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Start the incision 4 fingers inferior to the nipple in the midclavicular line and continue along the submammary crease.
Note: When making the incision in women, it is important to prevent possible cosmetic problems along the breast.
Continue the incision diagonally to the posterior axillary line at a point about 2 fingers superior to the tip of the scapula.
Note: Depending on the case at hand, the incision may be extended as far as the sternum. In posterolateral thoracotomy, continue the incision around the tip of the scapula to about 4 fingers lateral to the spinous processes.
Divide the subcutaneous fatty tissue with electrocautery down to the muscles.
Transecting the serratus anterior
Opening the intercostal space
Taking down the intercostal muscles, together with the intercostal nerve, from the inferior aspect of the superior rib with electrocautery will open the pleural space.
Note: Here, the author demonstrates a nerve-sparing technique to reduce post-thoracotomy pain. Detaching the intercostal muscles along the inferior aspect of the rib will result in a gradual en bloc displacement of the muscles and nerve into the pleural cavity. This can help prevent retraction injury where the nerve is compressed between the rib and the upper blade area of the rib retractor.
To avoid direct injury to the neurovascular bundle, the standard approach, not demonstrated here, dissects strictly along the superior aspect of the inferior rib. However, this technique does not address tissue injury due to pressure or strangulation.
Inserting the rib retractor
Closing the thoracotomy; chest tubes
Before closing the thoracotomy, the lung must be fully expanded by PEEP ventilation.
Note: PEEP is the acronym for "positive end-expiratory pressure" and is a parameter in mechanical ventilation. It refers to a positive pressure in the lungs at the end of exhalation (expiration).
After removing the rib retractors, insert two silicone tubes through two small stab incisions in a lower intercostal space anterior to the iliac crest. Advance one tube anterosuperiorly and the other posteroinferiorly. Anchor each tube with a strong U-stitch. To finish, shorten the tubes and clamp them together.
Suturing the ribs
Close the thoracotomy in layers, paying particular attention to reconstruct the divided structures in anatomically correct position.
Start by suturing the ribs: Circle around the superior aspect of the superior rib and carry the stitch through the inferior intercostal muscles while reliably sparing the nerve coursing on the inside. Before tightening and knotting the sutures, undo the lateral hyperextension of the patient by returning the back and leg plates of the operating table back to the neutral position.
Note: Avoiding pericostal stitches circling around the inferior aspect of the inferior rib will help prevent strangulation of the intercostal nerve.
Suturing the serratus anterior
Closing the subcutaneous tissue and skin