HOW TO DO IT
Simplified Muscle-Sparing Thoracotomy for Patent Ductus Arteriosus Ligation in Neonates Shreekanth V. Karwande, MD, and John R. Rowles, MD Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah
To reduce operative morbidity we have developed a simplified muscle-sparing thoracotomy that provides excellent exposure for patent ductus arteriosus ligation in neonates. Operative time has not increased and seroma formation has not occurred. Improved functional and cosmetic results as well as less postoperative pain may be obtained by preserving the latissimus dorsi and serratus anterior muscles. (Aim Tkorac Surg 1992;54:16&5)
H
emodynamically significant patent ductus arteriosus (PDA) in premature infants is a common problem, occurring in up to 80% of those weighing less than 1,200 g [l].Increased pulmonary blood flow from the left-to-right shunt may increase pulmonary artery pressure, decrease pulmonary compliance, worsen respiratory failure, and prolong mechanical ventilation. Complications of prematurity including respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage may be made worse by the presence of a PDA [2]. Medical management of infants with PDA includes oxygen administration, fluid restriction, and administration of diuretics and indomethacin, a prostaglandin synthetase inhibitor. A significant number of patients may fail nonsurgical therapy and require ligation [3]. The standard posterolateral thoracotomy involves division of the latissimus dorsi and serratus anterior muscles, resulting in paralysis of the caudal portion. Impaired respiratory mechanics, decreased shoulder mobility, increased postoperative pain, and increased operative time required for closure are adverse consequences. Musclesparing techniques have been developed in adults to reduce morbidity while providing adequate exposure for most procedures [ P 6 ] . We have developed a simplified muscle-sparing technique for thoracotomy in neonates to ligate PDA. Since January 1989 we have used this technique in 50 premature infants at the University of Utah Medical Center.
lateral position and secured with tape. A left posterolatera1 skin incision is made from the midaxillary line, around the tip of the scapula to the midposition between the scapula and spine (Fig 1A). Electrocautery is used for hemostasis. The auscultory triangle, bounded by the latissimus dorsi and trapezius muscles and scapula, is identified (Fig 1B). The connective tissue between the latissimus dorsi and trapezius muscles is divided. The latissimus dorsi is mobilized with electrocautery, taking care to minimize the subcutaneous dissection (Fig 1B). The muscles and tissues of the chest wall in neonates are pliable and, as a result, mobilization of the serratus anterior muscle is not required. The third or fourth intercostal space is entered between the latissimus dorsi and trapezius muscles (Fig 1C). A single rib retractor is used to facilitate exposure (Fig 2A). The mediastinal pleura is incised adjacent to the ductus with the recurrent laryngeal nerve kept medial. Minimal dissection around the ductus is necessary, and ligation is achieved with a medium-sized surgical clip [7] (Fig 2B). An 8F chest tube is placed through a lateral stab wound and secured. The ribs are reapproximated with a single paracostal figure-of-8 suture of 3-0 polyglycolic acid. The latissimus dorsi and
Technique All procedures are performed in the neonatal intensive care unit to prevent problems associated with transfer of these critically ill patients. After the induction of general endotracheal anesthesia the patient is placed in the right Accepted for publication Feb 28, 1992 Address reprint requests to Dr Karwande, Division of Cardiothoracic Surgery, University of Utah Medical Center, 50 North Medical Dr, Salt Lake City, UT 84132.
0 1992 by The Society of Thoracic Surgeons
Fig I . (A) The position of the patient and location of the skin incision. ( B ) The auscultoy triangle, bounded by the scapula and the latissimus dorsi and trapezius muscles. (C) The third intercostal space is entered between the latissimus dorsi and trapezius muscles.
0003-4975/92/$5.00
HOW TO DO IT KARWANDE AND ROWLES SIMPLIFIED THORACOTOMY FOR PDA LIGATION
Ann Thorac Surg 1992;54164-5
CURRPlTLARYNQLUn
e
Fig 2. (A) The rib retractor in place between the latissimus dorsi and trapezius muscles. ( B ) Patent ductus arteriosus ligation with a medium surgical clip, showing the lung reflected medially with malleable brain retractors and the recurrent laryngeal nerve medial to the surgical clip.
trapezius muscles are reapproximated with one or two interrupted sutures of 4-0 polyglycolic acid. The skin is closed with a running subcuticular suture of 5-0 polyglycolic acid. The procedure can usually be accomplished in less than 30 minutes. The chest tube is removed routinely on the first postoperative day.
Comment Surgical ligation of PDA has become a safe and effective procedure when medical therapy has failed or is contrain-
165
dicated. It is recommended as a first mode of therapy in infants less than 800 g [3]. In 1952, Dennis Browne [8] described an axillary approach for PDA ligation in infants and children that required division of the serratus anterior muscle, extensive mobilization of the pectoralis muscles, and an elaborate retractor system. The technique described in this report is a simplified muscle sparing approach with less operative morbidity. In adults, the main criticism of the muscle-sparing approach is reduced intrathoracic exposure and seroma formation in the subcutaneous space. We have found that exposure of the posterior mediastinum has been excellent and no detectable seromas have occurred with this technique. Minimal dissection of the subcutaneous space and limited mobilization of the latissimus dorsi muscle are made possible by the more pliant muscles of the neonate. The overall functional and cosmetic result is improved by avoiding division of the latissimus dorsi and serratus anterior muscles. Although we have no direct experience, we suspect this technique may be suitable for other procedures involving the posterior mediastinum in neonates and infants including repair of tracheoesophageal defects and coarctation of the aorta.
References 1. Heymann MA. Patent ductus arteriosus. In: Adams FH, Emmanouilides GC, Riemensch-Neider, Heart disease in infants, children, and adolescents. Baltimore: Williams and Wilkins, 1989:212. 2. Huhta JC. Patent ductus arteriosus in the preterm neonate. In: Long WA, ed. Fetal and neonatal cardiology. Philadelphia: W.B. Saunders, 1990:389. 3. Palder SB, Schwartz MZ, Tyson KRT, Marr CC. Management of patent ductus arteriosus: a comparison of operative versus pharmacologic treatment. J Pediatr Surg 1987;22:11714. 4. Mitchell R, Angel1 W, Wuerflein R, Dor V. Simplified lateral chest incision for most thoracotomies other than sternotomy. Ann Thorac Surg 1976;22:284-6. 5. Bethencourt DM, Holmes EC. Muscle-sparing posterolateral thoracotomy. Ann Thorac Surg 1988;48:337-9. 6 . Karwande SV, Pruitt JC. A muscle-saving posterolateral thoracotomy incision. Chest 1989;96:1426-7. 7. Adzick NS, Harrison MR, de Lorimier AA. Surgical clip ligation of patent ductus arteriosus in premature infants. J Pediatr Surg 1986;21:158. 8. Browne D. Patent ductus arteriosus. Proc R SOCMed 1952;45: 719-22.
Simplified Muscle-Sparing Thoracotomy for Patent Ductus Arteriosus Ligation in Neonates Shreekanth V. Karwande, MD, and John R. Rowles, MD Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah
To reduce operative morbidity we have developed a simplified muscle-sparing thoracotomy that provides excellent exposure for patent ductus arteriosus ligation in neonates. Operative time has not increased and seroma formation has not occurred. Improved functional and cosmetic results as well as less postoperative pain may be obtained by preserving the latissimus dorsi and serratus anterior muscles. (Aim Tkorac Surg 1992;54:16&5)
H
emodynamically significant patent ductus arteriosus (PDA) in premature infants is a common problem, occurring in up to 80% of those weighing less than 1,200 g [l].Increased pulmonary blood flow from the left-to-right shunt may increase pulmonary artery pressure, decrease pulmonary compliance, worsen respiratory failure, and prolong mechanical ventilation. Complications of prematurity including respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage may be made worse by the presence of a PDA [2]. Medical management of infants with PDA includes oxygen administration, fluid restriction, and administration of diuretics and indomethacin, a prostaglandin synthetase inhibitor. A significant number of patients may fail nonsurgical therapy and require ligation [3]. The standard posterolateral thoracotomy involves division of the latissimus dorsi and serratus anterior muscles, resulting in paralysis of the caudal portion. Impaired respiratory mechanics, decreased shoulder mobility, increased postoperative pain, and increased operative time required for closure are adverse consequences. Musclesparing techniques have been developed in adults to reduce morbidity while providing adequate exposure for most procedures [ P 6 ] . We have developed a simplified muscle-sparing technique for thoracotomy in neonates to ligate PDA. Since January 1989 we have used this technique in 50 premature infants at the University of Utah Medical Center.
lateral position and secured with tape. A left posterolatera1 skin incision is made from the midaxillary line, around the tip of the scapula to the midposition between the scapula and spine (Fig 1A). Electrocautery is used for hemostasis. The auscultory triangle, bounded by the latissimus dorsi and trapezius muscles and scapula, is identified (Fig 1B). The connective tissue between the latissimus dorsi and trapezius muscles is divided. The latissimus dorsi is mobilized with electrocautery, taking care to minimize the subcutaneous dissection (Fig 1B). The muscles and tissues of the chest wall in neonates are pliable and, as a result, mobilization of the serratus anterior muscle is not required. The third or fourth intercostal space is entered between the latissimus dorsi and trapezius muscles (Fig 1C). A single rib retractor is used to facilitate exposure (Fig 2A). The mediastinal pleura is incised adjacent to the ductus with the recurrent laryngeal nerve kept medial. Minimal dissection around the ductus is necessary, and ligation is achieved with a medium-sized surgical clip [7] (Fig 2B). An 8F chest tube is placed through a lateral stab wound and secured. The ribs are reapproximated with a single paracostal figure-of-8 suture of 3-0 polyglycolic acid. The latissimus dorsi and
Technique All procedures are performed in the neonatal intensive care unit to prevent problems associated with transfer of these critically ill patients. After the induction of general endotracheal anesthesia the patient is placed in the right Accepted for publication Feb 28, 1992 Address reprint requests to Dr Karwande, Division of Cardiothoracic Surgery, University of Utah Medical Center, 50 North Medical Dr, Salt Lake City, UT 84132.
0 1992 by The Society of Thoracic Surgeons
Fig I . (A) The position of the patient and location of the skin incision. ( B ) The auscultoy triangle, bounded by the scapula and the latissimus dorsi and trapezius muscles. (C) The third intercostal space is entered between the latissimus dorsi and trapezius muscles.
0003-4975/92/$5.00
HOW TO DO IT KARWANDE AND ROWLES SIMPLIFIED THORACOTOMY FOR PDA LIGATION
Ann Thorac Surg 1992;54164-5
CURRPlTLARYNQLUn
e
Fig 2. (A) The rib retractor in place between the latissimus dorsi and trapezius muscles. ( B ) Patent ductus arteriosus ligation with a medium surgical clip, showing the lung reflected medially with malleable brain retractors and the recurrent laryngeal nerve medial to the surgical clip.
trapezius muscles are reapproximated with one or two interrupted sutures of 4-0 polyglycolic acid. The skin is closed with a running subcuticular suture of 5-0 polyglycolic acid. The procedure can usually be accomplished in less than 30 minutes. The chest tube is removed routinely on the first postoperative day.
Comment Surgical ligation of PDA has become a safe and effective procedure when medical therapy has failed or is contrain-
165
dicated. It is recommended as a first mode of therapy in infants less than 800 g [3]. In 1952, Dennis Browne [8] described an axillary approach for PDA ligation in infants and children that required division of the serratus anterior muscle, extensive mobilization of the pectoralis muscles, and an elaborate retractor system. The technique described in this report is a simplified muscle sparing approach with less operative morbidity. In adults, the main criticism of the muscle-sparing approach is reduced intrathoracic exposure and seroma formation in the subcutaneous space. We have found that exposure of the posterior mediastinum has been excellent and no detectable seromas have occurred with this technique. Minimal dissection of the subcutaneous space and limited mobilization of the latissimus dorsi muscle are made possible by the more pliant muscles of the neonate. The overall functional and cosmetic result is improved by avoiding division of the latissimus dorsi and serratus anterior muscles. Although we have no direct experience, we suspect this technique may be suitable for other procedures involving the posterior mediastinum in neonates and infants including repair of tracheoesophageal defects and coarctation of the aorta.
References 1. Heymann MA. Patent ductus arteriosus. In: Adams FH, Emmanouilides GC, Riemensch-Neider, Heart disease in infants, children, and adolescents. Baltimore: Williams and Wilkins, 1989:212. 2. Huhta JC. Patent ductus arteriosus in the preterm neonate. In: Long WA, ed. Fetal and neonatal cardiology. Philadelphia: W.B. Saunders, 1990:389. 3. Palder SB, Schwartz MZ, Tyson KRT, Marr CC. Management of patent ductus arteriosus: a comparison of operative versus pharmacologic treatment. J Pediatr Surg 1987;22:11714. 4. Mitchell R, Angel1 W, Wuerflein R, Dor V. Simplified lateral chest incision for most thoracotomies other than sternotomy. Ann Thorac Surg 1976;22:284-6. 5. Bethencourt DM, Holmes EC. Muscle-sparing posterolateral thoracotomy. Ann Thorac Surg 1988;48:337-9. 6 . Karwande SV, Pruitt JC. A muscle-saving posterolateral thoracotomy incision. Chest 1989;96:1426-7. 7. Adzick NS, Harrison MR, de Lorimier AA. Surgical clip ligation of patent ductus arteriosus in premature infants. J Pediatr Surg 1986;21:158. 8. Browne D. Patent ductus arteriosus. Proc R SOCMed 1952;45: 719-22.
