Experience With a Total Muscle-Sparing Approach for Thoracotomies in Neonates, Infants, and Children By Steven S. Rothenberg and William J. Pokorny Houston,

Texas

l We have adopted a total muscle-sparing technique for thoracotomies in infants and children. The technique preserves the latissimus dorsi and serratus anterior muscles and provides excellent exposure for most thoracic and mediastinal operations. Thirty-two such procedures have been performed with only one complication, a small wound seroma. Use of this technique may not only decrease postoperative pain and splinting, but may decrease the incidence of scoliosis and muscle dysfunction found in children having undergone thoracotomies as infants. Copyright o 1992 by W.B. Saunders Company INDEX WORDS: Thoracotomy,

muscle sparing.

T

HE VAST majority of noncardiac, intrathoracic procedures performed in small infants and children are done via a standard posterolateral thoracotomy incision. This approach, which routinely results in the division of the latissimus dorsi and serratus anterior muscles, provides excellent exposure for most pulmonary and mediastinal procedures. However, division of two of the major muscles of the back and shoulder can result in significant postoperative pain, diminished pulmonary function (especially in the early postoperative period), and marked impairment of motion. While most of these impairments are thought to be short-term and self-limited, a few recent reports’” suggest that a thoracotomy incision early in life may result in long-term physical impairment and deformity. Because of these facts, as well as reports in the adult literature suggesting various muscle sparing techniques are associated with less postoperative pain and improved pulmonary function,4*5we have adopted a total muscle-sparing technique for use in infants and children. Our technique and results are described herein. MATERIALS AND METHODS

Latissimus dorsi Fig 1. Posterolateral skin incision with development lower skin flaps to expose latissimus dorsi muscle.

of upper and

inferiorly and inserts on the bottom of the intertubercular groove of the humerus superiorly. By cutting the thin fascial attachment along its anterior border, the latissimus can be retracted posteriorly thereby exposing the serratus anterior muscle (Fig 2). A similar maneuver is then performed on the inferior border of the serratus anterior muscle. Mobilization of its lower border, which originates on the eighth rib and inserts on the tip of the scapula, allows the scapula to be retracted superiorly and anteriorly along with the muscle, allowing for exposure of the thoracic cage (Fig 3). The chest can then be entered in the 3rd, 4th, 5th, 6th, or 7th interspace without difficulty. The intercostal muscle of the appropriate rib space may then be divided or stripped off the lower rib of the appropriate interspace. A rib retractor is inserted and, if necessary, a small retractor may be used to maintain posterior traction on the latissimus dorsi muscle (Fig 4). After the resection is finished one or two pericostal sutures are placed and the serratus anterior and latissimus dorsi muscle are allowed to fall back into their natural

The patient is placed in the lateral decubitus position with placement of an axillary roll and the upper arm supported on cushions or a rest. The incision is similar to that for a standard posterolateral thoracotomy. It extends from approximately the midaxillary line anteriorly, to 1 or 2 cm below the tip of the scapula and gradually curves superiorly. The extent of the incision varies with the size and weight of the patient. Dissection is carried down through the subcutaneous tissue until the fascia of the latissimus dorsi muscle is reached. Superior and inferior skin flaps are then raised, leaving the fascia intact on the muscle (Fig 1). The flaps are extended to allow for adequate visualization and then mobilization of the anterior border of the latissimus dorsi muscle. The latissimus dorsi originates on the posterior iliac crest

From the Section of Pediatric Surgery, Cora and Webb Mading Depanment of Susety, Baylor College of Medicine, Texas Children’s Hospital, Ben Taub Hospital, Houston, TX. Presented at the 43rd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New Orleans. Louisiana, October 26271991. Address reprint requests to Steven S. Rothenberg MD, Texas Children’s Hospital, Clinical Care Center, Suite 245, MC 3-2325, 6621 Fannin, Houston, TX 77030. Copyrtght o I992 by W B. Saunders Company 0022-346819212708-0044$03.0010

JournalofPediatric Surgery, Vol 27, No 8 (August), 1992: pp 1157-I 160

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ROTHENBERG AND POKORNY

Serratus anterior Fig 2. Mobilization and retraction of anterior border of latissimus dorsi muscle to expose serratus anterior muscle.

position. The mobilized edges may be tacked down with a single absorbable suture if desired. The skin is then closed in a standard fashion.

DISCUSSION

Thirty-two thoracotomies have been performed using this technique. Table 1 shows a breakdown of the procedures. Ages ranged from 25 weeks’ gestation to 13 years of age and weights from 580 g to 45 kg.

Fig 4. Rib retractor in place with latissimus dorsi muscle retracted posteriorly.

There were no intraoperative complications and only one postoperative complication, a small wound seroma that drained and resolved spontaneously. Because of this problem we now place a single hemovac drain in the subcutaneous space of those patients weighing over 10 kg. The operative technique does add 5 to 10 minutes to the incision time, but this is compensated for with almost spontaneous closure of the wound at the end of the procedure. Also, with experience the time required for mobilization has diminished. The approach has allowed adequate exposure for all procedures performed. However, if additional exposure were required, the latissimus dorsi muscle could be divided at any time during the operation.

Table 1. Operative Procedures Performed Using a Posteroleteral Muscle-Sparing

Approach

Operation

Patent ductus arteriosus ligation Lobectomy

NO.

19 3

LLL: congenital cystic adenomatoid malformation LLL: intralobar sequestration RML: RML syndrome

lntercostals Fig 3. Mobilization and retraction of inferolateral border of serratus anterior muscle to expose intercostal muscles and ribs.

Decortication

2

Diaphragmatic plication

2

Extralobar sequestration

1

Pleurodesis

1

Thoracic duct ligation

1

Bronchogenic cyst excision

1

Neuroblastoma resection

1

Exploratory thoracotomy

1

MUSCLE-SPARING

THORACOTOMY

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*Because of separate reports by Shelton et al,’ Durning et a1,2 and Vaizquez et al reporting significant physical and functiona impairment, including severe scoliosis, following thoracotomies in infants,

we feel that use of this muscle-sparing approach is warranted. Long-term follow-up in this series will be necessary to determine if less long-term morbidity is present.

REFERENCES 1. Shelton JE, Rosemary J, Walburgh E, et al: Functional scoliosis as a long-term complication of surgical ligation for patent ductus arteriosus in premature infants. J Pediatr Surg 21:855-857, 1986 2. Durning RP. Stoles PV, Fox OD: Scoliosis after thoracotomy in tracheoesophageal fistula patients. J Bone Joint Surg (Am) 7:1156-1158, 1980 3. Vaizquez JJ, Murcia J, DiezPardo JA: Morbid musculoskele-

tal sequelae of thoracotomy for tracheoesophageal atr Surg 20:.511-514,1985

fistula. J Pedi-

4. Bethencourt DM, Holmes EC: Muscle sparing posterolateral thoracotomy. Ann Thorac Surg 45:337-339.1988 5. Leminer JH, Gomez MH, Symreng T, et al: Limited lateral thoracotomy: improved postoperative pulmonary function. Arch Surg 12.5:873-877,199O

Discussion Thomas Holder (Kansas City, MO): I enjoyed this paper because it brings some of my own biases to the subject. In my experience, the patients who have significant clinical scoliosis have occurred not from the incision, but from an extensive fibrotic process secondary to esophageal leaks, and/or multiple thoracotomies. The other patients really have not had scoliosis. We have been using a muscle-sparing incision in infants for about 5 years now for esophageal atresia, coarctation of the aorta, interrupted aortic arch, patent ductus arteriosus, and some pulmonary resections. The approach has been posterior rather than anterior to the latissimus dorsi muscle. It is a quicker operation than the standard thoracotomy and is particularly easy in little babies. Through the triangle of auscultation, the interspace is identified and the chest opened. We have not had to transect the serratus in any patient and only rarely the latissimus. Dale Johnson (Salt Lake City, UT): I share both your enthusiasm and Dr Holder’s for eliminating the scoliosis and for the muscle-sparing approach. I would wonder, however, if you have any idea whether it is primarily the cutting of muscle or the bringing of ribs together that is the culprit. Spencer Beasley has reported a large series of patients from Australia and I think the more severe scoliosis patients were those who had had rib resection. Do you not think fusion of the ribs may be at least as important as incision across the muscle in causing scoliosis? A cardiothoracic surgeon in our area has been using essentially your same muscle-sparing approach for some time on larger adult patients. None of the other cardiovascular surgeons have adopted the approach because he seems to have a higher incidence

than you reported with wound seromas. Perhaps in the child it is less of a problem. I was interested that your series included no esophageal atresia patients. Why haven’t you used the muscle-sparing incision for esophageal atresia? Finally, I agree in concept, with your musclesparing objective, but less aggressive than you have been. For about 15 years we have just retracted the serratus but have cut the latissimus, though we have cut it very low. Do you think that is a reasonable compromise in order to save time and eliminate the subcutaneous dissection? Donald Nuss (Norfolk; VA): Do you raise a skin flap with the neonates as well? I haven’t found it necessary. Spencer Beaslq (Melbome, Australia): We actually reviewed 232 esophageal atresia patients over a 5- to 3%year follow-up period. We made the point that if you divide the serratus anterior very low at its origin, you are not going to affect its nerve supply if you have to divide it at all. Steven Rothenberg (response): My experience with this incision started initially in adults and I was impressed when I used it. Primarily, it diminished postoperative pain and markedly improved early range of motion in these patients. These subjective findings are much harder to evaluate in small children, but we believe they are significant factors and that’s why we proceeded to use it. After I reviewed the literature, it became evident that postthoracotomy scoliosis was a significant problem and, perhaps, the surgical injury to the muscles and the nerves were a factor. I think that the degree to which the innervation of the muscles is affected depends on the level of your

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incision. Therefore, it’s important if you do divide the muscles that you take them right along their insertions so you don’t deinnervate any significant portion of the muscle. But the degree to which that is a factor in the development of scoliosis, as opposed to taking a rib, or recurrent thoracotomies, is not clear. However, I think that if you can do these procedures with total preservation of the muscles and nerves, it would be hard to argue that it would not be

ROTHENBERG AND POKORNY

worthwhile if there’s any chance that there would be any long-term disability. As far as the skin flaps in neonates, I do develop the skin flaps to a lesser degree, but certainly in the prematures the skin just falls away from the muscle and it takes 10 seconds to develop them. In these patients it really is a limited time difference. It’s in the bigger, more muscular patients where you do more mobilization where it takes time.

Experience with a total muscle-sparing approach for thoracotomies in neonates, infants, and children.

We have adopted a total muscle-sparing technique for thoracotomies in infants and children. The technique preserves the latissimus dorsi and serratus ...
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