ORIGINAL REPORT
Muscle-Splitting Posterolateral Thoracotomy:
A Novel Technique
Sreekumar Subramanian, MD, and Kevin D. Halow, MD
Department of Surgery, David Grant USAF Medical Center, Travis AFB, California
PURPOSE: In an effort to decrease the morbidity of a stan-
dard posterolateral thoracotomy, numerous muscle-sparing ap-
proaches have been developed. However, these incisions have
been limited by the need for excessive muscle retraction with
resultant neuropraxia, difficulty with exposure, and postopera-
tive wound seroma. We report our results of a novel muscle-
splitting thoracotomy incision, which affords excellent expo-
sure without significant morbidity.
METHODS: We conducted a retrospective chart review of 37
consecutive patients who underwent “muscle-splitting” thora-
cotomy from June 1997 to June 1998. The technique, which
involves a bidirectional spread of the latissimus dorsi and serra-
tus anterior muscles, was performed by the same attending sur-
geon in all patients.
RESULTS: There were 22 male and 15 female patients, aged
26 to 81 (mean, 58), with a body mass index ranging from 18 to
40 kg/m2 (mean, 25 kg/m2). Procedures included lobectomy/
segmentectomy (19), wedge resection (5), pneumonectomy
(2), Belsey IV fundoplication (5), Ivor–Lewis esophagogastrec-
tomy (1), T8/T9 thoracic exposure (1), and miscellaneous tho-
racic cases (4). Operative time ranged from 90 minutes to 420
minutes (mean, 176), which was comparable with similar pro-
cedures through a standard incision. No patients required con-
version to a muscle-cutting thoracotomy.
CONCLUSIONS: Our technique of muscle-splitting postero-
lateral thoracotomy appears to provide excellent operative ex-
posure and to avoid problems seen with current muscle-sparing
incisions. A prospective, randomized trial to compare this tech-
nique with a standard thoracotomy incision would be useful in
determining its viability as an alternative thoracic approach.
(Curr Surg 2000;57:74 –77. © 2000 by the Association of Pro-
gram Directors in Surgery.)
KEY WORDS: thoracic incision, muscle-splitting posterolat-
eral thoracotomy, technique
The posterolateral thoracotomy incision is used for most gen-
eral thoracic surgical procedures. This incision, which involves
Correspondence: Inquiries to Sreekumar Subramanian, MD, Department of Surgery, David
Grant Medical Center, 101 Bodin Circle, Travis AFB, CA 94535
74 CURRENT SURGERY • © 2000 by the Association of Program Directors in Surgery
Published by Elsevier Science Inc.
division of the latissimus dorsi and serratus anterior muscles,
affords excellent exposure of the thoracic cavity. However, it is
associated with significant morbidity, including impaired pul-
monary function, postoperative chest pain, and restricted arm
and shoulder movement. Various muscle-sparing incisions have
been proposed to decrease the morbidity. These incisions are
limited by the need for vigorous muscle retraction resulting in
neuropraxia, inadequate operative exposure, or wound seroma
resulting from an extensive dissection with large subcutaneous
flaps. We have developed a novel muscle-splitting thoracotomy
incision that provides excellent operative exposure without sig-
nificant morbidity. The objective of this report is to describe the
operative technique, discuss its anatomic basis, and present our
preliminary results using this incision.
OPERATIVE TECHNIQUE
Following induction of general anesthesia and endotracheal in-
tubation with a double lumen tube, patients are placed in a
standard position for a thoracotomy (right or left lateral decu-
bitus). The arm ipsilateral to the skin incision is abducted and
placed on an arm lift. A posterolateral thoracotomy incision is
made (Fig. 1). The skin, subcutaneous tissues, and fascia are
dissected sharply to expose the underlying latissimus dorsi (“la-
tissimus”) muscle. Skin flaps are raised cephalad and caudad
using electrocautery for a distance of approximately 5 cm to 7
cm. The latissimus muscle is split (in line with its fibers) 2 cm
anterior to the anterior border of the scapula (Fig. 2). The fibers
of the latissimus are retracted anteriorly and posteriorly, expos-
ing the posterior border of the serratus anterior (“serratus”)
muscle (Fig. 3). After separating the latissimus muscle fibers,
the posterior border of the serratus is separated from the tho-
racic fascia, and the serratus anterior muscle is retracted anteri-
orly (Fig. 4). The appropriate intercostal space is then entered,
and a rib-speading retractor is inserted. Gentle spreading of the
retractor opens the intercostal space. To complete the exposure,
a second retractor, preferably a Toupet or a Balfour, is placed
90° to the first (Fig. 5).
The general thoracic operation is then performed. Closure
begins with rib reapproximation. Next, the latissimus dorsi is
reapproximated. The subcutaneous tissues and the skin are then
0149-7944/00/$20.00
PII S0149-7944(00)00137-9
 FIGURE 1. Standard posterolateral thoracotomy incision.

closed in a standard fashion. Because of the limited distance of

the subcutaneous flaps, we do not insert any drains.

METHODS FIGURE 3. Retracting the latissimus dorsi.

We conducted a retrospective chart review of 37 consecutive
patients who underwent “muscle-splitting” thoracotomy from utes (mean, 176), which was comparable with similar proce-
June 1997 to June 1998. All patients were operated on by the dures through a standard incision. No patients required con-
same attending surgeon with the assistance of the house staff. version to a muscle-cutting thoracotomy. No subcutaneous
Cases were evaluated by operative time, ability to perform the drains were placed. No seromas or wound complications ex-
planned procedure, need for conversion to a muscle-cutting isted.
incision, and wound complication rate.
DISCUSSION
RESULTS
Muscle-sparing incisions have been reported as a less invasive
There were 22 male and 15 female patients, aged 26 to 81 alternative to the standard posterolateral thoracotomy.1,2 Pro-
(mean, 58), with a body mass index ranging from 18 to 40 ponents of muscle-sparing incisions cite several advantages, in-
kg/m2 (mean, 25 kg/m2). Procedures included lobectomy/seg-
mentectomy (19), wedge resection (5), pneumonectomy (2),
Belsey IV fundoplication (5), Ivor–Lewis esophagogastrectomy
(1), T8/T9 thoracic exposure (1), and miscellaneous thoracic
cases (4). Operative time ranged from 90 minutes to 420 min-

FIGURE 2. Splitting the latissimus dorsi. FIGURE 4. Retracting the serratus anterior.

CURRENT SURGERY • Volume 57/Number 1 • January/February 2000 75


FIGURE 5. Final exposure.
cluding decreased postoperative pain and disability, less shoul-
der impairment, and improved pulmonary function.3–10
Not all authors agree on the benefits of muscle-sparing inci-
sions, and reported postoperative surgical outcomes vary as
much as the techniques themselves. One prospective trial com-
paring a muscle-sparing incision with a standard posterolateral
thoracotomy demonstrated a decrease in postoperative pain in
the muscle-sparing group, but noted no difference in postoper-
ative pulmonary function, shoulder range of motion, surgical
time, hospital stay, or mortality.6 Furthermore, they noted a
wound seroma rate of 23% in the muscle-sparing group, which
they attributed to the large skin flaps needed to mobilize the
intact latissimus muscle. Several investigators have indicated
that the intact latissimus is difficult to mobilize in large or
muscular individuals, resulting in limited exposure.4,6 Other
approaches, such as the vertical incision as reported by Hen-
nington,7 or the anterolateral incision as described by Nomori9
or Pochettino10 may provide poor access to certain regions of
the chest, such as the apex, diaphragm,or posterior mediasti-
num. Finally, the effect of the vigorous retraction needed to
move the intact latissimus on underlying muscle function and
viability is unclear. Benedetti et al noted that patients undergo-
ing muscle-sparing incisions still have significant postoperative
pain that may be related to underlying minor nerve injury.11
Landreneau et al summarized the current status of muscle-spar-
ing incisions by stating that their only advantage is in preserva-
tion of the chest wall musculature in the event that they would
be required for future rotational flaps.12
The purpose of our muscle-splitting incision is to maintain
76
muscle viability and to eliminate some of the disadvantages seen
with other muscle-sparing incisions. The anatomic basis of the
technique is the neurovascular innervation of the latissimus and
serratus muscles. Shusterman et al noted in 114/115 anatomic
latissimus dissections that a single thoracodorsal nerve pedicle
bifurcates to supply medial and lateral aspects of the muscle.13
Vu et al noted that the main thoracodorsal bundle bifurcates,
close to the insertion of the latissimus, into two trunks that
follow the medial and lateral borders of the muscle.14 Both
groups concluded that the latissimus muscle can be safely split
while maintaining function and viability in both.13,14 For the
serratus anterior, Vu noted that the best safeguard for the long
thoracic nerve is to detach it from the fascia along the pos-
terior margin and near the rhomboid complex and retract it
anteriorly.14 Based on these data, our muscle-splitting ap-
proach consists of an anatomic dissection of the latissimus
dorsi and serratus anterior that theoretically minimizes neu-
rovascular injury, preserves latissimus function, and pro-
vides excellent exposure.
Sadighi and Woodworth recently reported on their tech-
nique of muscle-splitting posterolateral thoracotomy.15 They
used a posterolateral incision with small skin flaps and split the
latissimus dorsi 5 cm anterior to the scapula. They reported
excellent exposure with little risk of seroma. In our series, we
have found that a limited lateral incision and small skin flaps
provide adequate room for mobilization of the latissimus and
serratus. Based on the data by Shusterman and Vu, we split the
latissimus 2 cm anterior to the anterior border of the scapula to
minimize the risk of thoracodorsal nerve injury.
Our technique affords exposure similar to that obtained with
standard posterolateral thoracotomy, without requiring an ex-
tensive dissection to create large subcutaneous flaps. This ana-
tomic dissection obviates the need for suction drains. Further-
more, bidirectional retraction of the latissimus dorsi enables
this technique to work well even in healthy, muscular individ-
uals, which has been difficult with reported muscle-sparing in-
cisions.16 –20 The technique has not added significantly to the
operative time, and we have not observed any permanent neu-
rologic sequelae, which may be because of the bidirectional
retraction of the latissimus, which distributes the tension evenly
in 2 directions. In addition, we believe this operation is more
“physiologic,” resulting in less pulmonary disability and im-
proved arm and shoulder mobility, whichcould shorten the
hospital stay after thoracotomy and lead to a more rapid recov-
ery.
Interestingly, the young and the elderly are excellent candi-
dates for this operative approach. Healthy, young patients are
likely to benefit by a faster recovery when their muscles are
spared, and they appear to prefer the muscle-sparing ap-
proach on theoretical grounds. Elderly, debilitated patients
with limited pulmonary reserve can also benefit, because this
technique may result in less morbidity than the standard
thoracotomy.
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
CONCLUSION
Our series demonstrates the utility of this incision for access to
all aspects of the thoracic cavity, regardless of patient size or
body habitus. The muscle-splitting thoracotomy can be per-
formed expeditiously, preserves the chest wall musculature, and
does not require the placement of drains.
Further evaluation will be needed to determine the effect that
this approach has on postoperative recovery, muscle function,
and long-term disability, compared with standard posterolat-
eral thoracotomy. Based on our preliminary results, however,
we advocate this approach as a viable alternative to both stan-
dard posterolateral thoracotomy and current muscle-sparing
thoracotomy techniques.
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