Ann Thorac Surg 2009;87:329-330. doi:10.1016/j.athoracsur.2008.05.065
© 2009 The Society of Thoracic Surgeons
How To Do It
The Split Latissimus Dorsi Muscle Flap to Protect a Bronchial Stump at Risk of Bronchial Insufficiency
Alberto Terzi, MDa,*,
Luca Luzzi, MDa,
Andrea Campione, MDa,
Alberto Gorla, MDa,
Francesco Calabrò, MDb
a Thoracic Surgery Unit, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy
b Thoracic Surgery Unit, Azienda Ospedaliera-Universitaria Verona, Verona, Italy
Accepted for publication May 21, 2008.
* Address correspondence to Dr Terzi, Head Thoracic Surgery Unit, Azienda Ospedaliera S. Croce e Carle Cuneo, Via Coppino 26, Cuneo, 12100, Italy (Email: alterzi{at}libero.it).
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Abstract
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Consistent branching of the thoracodorsal vessels to the latissimus dorsi makes it possible to split the muscle into independent branched units. The use of the lateral split latissimus dorsi muscle flap to protect the bronchial stump in case of bronchus at risk of insufficiency is described.
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Introduction
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Protection of the bronchial stump after major lung resection is a very important step in the presence of systemic comorbidities, such as tuberculosis or immunosuppression; the risk of developing a bronchopleural fistula is higher in these cases or when there are local factors that can contribute to the development of bronchial stump insufficiency such as devascularization, "difficult bronchus," or irradiated bronchus.
Vascular supply to the latissimus dorsi (LD) muscle comes from the thoracodorsal vessels, which are the direct extension of the subscapular vessels. Once the thoracodorsal vessels enter the LD, they show a constant bifurcation into a horizontal branch and a branch that runs approximately 2.5 cm (range, 1 to 4 cm) medial and parallel to the lateral free margin of the muscle, along its deep aspect [1]. Therefore, conditions are ideal for the creation of a well-vascularized, split muscle flap with a wide rotation arc that can be placed into the chest cavity without creating tension; moreover, because it is not bulky, it can also easily pass through an intercostal space without rib resection. Due to the constancy of vascular anatomy, the flap is very easily and quickly created, provided that a muscle-sparing thoracotomy has been performed.
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Technique
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Access to the pleural space is obtained through a lateral muscle-sparing thoracotomy according to Mitchell and colleagues [2] or Bethencourt and Holmes [3].
At the end of the resection, the free margin of LD is inspected and the vascular pedicle, embedded in a small amount of fat, is identified. The LD is freed from subcutaneous tissue as far as required. The submuscular dissection begins at the anterior-lateral border of the muscle and proceeds caudally toward the iliac crest for the necessary length; then it is transected medially for few centimeters. The lateral portion of the muscle can then be split so that a long strip of muscle is harvested from the lateral branch of the thoracodorsal vessels. Dissection proceeds in a clockwise direction for the right LD and counter-clockwise for the left LD (Figs 1A–1C).
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Fig 1. (A) The dashed area of the schematic drawing shows the latissimus dorsi (LD) split with its lateral vasculature. (B) Schematic drawing shows clockwise preparation of the right lateral LD split. (C) The intraoperative view of the right LD muscle split, prepared and elevated.
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While raising the flap, the lateral branch of thoracodorsal vessels can be easily observed and directly controlled. Once the LD has been split, the muscle flap is rotated anteriorly and is passed through the second or third intercostal space between the digitations of serratus anterior, into the pleural cavity where it is secured by "U" stitches to the bronchial stump (Figs 2A and 2B). Resection of a small tract of rib is routinely performed in cases of pneumonectomy due to the reduction of intercostal spaces that always follows, but in case of lobectomy rib resection it is not routinely performed, and the decision to resect or not is taken on the basis of the width of the intercostal spaces. After closing the chest cavity, a subcutaneous suction drain is left.
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Fig 2. (A) Mucormycosis with erosion into the upper lobe bronchus requiring a lobectomy and a wide bronchial wedge resection. (B) Computed tomographic scan demonstrates the latissimus dorsi lateral split flap introduced into the pleural space to protect the bronchial suture and separate it from the vascular structure.
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Comment
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Bronchopleural fistula is a dreaded complication of lung resection that mainly occurs after pneumonectomy in the presence of systemic comorbidities or local factors that can contribute to the development of bronchial stump insufficiency. To protect the bronchial stump, autogenous tissue has been used to cover the bronchus, indications, techniques, and applications of flaps and grafts that are well described by Anderson and Miller [4]. The use of the latissimus dorsi muscle transposition flap is not new and it is well described; however, a split technique has been reported only for reconstructive surgery, mainly as a split myocutaneous flap [5]. Island vascular pedicle flaps that are transferred onto a singular vascular pedicle have been used to permit flap transfer through intercostal incisions for closure of intrathoracic defects and cavities in which intact muscle pedicles would restrict transfer because of excess bulk or insufficient length [6]. The muscle split technique used to raise a LD lateral flap to be transposed into the chest to protect a bronchial stump at risk of bronchial insufficiency is a good compromise between transfer of the whole muscle and transfer of island vascular flap; as far as we know, it has never been reported. The split technique, which is made possible by a constant proximal branching of the thoracodorsal vessels to the LD, means that the entire bulky muscle need not be used. The flap can be passed through the intercostal spaces without difficulty, and it is much easier and quicker to perform than the island vascular pedicle flap. It should be preferred to serratus major transposition in that the wing scapula problem is avoided. Moreover, this type of flap allows for the coverage of the bronchial stump and surrounding mediastinal tissue in case of pneumonectomy, and effectively separates bronchial and vascular structure in case of lobar resections, and offers a valid protection against bronchovascular fistula.
In conclusion, although a few methods to protect the bronchial stump after routine major lung resections have been reported [4], we suggest the use of this type of flap as an alternative to standard intra-thoracic transposition of extra-thoracic muscle flaps to protect the bronchial stump at risk of bronchial insufficiency because it combines several advantages: (1) it is very well vascularized; (2) it is bulky enough to protect the bronchus and separate it from vessels, but not too bulky; (3) it is easy to raise and transfer into the chest cavity; (4) it leaves most of the latissimus dorsi intact.
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References
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- Tobin GR, Schusterman M, Peterson GH, Nichols G, Bland KI. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap Plast Reconstr Surg 1981;67:637-641.[Medline]
- Mitchell R, Angell W, Wuerflein R, Dor V. Simplified lateral chest incision for most thoracotomies other than sternotomy Ann Thorac Surg 1976;22:284-286.[Abstract/Free Full Text]
- Bethencourt DM, Holmes EC. Muscle-sparing posterolateral thoracotomy Ann Thorac Surg 1988;45:337-339.[Abstract/Free Full Text]
- Anderson TM, Miller JI. Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery Ann Thorac Surg 1995;60:729-733.[Abstract/Free Full Text]
- Tobin GR, Moberg AW, DuBou RH, Weiner LJ, Bland KI. The split latissimus dorsi myocutaneous flap Ann Plast Surg 1981;7:272-280.[Medline]
- Tobin GR, Mavroudis C, Howe WR, Gray LA. Reconstruction of complex thoracic defects with myocutaneous and muscle flaps J Thorac Cardiovasc Surg 1983;85:219-228.[Abstract]
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Abstract
Introduction
