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Ann Thorac Surg 2003;76:1050-1054
© 2003 The Society of Thoracic Surgeons

Original article: general thoracic

The effect of standard posterolateral versus Muscle-Sparing thoracotomy on multiple parameters

Yigit Akçali, MDa*, Hasan Demir, MDa, Bekir Tezcan, MDa

a Department of Thoracic and Cardiovascular Surgery, Erciyes University Medical Faculty, Kayseri, Turkey

Accepted for publication March 20, 2003.

* Address reprint requests to Dr Akçali, Mustafa Kemal Paa Bulvari, No. 131/20, 38090 Kayseri, Turkey
e-mail: yakcali{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Different alternative approaches to thoracotomy have been developed because of the considerable morbidity associated with the standard posterolateral incision.

METHODS: We studied a prospective, randomized, blinded study of 60 consecutive patients to compare surgical approcah time, postoperative pain (quantitated by narcotic requirements and the visual analogue scale), pulmonary function, shoulder strength, and range of motion between standard posterolateral (group I) and muscle-sparing (group II) thoracotomy techniques.

RESULTS: There were no differences in postoperative surgical time, pulmonary function, shoulder range of motion, mortality, or hospitalization time. There was significantly less postoperative pain in group II. In this group, narcotic requirement was less in the first 24 hours, and visual analogue scale scores were significantly lower (p < 0.05) throughout the first postoperative week. Muscle strength had returned to preoperative levels by 1 month in both groups. Morbidity was identical in the two groups with the exception of postoperative seromas. The prevalence of seroma was 16.6% in the muscle-sparing group.

CONCLUSIONS: We conclude that the muscle-sparing incision may be a sensible alternative to a standard posterolateral thoracotomy.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
The traditional posterolateral thoracotomy is currently the standard approach for most thoracic surgical procedures. It is associated with considerable morbidity, including significant postoperative pain followed by compromised lung function and diminished shoulder girdle function. Nevertheless, muscle-sparing thoracotomy as a means of reducing postoperative pain, preserving lung function, and lessening postoperative complications has been advocated. Despite claims of benefit from this procedure, there has been little objective information to support these statements. The present prospective, randomized study was undertaken to compare the differences in postoperative pain, the changes in lung function and shoulder range of motion, the duration of surgery, and the development of postoperative complications.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Patients
In our department, 60 patients requiring thoracotomy for different thoracic diseases were randomly selected to undergo either standard posterolateral thoracotomy (group I, n = 30 patients) or a muscle-sparing thoracotomy (group II, n = 30) after informed consent was obtained (Table 1). This study was undertaken between 1999 and 2000 years.


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  		Table 1. Patient Population

 
Procedures
The location and length of the skin incision were identical for the muscle-sparing procedure and for the standard posterolateral thoracotomy. For muscle-sparing thoracotomy, at this point, along the incision line and the areas for planned dissection, air was subcutaneously insufflated with a 60-mL syringe, which was connected to the large-bore needle through the three-way tap (ie, a "spacemaker"). Then, the incision was made. For adequate mobilization of the latissimus dorsi and serratus anterior muscles, a generous subcutaneous dissection was performed easily with the use of the electrocautery. The entire anterior border of the latissimus dorsi was freed from its superior aspect in the axilla to its inferior insertion at the iliac crest. After the deep aspect of the latissimus dorsi was freed, the muscle was retracted posteriorly to expose the serratus anterior. The serratus anterior was freed superiorly beyond the tip of the scapula and inferiorly to its attachment on the anterior aspect of the sixth rib. After the intercostal muscles were incised as tangential to rib, the chest was entered. In patients more than 40 years of age, to decrease the incidence of costal fracture, a 1-cm segment of the lower rib at the intercostal incision was resected near the junction with the vertebral process. Two rib retractors were positioned: one to retract the ribs and the other oriented perpendicular to the first retractor to separate the serratus anterior and latissimus dorsi muscles. During the procedure, care was taken to prevent injury to the long thoracic nerve. The standard posterolateral thoracotomy required transection of the entire latissimus dorsi and lower edge of the serratus anterior.

At the completion of the pulmonary operation, a single intercostal nerve block of 0.25% bupivacaine was administered to all patients to anesthetize two nerves above and below the intercostal space. Pericostal absorbable sutures were used around the ribs, followed by approximation of the intercostal muscles. In the muscle-sparing procedure, two soft closed suction drains were positioned to evacuate the subcutaneous flap. These drains were removed on the 4th postoperative day, or later if drainage was greater than 50 mL/day. For the prevention of seroma, which may occur postoperatively, along the incision line, the patient's chest was wrapped with an elastic bandage so it did not impede ventilation.

Measurement
The times from incision to retractor placement (opening time) and from retractor removal to incision closure (closing time) as well as the time from retractor placement to removal (real operating time) were recorded.

Muscle strength and range of shoulder motion were measured by the physical therapy department before surgery. These measurements were repeated at 7 and 30 days postoperatively by the same examiner, who was blinded as to the operative procedure performed. Range of motion was measured in shoulder flexion (0o to 180o), hyperextension (0o to 60o), abduction (0o to 180o), and external and internal rotation (0o to 90o). Muscle strength was graded on a scale from 0 to 5, with 0 representing no strength, and 5 equaling the normal strength as assessed by the phsysical therapist. Muscles evaluated included the latissimus dorsi, serratus anterior, shoulder abductors, pectorales, and supinators and pronators.

Narcotic analgesic used was intravenous/intramuscular meperidine (pethidine) in the first 24 hours. Postoperative pain assessed using a visual analogue scale (VAS) for pain, the McGill pain questionnaire, and postoperative narcotic requirements by the patient while in the hospital were recorded carefully. The VAS consisted of the patients marking a grade of their pain from 0 (absent) to 100 (most severe imaginable) on a 100-mm line drawing. The VAS was explained to the patient preoperatively and administered by the nursing staff every 6 hours for 2 days after surgery and then every 12 hours for a total of 1 week.

Pulmonary function tests (vital capacity, forced vital capacity (FVC), and forced expiratory volume in 1 second [FEV1]) were measured before surgery and at 7 and 30 days after surgery. These tests were performed with patient relaxed and sitting upright. Again, the examiner was bilinded as to the operative incision used for each patient.

On 10 patients from each group, a needle electroneuromyography was performed at 1 month postoperatively by the same neurologist, who was blinded as to the operative procedure performed. A bipolar recording electrode was positioned on the latissimus dorsi and serratus anterior muscle groups. A stimulus was given from the axilla, and the severity of stimulus was increased until a motor unit obtained. Amplitude and latency of motor unit obtained from both muscles were recorded. Also, fibrillation potantial was noted.

Statistical analysis
Data represent the means ± standard deviation. Statistical significance was determined using the unpaired t test for operation time; {chi}2 and variance analysis tests were used for other values. Values of p less than 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
There were no significant differences between the two surgical groups with respect to age, gender, diagnosis, or the procedure performed (p > 0.05). There was one death in group II. The patient died of sepsis and renal failure in postoperative 25th day (no significant difference). There were no seromas in group I, but five postoperative wound seromas (16.6%) occurred in the first 5 patients of group II (p < 0.05) (Table 2).


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  		Table 2. Complications

 
Preoperative pulmonary function values were similar between both groups (Table 3). Although these values fell significantly (p < 0.05) when measured 1 week postoperatively, no difference could be seen in these changes between both groups (p > 0.05). At 1 month after surgery, pulmonary functions were reduced in both groups, with no significant differences between groups (p > 0.05). There was no significant difference between the two groups according to arterial blood gases (p > 0.05).


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  		Table 3. Pulmonary Function Tests

 
Mean values for the range of motion on the operative side are shown Table 4. The range of shoulder flexion and abduction showed significant decreases at 1 week after surgery (p < 0.05). Whereas the range of shoulder motion returned to preoperative values of range by 2 weeks in group II, they returned to normal by 1 month in group I. In patients of both groups with bronchogenic carcinoma, there were no significant differences in the number of dissected mediastinal lymph node.


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  		Table 4. Range of Motion on Operative Sidea

 
A discernible decrease in strength in both the latissimus dorsi and serratus anterior was noted at 1 week in group I (Table 5). In group II, shoulder strength appeared to have been preserved in the latissimus dorsi and serratus anterior muscles at the 1-week postoperative assesment. It should be noted that shoulder girdle strength returned to preoperative levels of strength by 1 month in both groups.


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  		Table 5. Muscle Strength on Operative Side

 
There was a difference statistically between the groups according to surgical approach time (p < 0.05). Although it took an average of 9 minutes longer to open the chest in group II, this time was regained through a quicker closure that did not require suture reapproximation of the thoracic musculature. The real operating time was longer for group I compared with group II (Table 6).


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  		Table 6. Surgical Approach Time

 
The mean daily values of the VAS in group II, which was considered indicative of less perceived pain with this approach, were always less than those in group I (Table 7). Visual analogue scale differences were statistically significant between the groups (p < 0.05).


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  		Table 7. Visual Analogue Scale

 
The average analgesic requirement for group II was less as compared with group I for 8 days after surgery, and was significant statistically (p < 0.05) (Table 8). The average postoperative hospital stay was similar between the groups.


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  		Table 8. Narcotic Requirement (mg/day) After Surgery

 
Electromyographic studies revealed that 2 patients (20%, n = 10) in group I had moderate neurogenic damage, and 8 had severe damage (80%); 1 of them had winged scapula. However, 2 patients (20%, n = 10) in group II had mild neurogenic damage, and 2 had moderate damage (20%). According to the degree of neurogenic damage, the difference between the groups was significant statistically (p < 0.05). There was no significant between the groups regarding to blood loss and infused blood.

Cosmetically, the patients, especially slim ones, in group I had mild bulging, due to reapproximation of the thoracic musculature, along their incision lines. However, the incision lines of the patients in group II were perfect without any bulging.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
The traditional posterolateral thoracotomy, which provides excellent exposure of the lung, pulmonary hilum, and mediastinum, has been the standard incision for pulmonary procedures for the past 90 years. However, disadvantages of this approach include the division of the major muscles of the chest, resulting in increased potential for blood loss, a moderate time requirement for opening and closing the incision, prolonged ipsilateral shoulder and arm dysfunction, scoliosis [1], compromised pulmonary function, and chronic postthoracotomy pain syndromes. The muscle-sparing thoracotomy was described by Bethencourt and Holmes [2] in 1988 and does not involve transection of the major thoracic muscles. It has been advocated as a means of reducing postoperative pain, preserving pulmonary function, and lessening postoperative complications. It also involves the availability of extrathoracic musculature such as latissimus dorsi and serratus anterior for rotational flap control of postresectional space problems.

Thoracic access
The muscle-sparing thoracotomy provided acceptable access to the chest cavity for most pulmonary resections when required. Occasionally, its exposure may be difficult in heavily muscled individuals. However, if further visualization is required, it may be converted to the standard opening by simply incising the thoracic musculature. The muscle-sparing technique allows access to the mediastinum and complete lymphadenectomy [3].

Operative time
The muscle-sparing thoracotomy is not a "chronophore" (time-eater); the time required to create the subcutaneous flaps are made up at closure, because is not necessary to reapproximate the muscle edges. The total surgical time of muscle-sparing thoracotomy has been found to be longer (87 ± 13 minutes vs 66 ± 12 minutes) [3] or shorter (161 ± 73 minutes vs 198 ± 82 minutes) [4] than the standard posterolateral one in some studies. However, surgical time was similar (50.1 vs 51.5 minutes) in a study [5] or shorter slightly (72.2 ± 10.6 minutes vs 83.8 ± 7.2 minutes) in our study between thoracotomies as mentioned above.

Postoperative pain
The other advantage of the muscle-sparing thoracotomy is the reduction in postoperative pain, as determined by the visual analogue assessment and the narcotic requirement [3, 5, 6]. In some studies, the authors demonstrated no difference in postoperative narcotic requirements between both thoracotomies [4, 7]. According to Lemmer and associates, this may be because most thoracotomy pain is not due to the effects of muscle transection but rather to those of costal retraction [7].

Pulmonary function
Like our study, in different studies, the preoperative lung function as measured by FEV1 and FVC fell significantly when measured 1 week after the operation; no difference could be seen in these changes between both groups [3, 5]. Ponn and associates reported that the patients with muscle-sparing incisions showed significantly better late preservation of FVC and FEF25%–75%; however, the differences in lung function are small between both thoracotomy techniques [8]. Lemmer and associates reported that the use of muscle-sparing thoracotomy resulted in improved postoperative pulmonary reserve [7]. Whether preserving the seratus anterior, which reportedly does not contribute to respiratory function but stabilizes and rotates the scapula, enhances return of postoperative respiratory function is conjectural, but it does appear to facilitate earlier full arm and shoulder mobility [9].

Range of shoulder motion
Preservation of shoulder range of motion is significantly better when the muscle-sparing thoracotomy is performed than when the standard posterolateral approach is used [3, 5]. Whereas the range-of-motion returned to preoperative values of range by 2 weeks in mucle-sparing thoracotomy, they returned to normal by 1 month in the standard posterolateral thoracotomy in our study. These results have been noted at 1 week after the operation but have not been significant at the 1-month assessment in a previous study [5]. Lemmer and associates reported that they did not measure postoperative mobility of the upper extremity on the operated-on side; it was their impression that functional disability was less in the muscle-sparing technique [7]. According to Hennington and associates, preservation of the latissimus and serratus muscles allows range of motion and function of the arm to return more readily [10].

Muscle strength
Hazelrigg and associates reported that a discernible decrease in strength in the serratus anterior (p = 0.03) and latisimus dorsi (p = 0.05) muscles was noted at 1 week in the standard posterolateral thoracotomy, whereas preserving strength of these muscles in the muscle-sparing thoracotomy was similar to our study [5].

Postoperative complications
Complication frequency and nature were similar between thoracotomy techniques, except for subcutaneous seroma (2% to 23%) [4, 5, 8]. In our study, it only occured in the first 5 patients. After the subcutaneous air insufflation technique (no published) was used, and along the wound, the patient's chest was wrapped with an elastic bandage so that it would not impede his ventilation, we did not find any seroma. Soucy and associates reported that some cutaneous denervation may occur after the muscle-sparing thoracotomy in infants and children [6]. However, we did not found such a complication. Cherup and associates concluded that standard thoracotomies result in a high frequency of breast or pectoral maldevelopment; 60% of their patients had a greater than 20% difference in volume between the two sides [11]. Van Biezen and associates reported the high-risk period for the onset of scoliosis began about 3 years after thoracotomy for aortic coarctation [12].

We conclude that muscle-sparing thoracotomy incision provides adequate exposure for most pulmonary procedures together with the aesthetic aspects of preserving rather than severing the lateral thoracic musculature. It provides more rapid recovery of lung function and shoulder mobility, less severe postoperative pain, quicker closure, a better seal, and undivided muscles, and may be used subsequently for a flap. Its only real disadvantage aside from slightly less exposure is the development of seromas in some patients. It is a safe and effective approach that may benefit the patient in the early postoperative period. We believe that posterolateral thoracotomy should be reserved for major pulmonary procedures with anticipated thoracic wall resection, for intrathoracic vascular operations, for patients with acute trauma, for repeat thoracotomies, and for surgical procedures such as sleeve lobectomy. Otherwise, the muscle-sparing thoracotomy, which is a valuable addition to the armamentarium of the thoracic surgeon, is the incision of choice.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
The authors thank Dr Fevziye Çetinkaya, Eylem Ekinci, and Metin Tatli for their excellent technical assistance.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Durning R.P., Scoles P.V., Fox O.D. Scoliosis after thoracotomy in tracheoesophageal fistula patients. J Bone Joint Surg 1980;62:1156-1159.[Abstract/Free Full Text]
  2. Bethencourt D.M., Holmes E.C. Muscle-sparing posterolateral thoracotomy. Ann Thorac Surg 1988;45:337-339.[Abstract]
  3. Sugi K., Nawata S., Kaneda Y., Nawata K., Ueda K., Esato K. Disadvantages of muscle-sparing thoracotomy in patients with lung cancer. Worl J Surg 1996;20:551-555.
  4. Landreneau R.J., Pigula F., Luketich J.D., et al. Acute and chronic morbidity differences between muscle-sparing and standard thorocotomies. J Thorac Cardiovasc Surg 1996;112:1346-1351.[Abstract/Free Full Text]
  5. Hazelrigg S.R., Boley T.M., Schmaltz R.A., Johnson J.A., Curtis J.J. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991;101:394-401.[Abstract]
  6. Soucy P., Bass J., Evans M. The muscle-sparing thoracotomy in infants and children. J Pediatr Surg 1991;26:1323-1325.[Medline]
  7. Lemmer J.H., Gomez M.N., Symreng T., Ross A.F., Rossi N.P. Limited lateral thoracotomy: improved postoperative pulmonary function. Arch Surg 1990;125:873-877.[Abstract/Free Full Text]
  8. Ponn R.B., Ferneini A., D'Agostino R.S., Toole A.L., Stern H. Comparison of late pulmonary function after posterolateral and muscle-sparing thoracotomy. Ann Thorac Surg 1992;53:675-679.[Abstract]
  9. Heitmiller R.F. The serratus sling: a simplified serratus-sparing technique. Ann Thorac Surg 1989;48:867-868.[Abstract]
  10. Hennington M.H., Ulicny K.S., Jr, Detterbeck F.C. Vertical muscle-sparing thoracotomy. Ann Thorac Surg 1994;57:759-761.[Abstract]
  11. Cherup L.L., Siewers R.D., Futrell J.W. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
  12. Van Biezen F.C., Bakx P.A.G., De Villeneuve V.H., Hop W.C.J. Scoliosis in children after thoracotomy for aortic coarctation. J Bone Joint Surg 1993;75:514-518.[Abstract/Free Full Text]



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