|Year : 2022 | Volume
| Issue : 3 | Page : 309-316
Muscle-sparing skin crease incision posterolateral thoracotomies in pediatric patients: Our experience
Rahul Gupta1, Praveen Mathur1, Anu Bhandari2
1 Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Radiodiagnosis, SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||16-Mar-2021|
|Date of Decision||04-Jun-2021|
|Date of Acceptance||29-Oct-2021|
|Date of Web Publication||12-May-2022|
Dr. Rahul Gupta
Associate Professor, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Standard posterolateral muscle cutting thoracotomies in pediatric patients are associated with morbidities in terms of poor motor and esthetic outcomes and also more postoperative analgesia requirement, when compared with muscle-sparing technique.
Aims: The aim of this study is to evaluate the outcomes of muscle-sparing skin crease incision posterolateral thoracotomies in pediatric patients in terms of abovementioned variables.
Settings and Design: This prospective observational study was conducted over a period from January 2016 to July 2020 in a tertiary care teaching institute.
Materials and Methods: All patients of stage 3 empyema and pulmonary hydatidosis were included in the study.
Results: Thirty-nine patients fulfilled the inclusion criteria. There were 38 children with organized (Stage 3) empyema and one patient with bilateral lung hydatid. There were 24 males and 15 females; age ranging from 6 months to 15 years. Right thoracotomy was performed in 28, left in 10, and bilateral in one patient with lung hydatid. Adequate exposure was achieved in all cases. Decortication with complete excision of thickened parietal pleura with stripping of the visceral peel and release of the entrapped lung was performed in all 38 patients. In 5 children along with decortication, repair of bronchopleural fistula due to necrotizing pneumonia was performed. Bilateral thoracotomies with pericystectomies were performed with a gap of 3 weeks for lung hydatid. Lung expansion assessment at 3 months was satisfactory. Ultrasound assessment of the latissimus dorsi muscle and serratus anterior muscle at 4 weeks revealed complete integrity in all the cases. Most of the patients achieved satisfactory motor and esthetic outcomes.
Conclusions: Muscle-sparing skin crease incision posterolateral thoracotomy is a viable alternative to standard posterolateral muscle cutting thoracotomy, especially in a resource-challenged setting. The technique is easy to perform with satisfactory exposure.
Keywords: Modified, muscle-sparing, paediatric posterolateral, skin crease, thoracotomy
|How to cite this article:|
Gupta R, Mathur P, Bhandari A. Muscle-sparing skin crease incision posterolateral thoracotomies in pediatric patients: Our experience. J Indian Assoc Pediatr Surg 2022;27:309-16
|How to cite this URL:|
Gupta R, Mathur P, Bhandari A. Muscle-sparing skin crease incision posterolateral thoracotomies in pediatric patients: Our experience. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 May 17];27:309-16. Available from: https://www.jiaps.com/text.asp?2022/27/3/309/345128
| Introduction|| |
Standard posterolateral muscle cutting thoracotomies in pediatric patients are associated with morbidities in terms of poor motor (impaired arm and shoulder movements) and esthetic outcomes (big incision) and more postoperative analgesia requirement (severely painful), when compared with muscle-sparing technique., Muscle-sparing thoracotomies have been purported to result in lesser morbidity to the patient compared to muscle cutting procedure. Authors imbibed the technique of muscle-sparing thoracotomy from various studies and present their experience in this study.,,
Aims and objectives
This study is aimed to evaluate the outcomes of muscle-sparing skin crease incision posterolateral thoracotomies in pediatric patients with (1) Primary objective i.e., completeness of procedures and (2) Secondary objectives (to assess): (a) The adequacy of exposure and access to all the lobes, (b) motor outcomes, (c) esthetic outcomes, (d) postoperative analgesia requirement, (e) intraoperative and postoperative complications, and (f) difficulties encountered.
| Materials and Methods|| |
This prospective observational study was conducted over a period from January 2016 to July 2020 in a tertiary care teaching institute.
- All patients of stage 3 empyema (Organizing Phase)
- All patients of pulmonary hydatidosis.
Age >16 years.
At the time of admission, baseline blood investigation including complete blood counts, analysis of serum electrolytes, arterial blood gas, C-reactive protein levels, blood culture, and renal and liver function tests were performed.
All patients underwent thorough assessment of their symptomatology, clinical history, and complete clinical examination including chest wall deformities, radiographic, ultrasonography and computerized tomography (CT) of thorax, and comorbidities. Pro forma were made with focus on objectives: The utility of muscle-sparing skin crease incision posterolateral thoracotomy technique was assessed in terms of primary and secondary objectives of the study.
Muscle-sparing skin crease incision posterolateral thoracotomy technique
Patient positioning was similar to that of standard posterolateral muscle cutting thoracotomy [Figure 1]. The patient was placed in the lateral position with diseased side upward. The patient was immobilized with help of rolls, cushions, and paper tapes. Axillary roll was placed under the lower axilla and chest wall that protects the axilla and also increases the intercostal space (ICS) on the contralateral side. The arm was drawn forward extended to about 130° and placed by the side of the head on an armrest [Figure 1]. The peripheral pulse was monitored by the pulse-oximeter of the extended arm.
|Figure 1: Operative photographs showing: (a) Patient positioning in the lateral position, (b) proposed site of incision over the fifth or sixth interspace, (c) thick parietal peel is cut opened and pus is visible, (d) parietal peel being dissected out, (e) Removed thick custard like fibrino-purulent debris in kidney tray|
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The proposed site of incision was marked. Incision was given 1–2 cm below the tip of scapula. It extended from mid-axillary line to midway between scapula and spine (mid-portion of the belly of the latissimus dorsi muscle), approximately over the fifth or sixth interspace (9–10 cm) [Figure 2]. Skin flaps were created on either side over the body of the latissimus dorsi from the scapular tip to the level of the ninth rib. This subcutaneous dissection was also advanced anteriorly over the serratus anterior muscle slips from the fourth to the eighth ICS. This subcutaneous dissection was required to accomplish retraction of the latissimus dorsi and serratus anterior musculature for optimal thoracotomy exposure. The posterior fascial membrane of the serratus anterior was then incised along the posterior length of the muscle. With the combination of blunt and sharp dissection, which was performed medial to the anterior border of latissimus dorsi muscle, a space was created between latissimus dorsi and serratus anterior muscle and finally, access to the rib cage was accomplished [Figure 2]. Serratus anterior muscle splitting along its fibers on the targeted rib (when necessary) was performed. Latissimus Dorsi was retracted laterally and belly of the serratus anterior was elevated, retracted medially, and superiorly with retractors [Figure 2]. Appropriate ICS (from fourth to seventh) was entered. One-lung ventilation was not performed in any of the cases.
|Figure 2: Intraoperative photographs showing: (a) Muscle-sparing thoracotomy with latissimus dorsi being retracted laterally and belly of the serratus anterior elevated, retracted medially and superiorly with retractors; visible lung after appropriate intercostal space is opened; (b and c) completion of decortication with complete lung expansion following complete excision of thickened peel and release of entrapped lung along; (d) completely spared the latissimus dorsi and serratus anterior muscles following rib approximation; (e) thoracotomy closure with two chest drains (below images)|
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After completion of the procedure, two chest tubes were placed one with tip at the apex of the lung (residual air) and the other at the base of the thoracic cavity for residual fluid and debris [Figure 2]. Ribs approximation was done using absorbable Polyglycolic Acid (PGA) sutures. Muscles alignment was done as they were before the procedure [Figure 2]. Finally, layered closure of subcutaneous tissue skin was performed. All children were extubated on the operating table.
In the postoperative period, care of the chest tube, chest physiotherapy, posture changes, and breathing exercises were performed. Broad-spectrum antibiotics were prescribed; changed depending on pus culture report. Postoperatively intravenous analgesia was given. The effectiveness of pain control management was determined by the amount of intravenous analgesia and visual analog scale.
All the patients were subjected to chest X-rays on the first and fourth postoperative days and also as and when required. Radiological assessment of lung expansion was performed at 1 and 3 months and later at 1 year. Esthetic outcomes were assessed at 1 and 4 weeks.
Motor outcomes were assessed at 1 and 4 weeks. Ultrasound assessment of the latissimus dorsi muscle and serratus anterior muscle was done in the postoperative period at 4 weeks for evaluating the integrity of these muscles. The patients were assessed following discharge to 1-year follow-up. SPSS Statistics for Windows, version x.0 (SPSS Inc., Chicago, Ill., USA). A P < 0.05 was considered significant.
| Results|| |
Thirty-nine patients fulfilled the inclusion criteria. There were 38 children with organized (Stage 3) empyema and one patient with bilateral lung hydatid. There were 24 males and 15 females. Age ranged from 6 months to 15 years (mean age-5 years); most (43.59%) of the patients were 1 year to 5 years age group [Table 1]. Duration of illness (empyema) ranged from 3 weeks to 3 months; in 21 (55.26%) cases of empyema, the duration of symptoms ranged from 4 to 6 weeks [Table 1]. Among the comorbidities, significant weight loss was present in 9 (23.07%) children and moderate-to-severe anemia (Hb <8 g %) was elicited in 13 (33.33%) cases. All patients with empyema before presentation were on three to five antibiotics that were commenced irrationally in all cases. It was observed that 100% of the cases were delayed referrals for thoracotomy. No patient was on ventilator at the time of referral.
|Table 1: Age distribution, duration of illness and comorbidities of patients and postoperative complications in the study|
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Before presentation, tube thoracostomy was present in all patients. There was evidence of bronchopleural fistula (leakage of large amount of air in chest drain) in three patients. In addition to the chest radiographs and ultrasonography of thorax, CT Thorax was performed in all patients for confirming the diagnosis, and planning the surgical intervention. CT Thorax revealed empyema with or without loculation, marked thickening of pleura and lung encasement in all 38 patients with stage 3 empyema thoracis [Figure 3]. In five cases, lung abscess and/or necrotizing pneumonia were visible in addition to the findings of empyema [Figure 3]. The diagnosis of bilateral lung hydatid was confirmed in one patient on CT thorax [Figure 4].
|Figure 3: Computerized tomography of thorax with lung window showing: (a) Walled off cavity (nonenhancement) with loculated air and pus consistent with cavitary necrosis of the right lung (postero-laterally, (b) entrapped right lung with thick pleural peel, (c) right loculated empyema with thick pleural peel, (d) loculated air and pus with cavitary necrosis of the right lung (lower lobe) with thick pleural peel|
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|Figure 4: Chest X-rays showing: (a) Bilateral radiopaque spherical lung lesions (hydatid cysts) with right > left; (b) postoperative radiograph following bilateral muscle-sparing thoracotomy; (c) Computerized tomography of thorax showing bilateral lung hydatid cyst; (d) intraoperative photograph showing: intraparenchymal lung hydatid cyst; (e) muscle-sparing thoracotomy with pericystectomy in progress|
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Right thoracotomy was performed in 28, left in 10, and bilateral in one patient with lung hydatid. Adequate exposure was possible in all cases. In most cases with empyema, the pleura had become a hard, leathery peel densely adherent to the underlying lung [Figure 1]. Separation of thickened parietal pleura from chest wall was achieved by blunt dissection. Decortication with complete excision of thickened parietal pleura with stripping of the visceral peel and release of the entrapped lung was performed in all 38 patients [Figure 2]. In five children along with decortication, deroofing of the cavity, excision of sloughed off lobe of the lung, and/or repair of bronchopleural fistula due to lung abscess or necrotizing pneumonia was performed. No patient underwent lobectomy of the necrotic lung. Rib resection was not required in any of the patients. After decortication, ipsilateral lung expansion was achieved, residual spaces were checked, and closure of air leaks was performed in all 38 patients [Figure 2]. Bilateral thoracotomies with pericystectomies were performed with a gap of 3 weeks for lung hydatid in a 3-year-old boy [Figure 4]. Completeness of procedure was achieved in all 40 thoracotomies with a success rate of 100%. There were no intraoperative complications. Both latissimus dorsi and serratus anterior muscles were completely spared as no patient required conversion to muscle cutting procedure. Mean intraoperative time was 55 min (ranged from 45 min to 65 min).
Postoperative intravenous analgesia requirement was <48 h in all 40 thoracotomies. Oral analgesics were started on the second postoperative day. Chest tubes were removed sequentially. First chest tube removal on 3rd day (mean, range 2–4 days) and second chest tube was removed when there was satisfactory lung expansion on X-ray (mean 7th day, range 4–21 days). Two patients were given anti-tubercular treatment on the basis of histopathological confirmation of biopsy of pleural peel [Figure 1].
Postoperative complications were present in 5 (12.5%) patients. The most common complication 3 (7.5%) was seroma formation [Table 1]. Seroma formation was managed by repeated aspiration and dressing. Persistence of bronchopleural fistula in one of our patient was managed conservatively with chest tube in-situ for 21 days.
There was no mortality in our series. The mean hospital stay was 8 days (range 6–11 days). Weight gain was seen in nearly all patients, 3 months after surgery.
Most of the patients achieved satisfactory chest (Lung) expansion at 3 months and at 1-year follow-up [Figure 5]. Radiological assessment of lung expansion at 1 month, 3 months, and at 1 year was satisfactory in all cases [Figure 5].
|Figure 5: Preoperative (a) and postoperative (b) photographs showing: complete chest expansion and resolution of chest deformity and right-sided flattened chest wall after 3 months; (c) postoperative photographs showing scar length and (d) esthetically satisfactory outcome in inset image; (e) preoperative radiographs showing empyema with pleural peel and (f) postoperative radiographs showing complete lung expansion and resolution after 1 year|
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Most of the patients achieved satisfactory esthetic outcomes at 4 weeks. The average size of incision scar was 7.5 cm (3 inches, small scar) and major portion of scar lies hidden under the arm [Figure 5].
Most of the patients achieved satisfactory motor outcomes. There was no impairment of arm and shoulder movements at 1-year follow-up [Figure 6]. Ultrasound assessment of the latissimus dorsi muscle and serratus anterior muscle at 1 week and 4 weeks revealed complete integrity in all the cases [Figure 6].
|Figure 6: Photographs (a and b) showing satisfactory motor outcomes with good muscle strength after 3 months; no shoulder or scapular deformity is discernable; (c) high-frequency ultrasound images showing: complete integrity of the latissimus dorsi muscle (blue lines) and Serratus anterior muscle (yellow lines) with underlying ribs (red lines) and overlying skin and subcutaneous tissue (purple line)|
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| Discussion|| |
The selection of technique for surgical access to the thoracic cavity is focused on optimizing exposure, often at the expense of adjacent thoracic muscles. Video-assisted thoracoscopic surgery has become the new standard of care as it is less invasive. It has become preferred modality, especially for the early stages (exudative and fibrinopurulent stage) of empyema thoracis. In the late organizing phase, thoracotomy and decortication is the treatment of choice, especially in cases with very thick and peel when there are difficulties in cutting thick leathery peel with laparoscopic scissors.,
The standard muscle cutting posterolateral thoracotomy results in splitting up of the major chest wall muscles and include severe postthoracotomy pain, ineffective coughing and poor performance of chest physiotherapy exercises, limited ipsilateral shoulder mobility, and delayed ambulation. It is purported to be time-consuming, longer hospital stay, and as a result associated with increased cost of treatment.,
The muscle-sparing thoracotomy has been suggested as a substitute to the conventional posterolateral thoracotomy since it results in lesser morbidity to the patient. Various techniques of muscle-sparing thoracotomy are vertical and transverse axillary thoracotomy, auscultatory triangle thoracotomy, and limited lateral thoracotomy.,,,, The basic difference between the muscle-sparing and muscle cutting thoracotomies is primarily the preservation of the latissimus dorsi muscle and serratus anterior muscle. The technique was initially described by Noirclerc et al. in 1973. Muscle-sparing posterolateral thoracotomy was latter defined by Bethencourt and Holmes in 1988. It did not become widely accepted, most likely because of the extensive subcutaneous detachment of the latissimus dorsi up to the iliac crest.
In pediatric patients, the technique of axillary skin crease, muscle-sparing right lateral thoracotomy was described by Bianchi et al. in 1998. The thoracotomies' were performed through third or fourth ICS and restricted to target in the upper two-thirds of the thoracic cavity in neonates (esophageal atresia and patent ductus arteriosus). Kálmán and Verebély reported muscle-sparing thoracotomy with “axillary skin crease incision” in neonates and children, but with target restricted to the upper two-thirds of the thoracic cavity. Taguchi et al. completed muscle-sparing thoracotomies' through third to eighth ICS. Longer incisions extending from the axilla to ileac crest have also been reported. Approach to the thoracic cavity from a plane posterior to the latissimus dorsi muscle (the plane between the trapezius muscle and latissimus dorsi) has been described.,
Our technique is a modification of the technique of Bethencourt and Holmes and uses: (i) A small-sized incision similar to the standard muscle cutting thoracotomy, and (ii) raising the skin flap and mobilizing the latissimus dorsi muscle along its anterior border for an appropriate distance. It is an approach anterior to the latissimus dorsi muscle, and requires posterior retraction of latissimus dorsi and finally, through appropriate ICS. To promote an optimal exposure, in older children (muscular patient), two rib spreaders were required. Our technique allows procedures in any part of the thoracic cavity.
In our study, ultrasound chest was found to be very useful to distinguish between thick septated collection and consolidation. In our series, CECT thorax proved to be invaluable in preoperative evaluation and planning of the patient and elucidating in detail (a) location, number (single or multiple), density, characteristics (pus and/or air), and also extent and volume of the collection (or loculation), (b) pleural thickness, (c) degree of lung entrapment, (d) status of the underlying lung i.e., lung abscess, lung necrosis, and other pathologies (e) presence of associated pericardial effusion, (f) extent of chest deformity and rib crowding, (g) position of chest tube (in situ) in the thoracic cavity.,
In our study, seroma formation (minor complication) was less (7.5%) as compared to other studies (13.6%), employing longer incisions and skin flaps for muscle-sparing thoracotomy. Wound infection was only 2.5% in our study; while in other studies, wound disruption was also reported with axillary skin crease incision. Transient arm paralysis was seen with axillary incision, while none in our study. This may be primarily due to the level of the incision which was at a level, below the tip of scapula in our patients, and minimal use of energy devices (electrocautery) before entering the ICS.
Studies indicate less postoperative pain, less analgesic use in the first 24 h, lower visual analog scales for the 1st week, and increased muscle strength and shoulder mobility at 1 week with muscle-sparing technique., The studies also indicate better preservation of lung function.,,
In addition to its action on the shoulder joint, the latissimus dorsi muscle is essential for deep inspiration, efficient coughing, and acts as an accessory muscle of expiration. Sparing it helps to reduce postoperative pain and permits efficient coughing. This was evident from the low consumption of intravenous analgesia (<48 h) and faster return of functions in our study.
Surgical field was relatively small and there were technical difficulties related to relatively less exposure at the mediastinal side and lateral most aspect of the diaphragm in our study. With the use of axillary approach, good operational field was relatively difficult in older children, while in our study with posterolateral thoracotomy incision, operational field was good in all age groups. Longer instruments were required for stripping the pleura at mediastinal side, especially in older children. Rib resection was required in other studies with muscle-sparing technique, but in none in our study., Goals of decortication were achieved in all 38 patients with organized empyema in the present study.
Most authors agree that there is no difference in operating time among muscle-sparing and muscle cutting techniques; opening time is longer in former but the closing time is smaller (as seen in our series) as closure is simple as compared with the latter approach. Hence, the overall operating time is equal in both of the techniques.,, Operating time in our study was comparable with other studies and also with the muscle cutting procedure performed by the authors (personal experience).
Muscle-sparing thoracotomy resulted in complete preservation of function. It has been advocated in infants and children to avoid major structural deformities with growth. Furthermore, sparing the major muscles of the chest wall would make the availability of muscle flaps for future use.,
Ultrasound is a useful diagnostic tool in the imaging of soft tissue anatomy, especially for breaches, tears, and hematomas. It allows dynamic imaging and can clearly depict breach in both latissimus dorsi and serratus anterior muscle in the intercostal ultrasound image from the posterior and mid axillary approach., Our results on ultrasound imaging were satisfactory.
Authors recommend that before attempting muscle-sparing technique, the surgeon must obtain a sufficient experience with muscle cutting approach. It has a short learning curve, useful when there is conversion from thoracoscopic surgery, resource constraints, and time constraints in a high volume center.
| Conclusions|| |
Our experience suggests that muscle-sparing skin crease incision posterolateral thoracotomy is a viable alternative to standard posterolateral muscle cutting thoracotomy, especially in a resource-challenged setting. The technique is safe, easy to perform, and easily reproducible with satisfactory operative exposure. It was associated with completeness of procedure in all the cases in our study. This procedure provides good motor as well as cosmetic outcomes with relatively little postoperative pain and minimum postoperative morbidity. We recommend muscle-sparing skin crease incision posterolateral thoracotomy for stage 3 empyema and lung hydatidosis.
We are sincerely thankful to faculty, residents, and nursing staff of the Department of Paediatric Surgery, SMS Medical College Jaipur for helping us in this endeavor.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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