Ann Thorac Surg 2009;88:685-687. doi:10.1016/j.athoracsur.2008.11.068
© 2009 The Society of Thoracic Surgeons
How To Do It
Modified French Window as an Alternative to Thoracotomy for Complex Intrathoracic Pathology
M. Blair Marshall, MD*,
Yvonne M. Carter, MD
Division of Thoracic Surgery, Department of Surgery, Georgetown University Medical Center, Washington, DC
Accepted for publication November 26, 2008.
* Address correspondence to Dr Marshall, Division of Thoracic Surgery, Department of Surgery, 4 PHC, Georgetown University Medical Center, 3800 Reservoir Rd, NW, Washington, DC 20007 (Email: mbm5{at}gunet.georgetown.edu).
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Abstract
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Video-assisted thoracic surgery is associated with less pain and shorter recovery than open procedures. Due to limited exposure, video-assisted thoracic surgery is not suitable for the management of all intrathoracic pathology. Muscle-sparing thoracotomies are smaller, but they are not associated with less pain or faster recovery. A modified French window is a useful approach to complex intrathoracic pathology and may result in less postoperative pain and shorter recovery than standard and muscle-sparring thoracotomies. This technique is suitable for the management of complex intrathoracic disease.
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Introduction
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It has been our impression that lobectomy patients who undergo chest wall resection experience less postoperative pain than those who undergo a rib-spreading thoracotomy, in particular, those patients in whom the lobectomy is performed through the anatomic defect created by first dividing the chest wall. Given this, it is possible that postoperative pain from the division of ribs is less than that associated with rib spreading. Thus, we began using a modified French window as an alternative to thoracotomy for complex intrathoracic pathology (Fig 1). This technique allows for greater direct exposure than video-assisted thoracic surgery, but without rib spreading, stress on the costal articulations, or pressure on the intercostal bundle during surgery. The French window thoracotomy was initially reported in the Japanese literature in 2006; however, we independently began using a modified version of this technique 2 years ago [1]. International Review Board approval was obtained to review these cases.
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Technique
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We used a 4-cm to 5-cm skin incision, either that from conversion of the video-assisted thoracic surgical procedure or a vertical axillary incision. Once the skin and fascia were divided, the muscles were retracted and the underlying rib at the inferior aspect of the incision was cleared. The neurovascular bundle was freed at both the anterior and posterior locations along the same rib. We usually separated the two areas of dissection along the rib by approximately 7 cm (Fig 2A). An osteotomy with resection of approximately 1 cm of rib from each site was performed. This usually required a Kerrison (Aesculap Surgical Instruments, Center Valley, PA) or similar ronguer because of the limitations of the small skin incision. The intercostal insertion on the superior aspect of the divided rib was freed and the "rib flap" hung into the chest. This flap could be held out of the line of vision with a self-retaining retractor, but the bulk from the flap obscures the view. The exposure was optimized by tacking the rib inside the chest. A 0-silk suture was passed around the divided rib segment. An angiocatheter was inserted through the skin into the chest approximately three intercostal spaces below the level of the incision. A crimped polypropylene suture was passed through the angiocatheter and was used to loop the ends of the silk suture (Fig 2B), pulled through the angiocatheter, and clamped on tension at the skin surface, tacking the rib inside the chest wall (Fig 2C). We commonly used this technique to move intrathoracic structures out of the way and improve exposure when using small incisions, as when working on recurrent paraesophageal hernias or distal esophageal perforations.
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Fig 2. (A) Bovine chest wall demonstrating the osteomuscular flap with a suture around the flap to tack it inside the chest. (B) Looped polypropylene suture used to pull silk stay through the chest wall. (C) Window created as a result of tacking the flap.
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At this point, there was a "window" created that allows for the performance of many complex thoracic procedures (Table 1). Once the procedure was complete, the silk stay suture was released and a No. 1 Vicryl suture (Ethicon Inc, Somerville, NJ) was used to tack the free rib segment to the rib above. One must be careful to make sure that the rib edges are not in contact.
Our technique differs from the originally described French Window in that we have found it necessary to only cut one rib and optimize exposure by tacking the osteomuscular flap inside the chest rather than to creating two osteomuscular flaps and open the "window panes" into the wound. Also, due to the anatomic configuration of the intercostal bundle, maximal benefit is derived from division of one rib. Last, we have not found it necessary to suture the ribs together at the osteotomy site.
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Comment
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During the last decade, thoracic surgeons have begun to adopt less invasive approaches to thoracic disease. Video lobectomy is associated with quicker recovery but smaller incisions, such as an axillary thoracotomy are not [2, 3]. Although the incisions for these approaches are often the same size, it seems that rib spreading is a significant detriment to quick recovery.
For the past 2 years, we have used this technique for exposure in 28 patients undergoing thoracic procedures. Indications for extension of video-assisted thoracic surgery included in this patient population are seen in Table 1. Four patients in the lobectomy group were converted from video-assisted thoracic surgery, two with unanticipated fused pleural spaces and two with central nodal disease not evident on preoperative imaging. The remainder of patients included in the table was approached primarily using the modified French window technique as an alternative to thoracotomy. In these cases, a video thoracoscope is placed through the future chest tube site so that residents and students can follow the procedure. As our experience grew, especially in those patients who underwent conversion from a pure video-assisted thoracoscopic surgical approach, no epidurals were placed nor was there one needed for postoperative pain control. Currently, all patients receive intrathoracic intercostal blocks with a long-acting local anesthetic agent.
As more and more procedures are being performed under the video-assisted technique, and as the surgeon's experience grows, the complexity of what is able to be performed under thoracoscopic guidance increases. It is also recognized that such traditional wide exposure is unnecessary. We have found that the lack of rib spreading seems to result in less postoperative pain and earlier return of function, although this will need to be determined with a prospective study. In the interim, we have found this technique to be a useful addition to the armamentarium for exposure in thoracic surgery.
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References
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- Yamaguchi A, Hashimoto O, Tamaki S. French window thoracotomy: postoperative pain avoidance for short-stay lung cancer surgery Jpn J Thorac Cardiovasc Surg 2006;54:520-527.[Medline]
- Nicastri DG, Wisnivesky JP, Litle VR, et al. Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance J Thorac Cardiovasc Surg 2008;135:642-647.[Abstract/Free Full Text]
- Ochroch EA, Gottschalk A, Augoustides JG, Aukburg SJ, Kaiser LR, Shrager JB. Pain and physical function are similar following axillary, muscle-sparing vs posterolateral thoracotomy Chest 2005;128:2664-2670.[Abstract/Free Full Text]
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Abstract
Introduction
