Ann Thorac Surg 2008;85:678-680. doi:10.1016/j.athoracsur.2007.07.049
© 2008 The Society of Thoracic Surgeons
How To Do It
Resection of Apical Lung Tumors in High-Risk Patients Using Partial Sternotomy
Richard F. Heitmiller, MD*,
Jason M. Radecke, MD,
Christopher J. You, MD
Department of Surgery, Union Memorial Hospital, Baltimore, Maryland
Accepted for publication July 18, 2007.
* Address correspondence to Dr Heitmiller, 3333 N Calvert St, Johnston Professional Building, Ste 610, Baltimore, MD 21218 (Email: richard.heitmiller{at}medstar.net).
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Abstract
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Surgical management of patients with compromised lung function remains a challenge. We describe a technique that uses a partial sternotomy to manage high-risk patients with clinical stage 1 apical lung tumors. In our experience with four patients we found this method to be effective, quick, safe, and with good short term outcome.
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Introduction
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Surgical management of lung patients with severely compromised lung function remains a challenge. We describe our experience using partial sternotomy to selectively treat high-risk patients with clinical stage 1 apical lung tumors.
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Technique
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Patients are positioned supine and general endotracheal anesthesia is used. Double-lumen endotracheal intubation may be selected; however, it is not mandatory. The ipsilateral arm is positioned out on an armboard to expose the chest for potential counter incisions or chest drains. The other arm is tucked at the patient’s side.
A vertical midline incision is used from the level of the sternal notch to the third intercostal space. The upper sternum is exposed anteriorly and posteriorly. With the use of a Lebsche knife or an oscillating saw, the upper sternum is divided in the midline to the third interspace and then angled into the ipsilateral intercostal space, protecting the internal mammary vessels.
A patient with a right apical lung tumor is shown in Figure 1, illustrating the proximity of the sternal incision to the pathology. The midline sternotomy incision is T-d to the ipsilateral side as shown by the dashed line (right side) or the dashed and dotted line (left). The result of this sternal incision is to create a free segment of upper sternum that can be mobilized toward the side of the tumor. A pediatric sternal or minithoracotomy retractor is used for sternal retraction (Fig 2). As the sternal retractor is opened, it is angled upwards on the operative side as shown in Figure 3. This lifts the free segment of sternum upwards.
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Fig 1. Apical lung tumors are readily accessible through a partial sternotomy as shown. Sternotomy incisions are extended to the right (solid dash) or left (dotted line) depending on tumor side.
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Fig 2. A pediatric sternal or minithoracotomy retractor distracts the operative-side sternal fragment away from the main sternum.
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Fig 3. As the retractor is opened, it is tilted upward toward the operative side, as shown in the upper inset.
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The ipsilateral pleura is exposed and opened widely. The apical lung tumor is removed in a wedge fashion (Fig 4) using an Endopath GIA stapler (Ethicon Endo-Surgery, Cincinnati, OH). When needed, an additional chest trocar incision may be added for stapler insertion to complete the wedge resection. If so, the trocar site is used for chest tube drainage. Hilar and mediastinal lymph nodes are accessible for sampling.
After chest tube drainage, two sternal wires are used to reapproximate the sternum, and the soft tissue is closed in layers. No separate mediastinal drainage is needed.
Postoperative care is similar to post-thoracotomy routine.
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Comment
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Surgical management of patients with compromised lung function remains a challenge because of the markedly increased risk for postoperative complications, including respiratory failure, pneumonia, persistent air leaks, and problems with wound healing. Attempts to improve results in these high-risk patients have included regional anesthesia methods, muscle-sparing incision techniques, median sternotomy, and video-assisted thoracoscopy.
In this article we describe an additional technique that we have found useful in the select population of high-risk patients with clinical stage 1 apical lung tumors in whom limited lung resections are anticipated. This technique uses a partial sternotomy incision with apical lung wedge resection. We believe there are many advantages to this approach. Patients remain in the supine position throughout the case. Double-lumen endotracheal intubation may be selected; however, the procedure can be done with single-lumen tube ventilation as well.
Historically, median sternotomy has been thought to have the least impact on postoperative lung function of all standard open chest incisions [1]. Median sternotomy is used in lung-volume reduction surgery in patients with severely compromised lung function [2, 3]. Theoretically, partial sternotomy should have even less of an impact on lung function. We believe that our initial experience with this technique supports this hypothesis.
All 4 of our patients (Table 1) were older, had very compromised pulmonary function, and clinical stage 1 apical non-small cell tumors. Operative time averaged less than 1 hour (57 minutes). Single- and double-lumen endotracheal tubes were used in 2 patients each, respectively. All patients were extubated in the operating room and none were reintubated during the hospital stay. Intensive care unit stays were short, and the average hospital length of stay was 6 days. All chest tubes were removed before discharge. One patient, who needed oxygen before surgery, (Table 1, patient 1) was discharged home on oxygen. There were no early readmissions after discharge.
Partial sternotomy with wedge resection is a reasonable option to manage apical lung cancer patients with compromised pulmonary function. It is quick and the incision appears to have minimal impact on breathing capacity.
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References
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- Urschel HC, Razzuk MA. Median sternotomy as a standard approach for pulmonary resection Ann Thorac Surg 1986;41:130-134.[Abstract]
- Lederer DJ, Thomashow BM, Ginsburg ME, et al. Lung-volume reduction surgery for pulmonary emphysema: improvement in body mass index, airflow obstruction, dyspnea, and exercise capacity index after 1 year J Thorac Cardiovasc Surg 2007;133:1434-1438.[Abstract/Free Full Text]
- Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema N Engl J Med 2003;348:2059-2073.[Abstract/Free Full Text]
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Abstract
Introduction
