.
Thoracic incisions 79

Figure 1 (Continued) Anterior thoracotomy, continued. (C) Pericardium opened, heart exposed, sutures placed in stab
wound. (D) Chest closure with rib reapproximation and paracostal sutures.
80 D.B. Campbell

Table 1 Comparison of the Four Most Useful Incisions

Incision Advantages Disadvantages
Median sternotomy Wide mediastinal exposure Requires a saw
Access to both hila Poor access to descending aorta
Full cardiac access Poor access to left lower lobe
Option for cardiopulmonary bypass Suboptimal access to trachea and
Little postoperative pain bronchi
Augments liver and IVC exposure for difficult No esophageal access
abdominal cases
Good internal access to chest wall injuries
Anterior thoracotomy Rapid access to heart and hila, especially on left side Limited access to lung
Vertical and/or trans-sternal extensions possible No esophageal or large airway access
Moderate postoperative pain
Posterolateral Adequate for all lung and esophageal problems Frequent rib fractures
thoracotomy Best distal arch and descending aortic exposure Requires muscle division and
Conventional instruments used reconstruction
Intercostal flap can be harvested Cosmetically undesirable
Extension for thoracoabdominal exposure possible Moderate postoperative pain
Lateral muscle sparing Adequate for almost all lung and esophageal problems Requires dissection and retraction
thoracotomy Conventional instruments used (not rapid)
No muscle division, little to heal Inadequate aortic exposure
Cosmetically acceptable Moderate postoperative pain
Extension to posterolateral thoracotomy possible
Intercostal flap can be harvested

some bleeding. A retractor is inserted and opened as much
as needed, mindful that the anterior costal cartilages are
more fragile than bone. These cartilages can be divided
with rib shears to enhance the exposure (Fig 1B), although
wound closure is tedious and healing is not rapid. Stout
sutures are placed through the cartilages and interspace
musculature, and several paracostal sutures are placed
around the ribs of the interspace incision (Fig 1D). Two
chest tubes (apicoanterior and posterobasal) are brought
out below, and a subcutaneous drain may be prudent if
large muscle flaps were developed.
This incision provides access to the ipsilateral hilum that is
unrestricted (Fig 1C). In case of massive lung bleeding, a
large hilar clamp can be applied from above downwards
across the pulmonary artery, bronchus, and both veins.
Emergent clamping of the descending thoracic aorta is pos-
sible by pulling the lung forward. Relief of pericardial tam-
ponade or open cardiac message requires incision into the
pericardial space, and widest exposure is possible with a
longitudinal incision anterior and parallel to the phrenic
nerve. Pericardiotomy should avoid phrenic nerve divi-
sion. Finger pressure may be required to control bleeding
from a cardiac stab wound, and traction sutures maintain
exposure of the heart for suture placement. The pericar-
dium can be loosely re-approximated with interrupted su-
tures to provide cardiac support. Closure should be loose
enough to prevent tamponade from epicardial bleeding, but
sutures should be close enough to prevent cardiac herniation
through the defect.
Broken costal cartilages and ribs are frequent with this
emergency access. Transection of the anterior costal carti-
lages may be more prudent than applying increasing raw
retraction. Nevertheless, closure is routine with paracostal
sutures providing needed stabilization. This incision can be
extended across the sternum with a saw or rib shears, al-
though closure is less stable. Postoperative pain control ef-
forts (above) will be appreciated by the patient.
Posterolateral Thoracotomy
When uncompromised access to the lung and mediasti-
num is necessary, the patient should be placed in full
lateral position. If hemoptysis is a significant problem,
then the airway should be controlled with a double lumen
tube, or at least with an intrabronchial blocker. Turning
the patient into the lateral decubitus position places the
“good” lung down, making it more vulnerable to blood
and secretions in the airway. Posterolateral thoracotomy is
the classic incision for lung and mediastinal surgery and
on the left side this exposure is still preferred for descend-
ing aortic procedures. On the right side, it offers the best
access to the intrathoracic trachea and to the mid and
upper esophagus.
The skin incision for posterolateral thoracotomy is
generous, from behind the scapula around its inferior bor-
der to the submammary crease anteriorly (Fig 2A). The
blood and nerve supplies of the latissimus dorsi originate
above, so this muscle should be mobilized inferiorly and
transected at a low level to maximize its functional recov-
ery. Intercostal division is made widely from front to back,
and the serratus anterior can often be left intact and re-
Thoracic incisions 81

Figure 2 Posterolateral thoracotomy. (A) In-

cision with patient in left lateral decubitus
position. (B) Wide exposure with latissimus
dorsi divided, 5th rib incised posteriorly. (C)
Rib approximator allows secure closure with
paracostal sutures.
82 D.B. Campbell

Figure 3 Muscle sparing lateral thoracotomy. (A) Incisions, patient in left lateral decubitus position. (B) Subcutaneous
flaps allow serratus anterior muscle retraction upward and chest wall access.
Thoracic incisions
Figure 3 (Continued) Muscle sparing lateral thoracotomy, continued. (C) After interior front-to-back muscle division,
crossed Balfour and Tuffier retractors provide exposure without rib fractures.
tracted upward and forward. If wider exposure is required,
then a short length of rib can be transected posteriorly
with rib shears (Fig 2B) to prevent multiple complex frac-
tures. Closure is conducted in layers, with strong perma-
nent paracostal sutures (Fig 2C) and running absorbable
sutures for muscle re-approximation and subcutaneous
layers. When this incision is made, two interspaces lower,
extension across the costal margin for thoracoabdominal
exposure is straightforward.
Muscle Sparing
Lateral Thoracotomy
Large muscle division can be avoided for most routine
thoracic exposures, including those for acute chest wall
and lung trauma, and for late empyema drainage and de-
cortication. A lateral thoracotomy of 4 to 5 inches with
separation and retraction of latissimus and serratus mus-
cles allows manual palpation of intrathoracic structures
and use of conventional instruments for most elective op-
erations. Crossed Tuffier and Balfour retractors provide
ample access and exposure at the level of the hila over the
major fissure. Landmarks for the skin incision are a point
one inch above the scapular tip and the inframammary
crease (Fig 3A). The sixth rib underlies a line connecting
these points, but chest entry can be an interspace higher.
Skin and subcutaneous tissues are incised along this line
83
from just behind the midaxillary line (the anterior border
of the latissimus) forward about 5 inches. The anterior
border of the latissimus is mobilized above and below.
This muscle is retracted posteriorly and away from the
chest wall. With finger dissection, the underlying serratus
is separated, taking care not to injure the long thoracic
nerve on its surface. Traction is applied to the serratus in
an upward and anterior direction to allow identification of
its inferior border, and the fat below is cauterized and
divided to expose the chest wall (Fig 3B). When access to
the top of the thoracic cavity is desired (fourth intercostal
space) it is often advantageous to separate the lowest in-
sertion of the serratus from the chest wall. Maintaining
upward traction on the serratus, ipsilateral ventilation is
stopped and intercostal incision is made above a rib, from
back to front through the three layers of intercostal mus-
cle. Using a Kelly clamp for initial intercostal entry allows
the lung to fall away from the chest wall, minimizing the
chance of lung injury from cautery. The incision is en-
larged anteriorly and posteriorly with electrocautery.
Paraspinous muscles posteriorly and the upward sweep of
the ribs (short of the internal thoracic artery pedicle) an-
teriorly are practical limits for intercostal division. If an
intercostal flap is not required, a Tuffier retractor main-
tains intercostal distraction, and a Balfour is opened at
right angles to provide additional soft tissue retraction (Fig
3C). Rib division and fractures are avoided. This exposure
allows insertion of a hand for full palpation of the lung and
mediastinum, and conventional instruments and tech-
niques are used for necessary procedures.
84 D.B. Campbell

Figure 4 Median sternotomy. (A) Sternum is divided in the midline with a saw. (B) Pericardium is opened and
suspended, allowing full cardiac and hilar access.
Thoracic incisions
Figure 4 (Continued) Median sternotomy, continued. (C) Sternal halves impacted with interrupted wire closure.
Closure of this incision can be rapid. Chest tubes are
brought out inferior to the wound and posterior intercostal
nerve blocks are done internally under direct vision using a
small bore spinal or long aspiration (mediastinoscopy)
needle. After the chest is irrigated the lung is reinflated and
tested for air leaks. It is deflated and paracostal sutures are
placed and tied. The serratus and latissimus muscles re-
turn to normal positions when retraction is released. A soft
drain above the muscles prevents seroma formation, and fat
and subcutaneous layers are closed with running absorbable
sutures.
Median Sternotomy
Access for hilar dissection and control through this incision is
good, and median sternotomy offers optimal exposure and
control for resuscitation and penetrating cardiac wounds.
The dissections required for all lobectomies except the left
lower lobe can be done, so lung control is excellent. Although
the esophagus cannot be accessed through this anterior ex-
posure, transpericardial incision and retraction of the aorta
and vena cava offers excellent control of the distal trachea and
carina. With assistance from selective lung ventilation this
wide access also opens options for internal rib fixation for
complex blunt chest wall trauma. Upper abdominal exposure
shortcomings of laparotomy are resolved if the midline inci-
sion is extended cephalad with sternotomy. Surgeons who
have participated in multi-organ harvests for transplantation
understand the utility of access to the inferior vena cava and
85
hepatic veins. One of the few downsides of this incision is
that either a sternal saw or Lebsche knife and mallet must be
available.
Skin and subcutaneous tissue is incised to the midline of
the anterior sternal table, and the suprasternal “ligament”
is incised after palpating for anomalous neck vessels and
controlling crossing veins. The sternum is divided in the
middle with a saw (Fig 4A). Periosteal bleeding is arrested
with electrocautery and a retractor inserted. Bone wax
interferes with sternal healing, but can be used sparingly if
marrow bleeding is profuse. Access to the lungs is
achieved by opening the pleura, which is done most safely
at the level of the 3rd or 4th interspace, above the base of
the heart. The pericardium is usually opened vertically in
the midline, and the incised edges can be pulled up to the
wound edges to elevate and expose the heart. Manual car-
diac massage is conducted without restriction through this
incision, and air embolism can be addressed directly by
aspiration of pulmonary artery and right ventricle. If the
patient’s condition requires it and if massive anticoagula-
tion can be tolerated, cardiopulmonary bypass can be in-
stituted for resuscitation, to correct hypothermia, for mas-
sive pulmonary embolism or for irreversible airway
compromise (Fig 4B). Hilar access is straightforward if the
pericardium is pulled in the opposite direction, which
allows manual compression or clamping. Individual pul-
monary arteries and pulmonary veins can also be con-
trolled or clamped inside the pericardium.
After wound irrigation and hemostasis, closure is ac-
complished with circlage sternal wires and layers of ab-
sorbable sutures. Drainage tubes should be left in opened
86
pleural spaces, and anterior and posterior intrapericardial
tubes are customary. The pericardium is either left open or
loosely approximated by two or three interrupted sutures.
Tight impaction of the sides of the sternum assures union
with minimal pain and infection risk. A rule of thumb for
D.B. Campbell
closure is one wire per 10 kg patient weight, with the top
three wires through the bone above the angle of Louis and
the remainder of the wires passing around the sternal
halves in the intercostal spaces, avoiding the internal tho-
racic arteries (Fig 4C).