Incisions in cardiothoracic surgery

1. IN THE NAME OF GOD Incisions in cardiothoracic surgery Dr.mehdi hadadzadeh Assistant professore of cardiovascular surgery

2. A surgical incision opens an aperture into the thorax to permit the work of the planned operation to proceed

3. If an operation is difficult, you are not doing it properly," applies directly to the incision used

4. The choice of incision: • underlying pathology • the site (e.g. lung, chest wall, oesophagus) • experience of the surgeon

5. Types of incisions • Median Sternotomy • Posterolateralthoracotomy • Anterolateralthoracotomy • Lateral thoracotomy • Bilateral thoracosternotomy • Subxiphoid(pericardial window)

6. Posterolateral thoracotomy • gold standard ofthoracic incisions • excellent exposure for mostgeneral thoracic procedures including the lung, heart, aorta, the lower esophagus, and diaphragm • This approach is also used for spinal operations

7. Preoperative preparation • Assessment of pulmonary function • given a dose of antibiotics preoperatively • preoperative education and incentive spirometry training as to the importance of adequate inspiration postoperatively to prevent atelectasis (lung collapse

9. Position • complete lateral decubitusposition • use of sandbags, rolled sheetsfront and back or bean bags supporting the back and the abdomen

10. The lower leg isflexed at the knee and hip while the upper leg lies straighton the top of the pillow

11. to avoid post operative complications ; • cutaneous necrosis, • venous thrombosis • or nerve compression.

12. arm placed on an angle pad • free from any fixation.

13. Incision • The position of the vertebral spines and the nipple is notified. • The standard incision follows between scapula and mid-spinal line to the anterior axillary line • passing 3cm below the tip of the scapula.

16. The skin incision :No. 10 scalpel • latissimusdorsi and serratus anterior muscles :No. 10 scalpel or cautery • Posteriorly, the muscle layers of the rhomboid and trapezius are incised • The pleural space :incising the musculature between the ribs or via an osteotomy • transect the muscles on the superior border of the ribs to avoid injuring the neurovascular bundle. • ribs may be transected or resected

17. at the level of the 5th rib for exposure of the upper thoracic area :COA • level of the 6th or 7th rib for lower thoracic area (e.g., lower esophageal or diaphragmatic surgery)

18. After operation drainage tubes must be placed • The rib approximator is closed and No.1 chromic or No. 1 vicryl sutures are placed to encircle the bone along the length of the incision. • Silk sutures are to be avoided as it increases postoperative pain • The cut ends of the trapezius and latissimusdorsi muscles are then approximated and sutured • subcutaneous tissue is closed using an interrupted 3-0 absorbable sutures. • The skin is closed using surgical clips or a running 4-0 subcuticular stitch such as Monocryl.

20. disadvantages of this incision • increased potentialfor blood loss and moderate time requirement for opening andclosing the incision • prolonged ipsilateral shoulder and armdysfunctions • compromised pulmonary function and chronic postthoracotomy pain syndromes • scolioses have been described in children

21. Median sternotomy • Most common thoracic incision • Indications:cardiac operations-anterior mediastinal lesions-bilateral lung procedures • Speed in opening and closing • Supine position and arms in patient,s side

22. Incision • Incision from below the suprasternal notch toa point between the xyphoid and umblicus • An electric saw with a vertical blade is used • An oscillating saw is used for repeated sternotpmy

23. Bone wax is a useful tool to control bleeding from sternum • sterile mixture of beeswax and isopropyl palmitate

24. Sternal retractor is used in lower thired of the sternum and gradually opened

25. Stainless steel wire is at present the standard suture in mediansternotomy

26. Disadvantage of this incision • Scar formation • Brachial plexus injury • Chronic chest pain

27. Axillary(lateral)thoracotomy • Advantages:muscle sparing-ease and speed-good cosmetic • Disadvantages:limited exposure • Choice in majority of pulmonary resections ,PDA ligation,PA banding and…. • Lateral decubitus position homolateralarm is abducted at 90° at the shoulder level, flexed atthe elbow • Incision Between posterior border of pectoralis major and anterior border of latisimusdorsi • through the 4th or 5th intercostal space;

30. Bilateral thoracosternotomy(clamshell) • Previously choice for bilateral lung transplant • Incision along the inframammary creases and across the sternum • 4 or 5thintercostal space • Poor healing of wound

32. Anterolateralthoracotomy • Useful in variety of operation on heart,pulmonary resection and esophagus • Supine and operation site elevated30 degree

33. Incision from lateral border of sternum to midaxillary at 4or5interspace • Pectoralis major and seratus anterior is divided

34. Subxiphoid incision(pericardial window) • Indications:pericardialeffusion,pericardialbiopsy,epicardial pacemaker • Supine posision,midline incision over the xiphoid

35. Intrapleural(chest) tubes • Whenever thoracotomy has been done • exit of fluids and air and monitors of bloodloss • Separate incision