Anterior Transthoracic Approach

  • Unrivalled exposure to anterior portions of vertebral bodies T2 – T12
  • Operate in conjunction with Thoracic surgeon

Indications

  • Infections TB
  • Fusion
  • Tumour
  • Bone grafting
  • Correction of scoliosis
    • Dwyer instrumentation & rods
  • Correction of kyphosis

Position

  • Lateral
  • Stabilised with lateral supports
  • Patient's arm placed above the head
  • Axillary roll & feel for radial pulse in dependent arm
  • Surgeon is behind the patient
  • Approach from RIGHT side to avoid aortic arch & aorta
  • NG tube to help identify oesophagus

Landmarks

  • Tip of scapula
  • Spines of thoracic vertebrae
  • Inframammary crease

Incision

  • L shaped incision over 7th or 8th rib
  • Start: 2 fingerbreaths below tip of scapula
    • curved forward towards inframammary crease
    • curved backward & upward midline between spine & medial border of scapula

Superficial Dissection

  • Divide latissimus dorsi in line with skin incision
  • Divide Serratus Anterior along the same line, down to the RIBS
  • scapula can now be elevated to expose the underlying ribs
  • Many vessels are encountered & are cauterised
  • Intercostral space or Rib resection
    • intercostal space / rib to be resected depends on the location of pathology
    • 5th intercostal space
      • T2 - T10
    • 6th intercostal space
      • T10 – 12
  • Cut down to rib with cutting diathermy
  • Cut the periosteum on the upper border of the rib
  • If resecting the rib
    • Resect the posterior ¾ of the rib as far posterior as necessary
  • Insert rib spreader to hold ribs apart

Deep Dissection

  • Ask Anaesthetist to DEFLATE the lung
    • Gently retract it anteriorly with moist lap pads to protect it
  • Identify the Oesophagus
  • Incise the pleura over the oesophagus so that it can be mobilised
    • Ligate / tie off intercostal vessels that are necessary
    • Retract & hold oesophagus medially with 2 penrose drains
  • vertebral bodies are now exposed
  • If need to reach T11 –T12
    • Part of diaphragm may need to be resected
    • Remove arcuate ligament from its origin on transverse process of L1

Dangers

  • Intercostal vessels
  • Lungs
    • Inflate lungs every 30 minutes to help prevent microatelectasis postop
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