Ann Thorac Surg 2004;78:e74-e76
© 2004 The Society of Thoracic Surgeons
How to do it
Pleural Partition With Intrathoracic Muscle Transposition (Muscle Tent) To Manage Residual Spaces After Subtotal Pulmonary Resections
Gaetano Rocco, MD, FRCS (Ed), FECTSa,*
a Department of Cardiothoracic Surgery, The Price-Thomas Unit, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, United Kingdom
Accepted for publication April 5, 2004.
* Address reprint requests to Dr Rocco, Department of Cardiothoracic Surgery, The Price-Thomas Unit, Northern General Hospital, Sheffield Teaching Hospitals, Herries Rd, Sheffield S5 7AU, UK
gaetano.rocco{at}btopenworld.com
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Abstract
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The concept of separating the pleural cavity to better control residual spaces has been revisited by introducing a technique of pleural partition through transposed chest wall muscles (muscle tent). This technique has been successfully used in 3 patients with severe lung destruction due to chronic infections who required subtotal pulmonary resections.
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Introduction
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Residual spaces after subtotal pulmonary resection still pose a challenge to thoracic surgeons. Although not all residual spaces deserve surgical attention, their management in special situations (ie, chronic infections, neoadjuvant chemoradiotherapy) requires a multifaceted approach. Intraoperatively, the most popular methods of reducing air spaces are pleural tent, intrathoracic transposition of muscle flaps, and pneumoperitoneum [1–3].
The concept of the partition of pleural cavity was first introduced by Brewer [4, 5] who investigated the possibility of reducing spaces after lobectomy by subdividing the pleural space into two overlying compartments by suturing a graft of fascia lata to the chest wall and the mediastinum onto of the residual lung. A modification of this technique has been recently used to reduce air spaces after pulmonary resection for chronic and destructive pulmonary infections.
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Technique
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In all instances, the pulmonary resection is performed through an extrapleural route.
The serratus anterior and the latissimus dorsi muscles—entirely or based on the proximal thoracodorsal vascular supply—can be harvested, alone or in combination, at the same time of the pulmonary resection or during a separate operation according to a standard technique [6]. A short segment (usually up to 5 cm) of the second or third rib is removed laterally, and the muscle flaps are transposed into the chest cavity, taking full advantage of their arc of rotation (Fig 1, A) [7]. The muscles are sutured to the residual pleura or, alternatively, to the periosteum or intercostal muscles so as to lie on the lung (Fig 1, B). Care is taken at drawing the muscles not too tightly to avoid rupture with coughing. In some circumstances, when the potential for some degree of lung reexpansion is anticipated, the muscle can be only partially sutured to the chest wall to create a "drawbridge" effect. At the end of the procedure, only the lowermost chamber of the chest cavity and the donor site are routinely drained (Fig 1, C).
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Fig 1. Diagrams representing (A) harvesting, (B) transposition, and (C) placement of the chest wall muscles to create a pleural partition (muscle tent).
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The technique was first used in a 39-year-old woman with active tuberculosis in a bronchiectatic right upper lobe who was referred for surgical consideration after a 6-month course of antitubercular drugs. A week after her right upper lobectomy, the residual lung had not shown any sign of reexpansion while the patient was persistently dyspneic and hypoxic (Fig 2, a). A decision was made to reoperate by creating a muscular pleural partition by harvesting the proximal latissimus dorsi and the serratus anterior and transposing them into the chest (Fig 2, b). The chest drains were removed on day 5, and the patient was discharged home 7 days after the second operation. Follow-up imaging denoted stabilization of the apical pleural cavity and some reexpansion of the residual lung (Fig 2, c–e). A mild postthoracotomy pain was the only complaint at 7 months from surgery in the absence of signs of tubercular reactivation.
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Fig 2. Postoperative radiographs and computed tomography scans demonstrating the evolution of the apical space (patient 1). (a) Seven days postoperatively; (b) immediately after reoperation and pleural partition; (c) at 1 month after partition; (d) 3-month follow-up radiogram; and (e) chest computed tomograms showing the organizing apical pleural space.
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In the second case, a 53-year-old woman with history of recurrent destructive infectious episodes of the right upper and middle lobe superimposed on bronchiectatic changes was offered surgery. The latissimus dorsi and the serratus anterior were harvested at the time of thoracotomy and a right upper bilobectomy performed. The muscles were transposed into the chest and tacked to the mediastinal pleural and the chest wall. The chest drains were removed on day 6, and the patient was discharged on day 7 after an uneventful postoperative course. At 1 month from surgery, the apical space was noted to be obliterated on routine radiograms.
The third case was a 66-year-old man with severe emphysema who was referred for a giant bulla in the right upper lobe complicated by recurrent infections and several additional bullae in the remaining lobes. At operation, the latissimus dorsi and the serratus anterior were harvested before entering the chest (Fig 3, left). After completion of the bullectomy through an extrapleural route, the muscles were transposed into the chest to create a muscle tent (Fig 3, right). The chest drains were removed on day 7. The patient was discharged on day 9 and made an uneventful recovery with stabilization of the apical space 1 month after surgery.
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Fig 3. Operative illustrations showing the harvesting of the serratus anterior and the latissimus dorsi muscles (left) and the subsequent creation of the muscle tent (right).
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Comment
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The decision to resect the involved parenchyma in patients with chronic, destructive pulmonary infections has to be made during a window of relative quiescence of the disease [8]. Intraoperatively, the surgeon usually elects to mobilize the lung through an extrapleural route to avoid entering the infected cavitated or bullous lesions in the upper lobes. A common feature after lobectomy or bilobectomy for destroyed lung is the lack of compliance of the residual lobes due to extensive fibrosis and initial bronchiectatic changes scattered throughout the parenchyma. A persistent apical air space is the rule and exposes the patient to the risk of pleural contamination and respiratory failure.
In severely debilitated patients, the absence of muscle bulk to fill the residual cavity and of viable parietal pleura after the extrapleural pneumonolysis is frequently noted. In addition, the overall clinical condition and underlying pulmonary disease may contraindicate the use of omentum and even pneumoperitoneum to avoid communication between the potentially infected pleural cavity and the abdomen. On the other hand, phrenic nerve crush may fail to shrink the pleural cavity, whereas thoracoplasty is considered the last resort owing to its cosmetic pitfalls.
In the original description of the procedure [4, 5], the assumption was that the isolated apical compartment would be managed as a postpneumonectomy space that would in time become organized (as in our first patient).
Alternatively, Brewer himself recognized the possibility of a gradual reexpansion of the lung in a way to displace the partition cranially (patients 2 and 3). In the latter circumstance, the transposed muscle would function as a sort of "muscle tent" with a greater blood supply than the parietal pleura to convey antibiotics and oxygen to the apical chest compartment. The intrathoracic muscle tent would also protect areas of the residual lung at risk for potential contamination of the pleural space from microscopic alveolar leaks resulting from suture lines or decorticated segments.
The drawbacks of this technique reside in the limited prolongation of operative times, the pain caused by the additional thoracotomy, and the potential infectious complications at the muscle donor sites.
The benefits are identified in the reduction of the significant postoperative morbidity routinely observed in these patients and in the shortening of hospital stay compared with the literature [8], which, per se, seem to justify the resort to this procedure for this selected group of patients.
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Acknowledgments
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The contributions of Heather Allen and Robert Salthouse from Medical Illustration are gratefully acknowledged.
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References
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- Robinson LA, Preksto D. Pleural tenting during upper lobectomy decreases the chest tube time and total hospitalization days. J Thorac Cardiovasc Surg. 1998;115:319–326[Abstract/Free Full Text]
- Widmer MK, Krueger T, Lardinois D, Banic A, Ris HB. A comparative evaluation of intrathoracic latissimus dorsi and serratus anterior muscle transposition. Eur J Cardiothorac Surg. 2000;18:435–439[Abstract/Free Full Text]
- De Giacomo T, Rendina EA, Venuta F, et al. Pneumoperitoneum for the management of pleural space problems associated with major pulmonary resections. Ann Thorac Surg. 2001;72:1716–1719[Abstract/Free Full Text]
- Brewer LA, Bai AF, Jones WMG. The development of pleural partition to prevent overexpansion of the lung following partial pulmonary resection. J Thorac Surg. 1956;31:165–187
- Brewer LA. Pleural partition procedure. Bull Soc Int Chir. 1958;17:305–309[Medline]
- Harris SU, Nahai F. Intrathoracic muscle transposition. Chest Surg Clin North Am. 1996;6:501–518[Medline]
- Deschamps C, Pairolero PC, Allen MS, Trastek VF. Management of postpneumonectomy empyema and bronchopleural fistula. Chest Surg Clin North Am. 1996;6:519–527[Medline]
- Furak J, Trojan I, Szoke T, et al. Surgical intervention for pulmonary tuberculosis: analysis of indications and perioperative data relating to diagnostic and therapeutic resections. Eur J Cardiothorac Surg. 2001;20:722–727[Abstract/Free Full Text]
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