Anterolateral thoracotomy

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.

Next, divide the serratus anterior down to the ribs while sparing the latissimus dorsi, by retracting it posteriad.

Note: Minimize blood loss by dividing the muscles of the chest wall with electrocautery.

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.

After covering the wound edges with moist towels, insert and spread the rib retractor. To further widen the access and improve the overview, insert a second retractor at right angles to the intercostal space.

Note: Spread the rib retractor slowly to avoid rib fracture.