Muscle-sparing Lateral Thoracotomy Research Articles

Malignant solitary fibrous tumor of the pleura

BackgroundSolitary fibrous tumors of the pleura are rare diseases of the thoracic cavity. They frequently grow unnoticed until they exert compressive effects on adjacent organs. Treatment of solitary fibrous tumors of the pleura is surgical resection. Post-operative surveillance is recommended to identify early recurrent disease.Case presentationWe present a rare case of a 76-year-old female patient with no previous pulmonary history who presented with progressive dyspnea, fatigue, and involuntary weight loss. On chest X-ray and computed chest tomography scan, she was found to have a 16.7 cm × 12.8 cm × 10.1 cm bulky mass occupying the left hemithorax with associated compressive atelectasis of the lung. She underwent a computed tomography guided biopsy that revealed the mass to be a solitary fibrous tumor. The patient underwent left muscle sparing lateral thoracotomy with complete resection of the tumor. Post procedure, the left lung fully expanded. 18 months post-resection, she developed a 3.3 cm × 1.7 cm tumor along the left internal thoracic artery lymph node chain which was histologically identical to the resected tumor. The patient is currently being treated with bevacizumab and temozolomide.ConclusionSolitary fibrous tumors are very rare pleural tumors. Surgical resection is the treatment of choice followed by close post-operative surveillance.

Influence of muscle-sparing lateral thoracotomy on postoperative pain and lameness: A randomized clinical trial.

To assess and compare the magnitude of lameness and level of pain after muscle-sparing lateral thoracotomy (MSLT) and standard lateral thoracotomy (SLT) in dogs. Randomized, blinded, prospective clinical study. Twenty-eight client-owned dogs. The latissimus dorsi muscle was retracted in the MSLT group and was transected in the SLT group. Gait was analyzed with a force plate, and the peak vertical force symmetry index (SI) was calculated within 24 hours before surgery, 3 days postoperatively, and 8 to 12 weeks postoperatively. Symmetry index and pain scores as measured by the Glasgow Composite Measure Pain Scale - Short Form were assessed as primary outcome measures. The SI 3 days postoperatively was lower compared with the preoperative SI value in all dogs, consistent with lameness of the ipsilateral thoracic limb (P < .001). The absolute differences in preoperative and 3-day-postoperative SI provided evidence that this change was 3.1-fold greater after SLT compared with after MSLT (P=.009). Pain scores 1 day after surgery were lower after MSLT (1) compared with after SLT (2.5, P < .001). Lateral thoracotomies caused postoperative pain and ipsilateral forelimb lameness, and both were reduced by sparing the latissimus dorsi. Sparing the latissimus dorsi should be considered to decrease immediate postoperative morbidity in dogs undergoing lateral thoracotomy.

Surgical treatment of pulmonary sequestration in adults and children: long-term results.

Few experiences comparing paediatric and adult patients treated for pulmonary sequestration (PS) have been reported. Surgical treatment is considered the best choice, but the time of surgery is still controversial. We present our experience in this setting, comparing characteristics, histological results and outcome of paediatric and adult patients undergoing PS resection. Between 1998 and 2017, a total of 74 patients underwent lobectomy or sublobar resection for PS. Sixty patients were children (group A: ≤16 years old) and 14 were adults (group B: >16 years old). Preoperative diagnosis was radiological. PS was intralobar (42 cases) and extralobar (32 cases). The operation was a muscle-sparing lateral thoracotomy or video-assisted thoracoscopic surgery. Preoperative characteristics, histological results and short-/long-term results of the 2 groups were retrospectively analysed and compared. Thirty-seven percent of the patients in group A presented with respiratory symptoms and 79% in group B (P = 0.44). Most symptomatic patients were treated with a lobectomy. In group A, 2 patients (3%) had a malignant transformation of the lesion. Patients with a prenatal diagnosis treated after the age of 1 year became more symptomatic than those operated on before the age of 1 year (57% vs 23%; P = 0.08). No differences were found in postoperative complications. Long-term stable remission of respiratory symptoms was obtained in 91% of patients in group A and 100% in group B. Adulthood (P = 0.03) and the association with congenital cystic adenomatoid malformation (P = 0.03) were negative prognostic factors for the development of respiratory symptoms. Surgical treatment of PS is safe and feasible. Despite the small number of patients included, study results indicated that an early operation during childhood may prevent the subsequent development of respiratory symptoms. Surgical treatment is also recommended to prevent the rare transformation into malignancy.

Single centre experience in video-assisted thoracoscopic surgery resection of pleural schwannoma

Background: Intrathoracic neurogenic tumor account between 12% and 21% of all mediastinal masses and represent for 75% of posterior mediastinal tumors and the elective treatment of these tumors is surgical excision, also if the outcome after minimally invasive excision has not well described yet. Aim of this study is to analyze the outcome of surgically treated patients especially regarding the use of minimally-invasive techniques. Methods: We conducted a retrospective study on 28 patients surgically treated for posterior mediastinal tumors during the period from 1/1/2007 to 31/12/2918. Data regarding the surgical technique, intra-operative findings and post-operative outcome were collected and retrospectively considered. Results: Muscle sparing lateral thoracotomy was performed in 8 patients while 20 patients underwent minimally invasive surgery: 11 were subjected to three-port video-assisted thoracoscopic surgery (VATS); 1 to two-port VATS; 5 to uniportal VATS and 3 to robotic excision. Histology proved the masses to be benign neurogenic tumors in all cases. Complete surgical excision was achieved in 26 patients, in the other two there were no recurrences of disease during follow up. Conclusions: VATS is a reliable approach with better post-operative results than traditional surgery in the treatment of neuronal tumors. The thoracotomy approach to these tumors should be reserved for large tumors or those with an involvement of the vertebral canal.

Approaches to the thoracic cavities

In the past, posterolateral thoracotomy was utilized as the usual incision for pediatric patients. Nevertheless, in children, most thoracotomic operations could be performed through a muscle sparing lateral thoracotomy. The video-assisted thoracic surgery (VATS) is progressively more used since most procedures can be tailored to VATS. On the contrary, median sternotomy has a partial role and consent the access to both lungs and mediastinal structures.

Muscle sparing lateral thoracotomy: the standard incision for thoracic procedures

Lateral thoracotomy is a versatile approach with many variations and is currently the most widely used incision in thoracic surgery. In the current article we are presenting the muscle-sparing lateral thoracotomy in the lateral decubitus position which we consider to be the “standard” for lateral thoracotomies. Indications, surgical technique and pitfalls are described alongside our experience with thoracic drainage. Although there is no consensus regarding the name of this incision, some authors call it “axillary thoracotomy” while others call it a “modified lateral thoracotomy”, they all agree on one aspect – the importance of muscle sparing – which makes it the go-to thoracotomy for both small and large procedures involving the lung. Lateral muscle sparing thoracotomy allows for good exposure of the pulmonary hilum, fissures, apex and diaphragm. The approach is easy and quick to perform while at the same time ensuring faster postoperative recovery by sparing the latissimus dorsi muscle, better cosmetics and lower postoperative pain score when compared to the posterolateral or classical lateral thoracotomies.

Popcorn in the Lung

®65-year-old man was admitted for breathlessness and dry cough of 3-month duration. He denied any history of cigarette smoking and asbestos exposure. The patient’s physical examination revealed reduced breath sounds over middleupper right hemithorax. The patient’s laboratory data and vital signs were normal. A posteroanterior chest radiograph showed a large and well circumscribed pulmonary mass on the right side (Fig. 1). Computed tomography scan confirmed a large, solitary, well delimited, round, inhomogeneous, mass of 12 × 8 × 15 mm in size in the right upper lobe, with calcifications of a linear, nodular, irregular shape (Fig. 2). There was no mediastinal or hilar lymphadenopathy. The radiological findings were highly suggestive of a giant pulmonary chondroid hamartoma. Through a muscle sparing lateral thoracotomy, a right upper lobectomy was performed. Histologic examination yielded a well circumscribed hamartoma with predominantly benign chondroid differentiation. The patient was discharged 5 days after surgery. Pulmonary hamartomas are the most common form of benign lung tumors, derived from the peribronchial mesenchyma. The prevalence varies from 0.025% to 0.32% according to different necropsy studies. They are more common in males with a peak incidence in the sixth or seventh decade of life. Pulmonary hamartomas can be divided into parenchymal (90%) and endobronchial (10%) and can be chondromatous or leiomyomatous or a combination thereof. 1 The parenchymal lesions are usually an incidental radiological finding of a round opacity in the periphery of the lung. The presence of calcifications typically dispersed in the form of multiple clumps throughout the lesion in a popcorn configuration can be found in 10–15% of pulmonary hamartomas on chest radiographs. 2 Pulmonary chondroid hamartomas measuring over 10 cm are very rare. 1 Lobectomy is the operation of choice when a giant tumor causes complete replacement of the lobe as in our case.

Efficacy of anterior fissureless technique for right upper lobectomies: a case-matched analysis

In pulmonary lobectomy, the dissection through the fissure to gain access to the pulmonary artery may increase the risk of postoperative air leak. For several anatomic reasons, this risk is especially high after right upper lobectomies (RULs). The objective of this investigation was to verify the efficacy of an anterior fissureless lobectomy (FL) technique in reducing the incidence and duration of air leak after RUL. An observational analysis was performed of 206 consecutive patients (2002-2009) submitted to RUL for non-small-cell lung cancer. Operations were performed through a muscle-sparing lateral thoracotomy. Patients with completely developed fissures were excluded. No sealants or buttressing material were used. For group TR (traditional resection, 146 patients), RUL was performed by traditional intra-fissure dissection of the pulmonary artery; for group FL (60 patients), RUL was carried out by fissureless division of all hilar vascular structures. Several perioperative variables were used in identifying propensity score-matched pairs of patients undergoing traditional and fissureless lobectomies. The matched groups were then compared in terms of incidence of prolonged air leak, air leak duration, operation time, chest tubes duration, hospital stay and costs. Propensity score analysis yielded 58 well-matched pairs of patients operated by traditional or fissureless RUL. Compared to those in the traditional group, patients in group FL had a mean reduction in air leak duration, duration of chest tube and postoperative stay of 1.1, 1.4 and 1.2 days, respectively. This translated into an average hospital cost saving of 569 € per patient. The use of an anterior fissureless technique during RUL reduced the duration of air leak and hospital costs without increasing the surgical time. Given its simplicity and efficacy, we regard it as a useful tool for implementing fast-tracking policies and cutting hospital costs.

Safe Treatment of Post Thoracotomy Seroma

Postoperative seroma is a common complication after muscle-sparing lateral thoracotomy. The main cause is considered to be the result of subcutaneous flap mobilization. We present a case of seroma which occurred following a pneumonectomy owing to subcutaneous flooding with pleural fluid, which was successfully treated by subclavian catheter insertion. The technical aspect of the procedure is described.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …

A new technique for prosthetic reconstruction of the superior vena cava

CASTLE seem to have a better prognosis. However, CASTLE has a potentially invasive behavior, and invasion of neighboring cervical structures is possible. In particular, tracheal or laryngotracheal resections have been necessary to excise the lesion. The extent of this invasion may sometimes prevent a complete resection or require surgically challenging procedures, as in our experience. The parietal invasion can involve the muscles, connective tissue, and skin. Nodal involvement is probably a negative prognostic factor, because it has been associated with the occurrence of locoregional or systemic spread. Adjuvant radiotherapy is generally advocated in case of nodal metastasis. On the other hand, local recurrence is possible in the absence of nodal disease, thus suggesting a role for systematic adjuvant radiotherapy because of the radiosensitivity of this tumor.

Combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer

Background. Combined superior vena cava and tracheal sleeve resections are occasionally indicated in the treatment of non–small cell lung cancer. However, more effective induction therapy may potentially expand the benefit of locally extended resections. Methods. From January 1998 to December 1999, 6 consecutive patients had combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer after induction treatment. Surgical approach was muscle-sparing lateral thoracotomy in 4 patients and hemiclamshell approach in 2 patients. There were four tracheal sleeve pneumonectomies, one tracheal sleeve bilobectomy, and one tracheal sleeve lobectomy. Three patients (50%) had complete superior vena cava resection with graft replacement, whereas the other patients had partial superior vena cava resection using vascular staplers. Results. There were no perioperative complications. Three patients (50%) had major postoperative complications, but there were no postoperative deaths. Four patients are still alive, 2 without evidence of disease. The median survival was 14.5 months (range, 3 to 17 months). Conclusions. These combined resections are technically feasible with no postoperative mortality but high morbidity (50%). This aggressive surgery may be useful in highly selected patients where adequate local control can achieve long-term survival.

Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule

The solitary pulmonary nodule often presents a diagnostic challenge to the specialist because the nature of the nodule is often indeterminate at the end of the usual diagnostic process, and operation frequently is required before a definite diagnosis can be made. We have conducted a randomized, prospective trial to evaluate the diagnostic efficacy of video-assisted thoracic surgery versus muscle-sparing lateral thoracotomy. Between January 1991 and May 1994, 44 patients suffering from solitary pulmonary nodule were divided at random into two groups: the nodule was removed in 22 cases by video-assisted thoracic surgery and in 22 cases by lateral thoracotomy. Nineteen wedge resections, 1 segmentectomy, and 2 lobectomies were performed in the first group and 13 wedge resections, 8 segmentectomies, and 1 lobectomy in the second group. An "access" thoracotomy had to be performed in 5 patients in the video-assisted thoracic surgery group. The operating room time was 97.2 +/- 32.9 minutes in the video-assisted thoracic surgery group and 130.5 +/- 14 minutes in the lateral thoracotomy group (p > 0.05). In both groups a final diagnosis was made in 100% of cases. The postoperative hospital stay was 4.6 +/- 1.08 days in the video-assisted thoracic surgery group and 7.8 +/- 0.89 days in the lateral thoracotomy group (p < 0.01). Pain was evaluated on a visual analogue scale; the scores were 26.5 +/- 11.6 in the video-assisted thoracic surgery group and 48.3 +/- 12.8 in the lateral thoracotomy group (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Lateral Thoracotomy for the Automatic Implantable Defibrillator

In 51 patients who required automatic implantable cardioverter defibrillator implantation without additional cardiac procedures, the lead system was implanted using a lateral thoracotomy approach, with complete muscle sparing in the last 24 patients. Exposure was excellent and allowed repositioning of leads for optimal defibrillation thresholds in 18 patients. Five of 19 patients who had previously undergone intrapericardial procedures required intrapericardial dissection for lead placement to provide satisfactory defibrillation thresholds. There were no intraoperative deaths or infarctions. The 30-day mortality rate of 3.9% was comparable with those in other series, and the use of muscle-sparing techniques and supplemental epidural anesthesia prevented pulmonary complications or the need for prolonged ventilatory support. We favor a muscle-sparing lateral thoracotomy incision for automatic implantable cardioverter defibrillator insertion, particularly in patients with a history of previous intrapericardial procedures.