The philosophy of a nerve-sparing thoracotomy closure

Abstract

We read with interest Bayram and colleagues’ recent article [1] on the randomized trial evaluating a modified thoracotomy closure technique to reduce compression of the intercostal nerve and thereby reduce post-thoracotomy pain. The authors’ report a statistically significant reduction in postoperative pain using this technique. The described procedure is a modification of a technique proposed by Cerfolio and colleagues [2, 3], who harvest the intercostal muscle flap at the beginning of surgery, retract the flap outside the thoracotomy field using a soft Penrose drain, and, at closure, drill holes in the lower rib to avoid compressing the nerve. This approach is theoretically a more attractive concept as it avoids nerve entrapment both by the chest retractor during surgery and the pericostal sutures after closure. Bayram’s technique, on the other hand, does not avoid nerve compression intraoperatively by the chest retractor, and nerve compression at this stage could still cause postoperative neuropathic pain. We have seen Cerfolio’s group perform their procedure with impressive results and are halfway through a randomized trial to evaluate the technique in our unit. Similar to Cerfolio’s group, we retract the harvested flap with a soft drain and this gives unrestricted intrathoracic access.