2008, Vol.10, No.2, Incisions and Operative Exposures

Volume 10, Number 2
June 2008
Editorial
n this modern age of minimally invasive surgery, it is easy to forget or lose the sometimes subtle skills necessary to perform major surgical procedures through larger, more conventional incisions. We all realize that the larger the incision the more the risk for wound complications, but the priority in any surgical procedure is still the successful completion of that procedure, even if it means extending the incision. In addition, the default midline abdominal incision may not be the best for the disease being addressed. Careful preoperative assessment and planning can dictate a more limited incision that provides for even better exposure at the exact site of disease. Thus the general surgeon must have a full armamentarium of incisions and exposures and be able to choose and perform the correct one for the problem at hand. These more rarely used incisions however, have subtleties of management that if improperly performed, can result in signicant morbidity. This is especially true for surgical exposures that cross conventional partitions of anatomy. Thus the thoracoabominal and abdominoinguinal incisions have specialized applications and details of performance that can make all the difference in the success of the surgery and the morbidity associated with it. Similarly, thoracic incisions and
retroperitoneal exposures are less commonly performed by most general surgeons but, when needed, familiarity with the anatomy and technique of reconstructive closure is critical. Cervical exposures are needed for more than just thyroid disease and clearly a meticulously performed incision in this relatively cosmetic area of the body is important for patient satisfaction as well as for minimizing complications. The present collection of operative incisional techniques provides the detail and description necessary for the general surgeon who may be somewhat less practiced in these more unusual exposures to perform them in a fashion that will provide the greatest operative success with minimal subsequent morbidity. Walter A. Koltun, MD Professor of Surgery Peter and Marshia Carlino Professor of Inammatory Bowel Disease Chief, Section of Colon and Rectal Surgery Penn State College of Medicine Milton S. Hershey Medical Center Editor-in-Chief
1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2008.05.004
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Volume 10, Number 2
June 2008
Introduction
dequate exposure is the key to successful surgery. Although the abdominal incision has become the mainstay of the general surgeons exposure, there are a number of other incisions that are critical to the general surgeons armamentarium. In this issue, we describe in detail the following exposures: cervical, retroperitoneal, thoracic, thoraco-abdominal, and abdomino-inguinal. Each of the authors has extensive clinical experience with the techniques described, allowing them to share the critical nuances that make the exposures successful. As a result, they have been able to detail in a stepwise fashion the indications for each incision, the positioning of the patient, the surgical anatomy, the appropriate retraction systems, and the closure of the surgical wound. The anatomical exposures are care-
fully illustrated with the aim of allowing an experienced surgeon who is unfamiliar with the incision to perform the technique. One of the beauties of general surgery is the variability in the clinical and operative challenges that it presents. By being well versed in a variety of exposures, the surgeon is much better equipped to successfully meet these challenges. It is my sincere hope that this issue will increase the practicing general surgeons versatility. It was a pleasure preparing this issue and seeing it come together in its nal form. Im very grateful to the authors for their hard work. Kevin F. Staveley-OCarroll, MD, PhD, FACS Guest Editor
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Incisions and Exposure of the Neck for Thyroidectomy and Parathyroidectomy

Scott Pinchot, MD, Herbert Chen, MD, and Rebecca Sippel, MD
hile many articles in the medical literature focus on the complications of thyroid and parathyroid surgery such as nerve injury and hypoparathyroidism, very little attention has been directed toward incision length and location as they relate to conventional open thyroidectomy and parathyroidectomy.1,2 Current techniques for open thyroidectomy and parathyroidectomy are evolving to enable shorter incisions; however, descriptions of the optimal location for a cervical incision remain varied.3 In this review, we aim to briey outline the historical background as it pertains to the cervical incision for these procedures, and we hope to provide a thorough review of current methodological approaches to thyroidectomy and parathyroidectomy.
Historical Background
Some of the rst descriptions of operations for lumps in the neck may be found within the writings of The School of Salerno, the 12th and 13th century cradle of thyroid surgery.4 Published in 1170, the writings of Roger Frugardi describe some of the earliest accounts of the cervical incision for treatment of a single, large goiter; he writes, two setons were inserted at right angles, with the help of a hot iron, and manipulated toward the surface [of the skin] twice daily until they had cut through the esh.4 It is little wonder why (based on these writings) the mid-19th century English surgeon Gross denounced thyroid surgery as horrid butchery . . . deserving of rebuke and condemnation.5 Less barbaric means of performing a cervical incision for thyroidectomy were detailed in the writings of Pierre-Joseph Desault, a French surgeon practicing in Paris during the years of the French Revolution (1789-1799), during what would become the rst well-documented partial thyroidectomy.4 Desault notes the use of an anterior median longitudinal skin incision to gain access to the thyroid.6 By the early 19th century, the technical principles governing cervical incisions for thyroidectomy usually included either a longitudinal or oblique incision, although Y-shaped
and cruciate incisions were still documented in the literature.4 However, thyroid surgery would truly come of age during the 1850s, largely through the efforts of outstanding surgeons like Theodor Billroth of Vienna and Theodor Kocher of Berne. Before settling in Austria, Billroth held the Chair of Surgery in Zrich, where he instituted surgery for compressive symptoms of endemic goiter. While in Switzerland, Billroth used a lateral incision parallel to the inner border of the sternocleidomastoid muscle to gain access to the thyroid.6 Unfortunately, disheartened by a nearly 40% mortality among his thyroidectomy patients, Billroth abandoned thyroid surgery for some time, though not before passing the baton to Theodor Kocher, a surgeon 12 years his junior.4,5 Kocher, who would later be lauded as the Father of Thyroid Surgery, initially performed his thyroidectomy through an incision along the anterior border of the sternocleidomastoid.5 His technique would later evolve to include a midline and vertical component, adding his oblique extension to the anterior border of the sternocleidomastoid (Winkelschnitt) only when he needed better access.4 By 1895, Kocher had reduced the mortality from thyroidectomy to less than 1% and then became more concerned with the cosmetic aspects of his surgical incision. Employing an 8 to 10 cm collar incision that would later bear his name, Kocher popularized an approach that would last well into the 20th century (Fig 1).
Central Incisions in Modern Thyroid Surgery

The cervical collar incision is generally regarded in modern texts of surgery as the appropriate neck incision for thyroidectomy.7-10 However, unlike the long transverse incision popularized by Kocher, current techniques in thyroid incisions have evolved, enabling surgeons to minimize the size of their surgical incision.3 Although this transition toward smaller incisions has been readily put to practice, very little has been published with regard to the optimal position and length of the cervical collar incision. Positioning of the collar incision during thyroidectomy is of critical importance, as an inappropriately placed incision may lead to needless scarring or unusual prominence. Incisions placed less than 2 cm or one nger breadth from the sternal notch frequently lead to hypertrophic scarring, especially when the scar overlies the manubrium.10 Furthermore, appropriate placement of the surgical incision may allow 63
Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI. Address reprint requests to Herbert Chen, MD, Associate Professor, Division of General Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792. E-mail: chen@surgery.wisc.edu
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S. Pinchot, H. Chen, and R. Sippel
Figure 1 Historical incisions. Before the transverse cervical collar incision was popularized, skin incisions were of myriad variety, length, and direction. The incisions of many great pioneers of thyroid surgery are shown above.
scarring to be hidden by clothing.12 Several techniques have been described to aid in optimal incision placement. They include (1) 1.5 to 2.0 cm superior to the sternoclavicular joints,9 (2) 1 cm caudal to the cricoid cartilage,3,10,11 (3) 3 to 4 cm above the sternum extending laterally to the sternomastoid muscles,13 (4) midway between the sternal notch and the notch of the thyroid cartilage.14 Of note, all techniques recommend incision placement in a pre-existing neck crease whenever possible. In 2002, in a detailed prospective study, Jancewicz and co-workers proposed the optimal position for marking the midpoint of a collar incision is one nger-breadth above the sternal notch in the neutral upright neck position, or two nger-breadths above the sternal notch in the supine, extended neck.7 These suggestions were reached after performing a thorough study
of incision migration in the supine and hyperextended neck and after evaluating the inuence of the degree of neck pathology (factors such as goiter size, patient body mass index, neck circumference, and type of surgery) on incision position.7 More recently, Sturgeon and colleagues disputed this claim after an evaluation of several patients referred to their practice for a missed thyroid during initial operation.11 They noted one of the main reasons for failure at the initial operation to locate the thyroid was that the incision was made too low on the neck of patients with subjectively long necks.11 Based on their recommendations, the cricoid cartilage should be palpated and the incision made approximately 1 cm inferior to this site because it centers the incision directly over the mid portion of the thyroid gland.11 This approach also gives the surgeon better exposure of the superior
Incisions and exposure of the neck

pole vessels, allowing an overall smaller incision length. This is our current procedure of choice. Driven by patient demand for less pain and better cosmetic results, the length of incision for thyroid surgery has been decreasing in size.3,15-19 Unlike the traditional 8 to 10 cm collar incision popularized by Kocher and his contemporaries, several studies now indicate that thyroidectomy may be accomplished through a much smaller incision.3 Much of the decrease in incision length can be attributed to a higher placement of the incision, which allows better and safer exposure of the superior pole vessels through a much smaller incision. Ferzli and colleagues described the use of a 2.5 cm to 3 cm incision, termed a mini-thyroidectomy.15 Similarly, Takami16 outlined the use of a 3 cm skin incision, and Park and co-workers described a minimally invasive open thyroidectomy technique through a 3 to 3.5 cm incision.17 Brunaud and colleagues at the University of California, San Francisco claried the demarcation between conventional thyroidectomy and its minimally invasive counterpart.3 After determining the minimum incision length in over 200 consecutive operations, this group proposed the term minimally invasive should be associated with an incision shorter than 3 cm for thyroidectomy and 2.5 cm for parathyroidectomy.3 Several studies identify the only limiting factor to mini-thyroidectomy is the size of the gland; glands larger than 7 cm frequently required extension of the incision beyond 4 cm.15,16 Brunaud and colleagues suggest patient BMI, extent of the planned exploration, and the resident clinical training stage should also be taken into account before performing a minimally invasive thyroidectomy or parathyroidectomy.3
65 tive surgery, the lateral approach allows dissection through a relatively unspoiled tissue plain.23-24 Park and co-workers initially described the use of a lateral incision for hemithyroidectomy in a cohort of 466 patients; compared with historical controls, these patients had no difference in demographics, complications, or extent of surgery including central compartment lymph node dissections but exhibited smaller scar size, operative time, blood loss, and analgesia requirements.17 Stemming from the study of over 500 minimally invasive parathyroidectomies, Delbridge and colleagues from the University of Sydney Endocrine Surgical Unit have extensively described their focused lateral approach to thyroidectomy/(MATS).20-23 Delbridge and co-workers have shown MATS utilizing a 2 cm lateral incision may be a superior approach and is especially suited to patients with a single follicular thyroid nodule 2 cm in diameter.20 Some contraindications to the focused lateral approach to thyroidectomy include a history of neck irradiation, history of prior neck surgery, multinodular goiter, a diagnosis or family history of multiple endocrine neoplasia, proven autoimmune thyroiditis, signicant comorbidity such as pregnancy, a nodule size 3 cm, ne needle aspiration biopsy conrmation of carcinoma, and anatomic considerations such as extreme obesity.21,23 Indeed, a thorough understanding of the anatomy and embryology of the thyroid and parathyroid glands is of paramount importance when performing a lateral approach. Anatomic considerations will be detailed later in this paper. Delbridge and co-workers have clearly shown that with sufcient light and retraction, key anatomical structures in the neck may be safely dissected through a small lateral incision.21,23
Lateral Focused Incision for Minimal Access Thyroid Surgery and Parathyroidectomy
While historically the traditional approach to the central neck has been a central incision, recently there has been a signicant increase in the use of a lateral incision to approach the central neck. It has been recently shown that neck surgery, either parathyroidectomy or hemithyroidectomy, may be feasibly performed through a 2 cm lateral incision and is safe.20 We nd the lateral approach is especially useful for focused parathyroidectomies and for reoperative neck surgery. The lateral approach has also been applied to primary thyroidectomy for Minimal Access Thyroid Surgery (MATS).20-24 For parathyroidectomies, the lateral approach gives excellent exposure for an upper gland, especially if located deep in the tracheoesophageal groove. For reopera-
Perioperative Care
Anesthesia
Most thyroid and parathyroid operations are performed under general anesthesia; however, it is possible to perform the procedure under local anesthesia. In fact, Spenknabel and co-workers recently reported prospective data on 1,025 consecutive thyroidectomies performed under local anesthesia and noted that this method appears safe and applicable to a wide range of patients.25 Confounding factors, including patient anxiety and comfort, suggest this approach may be best for high-risk patients in whom general anesthesia is contraindicated or in remote areas where an anesthetist is unavailable. More commonly, general inhalation anesthetic agents are utilized via endotracheal intubation; this airway is especially preferred for those in whom large goiters exert chronic pressure against the trachea or in those with large substernal goiters.
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Position and Operative Preparation
Figure 2 General topography of the thyroid gland (with left-sided tumor) in gentle neck extension. The technique for thyroidectomy demands a thorough working knowledge of the anatomical details of normal and pathological thyroid glands and their relationship to anatomic landmarks in the neck. A general understanding of the surface anatomy will facilitate placement of cosmetically desirable incisions whereas minimizing complications relating to poor wound healing, such as scar widening or keloid formation. Prominent landmarks of the necks surface anatomy include the sternocleidomastoid muscle and the midline landmarks including the thyroid cartilage, body of the hyoid bone, arch of the cricoid cartilage, and the sternal notch. Of the midline structures, the most prominent is the crest of the thyroid cartilage, or Adams apple. Prominent in postpubertal men, this structure is usually located between the 3rd and 5th cervical vertebrae. The body of the hyoid bone is palpated approximately 1.5 cm above the thyroid cartilage at the level of the 3rd cervical vertebra. Likewise, the arch of the cricoid cartilage, the only complete cartilaginous ring around the airway, is located on the same horizontal plane as the 6th cervical vertebra. As the consistency of cervical skin changes with age, gentle extension of the neck facilitates identication of these structure.27 The thyroid gland lies immediately caudal to the larynx, deep to the stenothyroid and sternohyoid muscles at the level of the C5-T1 vertebral bodies. Though the gland may lie cephalad to C5 (lingual thyroid), it is rarely found lower than T1.27 Weighing approximately 30 g in the adult, the thyroid gland typically consists of two lobes, a connecting isthmus, and an ascending pyramidal lobe. Each lobe is approximately 5 cm in length, 3 cm at its greatest width, and 2 to 3 cm thick,28 though one lobe may be smaller than the other or may be congenitally absent. The thyroid isthmus unites the lobes over the trachea, usually at the 2nd through 3rd tracheal rings. Interestingly, the isthmus may be absent in up to 10% of thyroid glands while the pyramidal lobe is absent in about 50%.
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Figure 3 Optimal placement of the cervical collar incision for thyroidectomy. After the induction of general anesthesia, the patient is placed in a supine position and the neck is gently extended. Perfect alignment of the head and body must be ensured to prevent erroneous placement of the cervical incision. Appropriate positioning ensures the isthmus of the thyroid overlies the second and third tracheal rings just caudal to the cricoid cartilage.11 The cricoid cartilage is then palpated and its location noted. The skin incision is placed in a skin crease approximately 1 cm below the cricoid cartilage. The orientation of the incision should be along the lines of Langer, since crossing the normal skin lines may lead to more prominent scarring.27 It is of paramount importance to place the incision in a neck crease whenever possible, as neck creases have the least amount of tension. An incision made too low will result in pronounced scar formation, difculty in dissecting the superior pole, or perhaps missing the thyroid entirely. Incisions made too high will make it difcult to remove lymph nodes in the superior mediastinum if indicated and can be cosmetically unappealing.11 In smaller masses, we traditionally begin with a 3 to 4 cm incision, though lateral extension of this incision may be warranted based on the size of the gland. Factors that affect the size of the incision include gland size, patient body mass index, extent of planned exploration, and resident training level.3,15-16 The skin incision should be made with a deliberate sweep of the scalpel, dividing the skin and subcutaneous tissue simultaneously. Hemostasis is achieved with bipolar electrocautery; alternatively, larger bleeding subcutaneous vessels may require application of hemostats with subsequent ligation of the bleeding vessel. The latter method should be limited to one or two ligatures, as many more may result in tissue strangulation with subsequent induration and inammation.26 The incision is deepened to the areolar tissue plane just deep to the platysma muscle where an avascular plane is reached.
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Figure 4 Development of the subplatysmal plane. Once the incision is made and deepened through the platysma, the superior and inferior subplatysmal planes are developed. Using two Alice clamps or 3 to 5 straight Kelly clamps, the superior edge of the platysma muscle or dermis is grasped and placed under tension. Ideally, dissection should proceed within the relatively avascular plane between the platysma muscle bers and the anterior jugular veins. Utilizing a combination of blunt and sharp dissection within this planealternatively, bipolar electrocautery is acceptable to raise the skin ap in the hands of an experienced surgeonthe upper skin ap is freed to the level of the thyroid notch. The inferior edge of the platysma is then grasped and an inferior ap is created in similar fashion. Dissection should be carried down to the level of the suprasternal notch. The anterior jugular veins symmetrically ank the midline raphe of the neck. Special care must be taken to avoid injury to these veins, as active bleeding and danger of air embolus have been reported with openings made into the anterior jugular vein.26
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Figure 5 Exposing the thyroid gland. The skin aps are held apart with a self-retaining retractor. With a scalpel or bipolar electrocautery device, the cervical fascia investing the paired sternohyoid muscles is then incised, separating the strap muscles (sternohyoid and sternothyroid). As the length of this incision will ultimately determine access to the thyroid gland, the incision should be placed exactly in the midline of the neck between the sternohyoid muscles, extending from the thyroid notch to the level of the sternal notch. There are frequently crossing veins at both the superior and inferior aspects of the midline and care must be taken to avoid bleeding. The strap muscles are then elevated and gently dissected off the thyroid capsule bilaterally. This step may be facilitated by the use of a peanut dissector or blunt forceps. The blunt handle of the forceps may be inserted beneath the paired sternohyoid muscles to assist with dissection. This avascular plane between the strap muscles and the thyroid gland can be bluntly dissected until the middle thyroid vein is identied. Alternatively, should the strap muscles and thyroid capsule be densely adherent, the loose fascia investing the thyroid gland may be elevated with forceps and incised with a scalpel to develop the appropriate cleavage plane.26 Development of the proper cleavage plane will allow lateral mobilization of the sternohyoid and sternothyroid muscles. Complete incision and reection of the fascia of the sternothyroid muscle clearly reveals the blood vessels within the capsule of the thyroid gland. Further exposure of the thyroid gland may be facilitated by the use of small Richardson retractors, which are utilized for exposure of the gland via lateral retraction of the strap muscles. Routine division of the strap muscles is unnecessary unless greater exposure is required to gain safe access to an extremely large or vascular goiter.13
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Figure 6 Central approach to thyroidectomy. Before lateral dissection, the isthmus should be identied and mobilized both superiorly and inferiorly just anterior to the trachea. The isthmus is divided at this point if a lobectomy is indicated; alternatively, if a total thyroidectomy is to be done, our preference is to remove the gland in one piece. During this medial dissection, the pyramidal lobe, if present, is dissected free from the surrounding tissues with electrocautery. The superior extent of this lobe is divided at the point in which the gland tapers to a brous band, usually near the level of the thyroid cartilage. Small Richardson retractors are then utilized for lateral retraction of the strap muscles. The dissection should proceed laterally until the middle thyroid vein is identied. The thyroid lobe is retracted anteromedially and the carotid is retracted laterally, placing the middle thyroid vein on tension. The vein is then divided to allow better exposure of the superior pole and posterior thyroid. The lateral tissues are then bluntly dissected up to the level of the superior pole. The superior pole is then dissected free medially, between the cricothyroid muscle and the thyroid capsule. The space medial to the superior thyroid artery is carefully opened to expose the external branch of the superior laryngeal nerve (ESLN). Using right angle clamps from medial to lateral, the superior pole vessels are dissected and doubly clamped and tied with 2-0 silk ties. These vascular branches must be tied close to the thyroid gland to prevent injury to the ESLN. With the superior pole mobilized, the upper parathyroid gland is identied and separated from the thyroid gland, taking care to protect its vascular pedicle. Through careful dissection of the tissues along the lateral aspect of the mid thyroid gland, the recurrent laryngeal nerve (RLN) is visualized. Once identied, the inferior pole vessels can be safely divided using 2 to 0 silk ties. Care should be taken to avoid injury to the inferior parathyroid gland, which lies anterior to the RLN on the posterior lateral surface of the thyroid. The ligament of Berry is then sharply divided, taking care to perform dissection anterior to the RLN to avoid injuring any medial branches. For a total thyroidectomy, the above procedure is repeated on the contralateral side.
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Figure 7 Focused lateral approach to the neck. The lateral approach was developed for minimal-access parathyroidectomy, but after much success has also been applied to minimal access thyroidectomy.23 A thorough understanding of the anatomical details of normal and pathological thyroid and parathyroid glands and their relationship to anatomical landmarks in the neck is critical. As thyroid gland anatomy has been previously reviewed, emphasis will be placed on important parathyroid considerations. The superior parathyroids develop from the fourth pharyngeal pouch and are relatively constant in their location. An enlarged superior parathyroid gland frequently descends along the tracheoesophageal grove and may be found in a relatively posterior plane in the lower part of the neck.21 The inferior parathyroid glands develop from the third pharyngeal pouch and are more inconsistent in their location. Descending with the developing thymus, the inferior parathyroids are found in a relatively anterior plane. Intraoperative identication of the tumor is the critical, though often daunting, task of any minimally invasive neck surgeon. Important anatomic landmarks that aid in the localization of pathology include the tracheoesophageal groove, prevertebral fascia, tubercle of Zuckerkandl, and recurrent laryngeal nerve (RLN).21 Deformities from large thyroid nodules or parathyroid adenomas may displace the RLN; therefore, the nerve must be visualized and preserved through gentle dissection to avoid vocal cord dysfunction and/or paralysis. With this said, similar to conventional thyroidectomy, the patient is positioned in a supine position with the arms tucked at their side. The neck is placed in mild extension and the head supported with a donut pillow or foam head support. The bed is placed in 15 to 30 degrees of the reverse Trendelenburg position to lessen venous congestion in the neck veins. A ber optic operating headlight is used for optimal viewing of the surgical eld.
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Figure 8 Incision and exposure during lateral approach. The site of the incision depends on the location of the thyroid or parathyroid pathology. Important anatomical landmarks including the midline, suprasternal notch, and medial margins of the sternocleidomastoid (SCM) muscles are identied and may be marked. With a deliberate sweep of a scalpel, a 2.5 cm lateral transverse incision is made directly over the pathology or over the middle of the thyroid lobe, straddling the medial margin of the SCM. The incision should be performed sharply through the platysma. Counter traction on the skin with a sterile sponge prevents back bleeding. Again, electrocautery should be limited on the subcutaneous bleeding sites to prevent thermal injury. The subplatysmal plane is developed using a combination of blunt nger dissection and electrocautery. Any vessels encountered may be ligated or clipped with metal clips. For parathyroidectomy, minimal subplatysmal plane is needed. However, for thyroidectomy adequate development of the subplatysmal plane will allow mobility of the skin incision over the relevant area of dissection throughout the procedure. Skin and platysma aps may be retracted with a self-retaining retractor; alternatively, a hand-held retractor (i.e., vein or loop) may be utilized to allow for greater mobility and repositioning of the incision to where the dissection is being done. The SCM is then identied and its overlying investing layer of cervical fascia is incised. Lateral dissection along the SCM will allow exposure of the lateral margin of the strap muscles. The SCM is retracted laterally; a silk stay stitch may be placed to hold the muscle in position and allow adequate exposure.
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Figure 9 With the SCM retracted laterally, the investing fascia of the strap muscles is incised. Exposure of the thyroid gland is facilitated by careful dissection of the space posterior to the strap muscles. Adequate dissection of this space will allow for visualization of the inferior pole of the thyroid and trachea. The thyroid gland and strap muscles are then retracted medially together, exposing the middle thyroid vein. The middle thyroid vein is divided and ligated with 2-0 silk ties or metal clips. The space medial to the common carotid artery is then dissected down to the prevertebral fascial plane. Gentle nger dissection facilitates the development of the space between the posterior aspect of the thyroid gland and prevertebral fascia. This essentially frees up the entire parathyroid-bearing region of that side of the neck.21,23
74 Following induction of general anesthesia, the patient should be placed in a supine, semierect position on a standard operating table. Neck extension is facilitated by placing a folded sheet, pillow, or sandbag beneath the shoulders. Jancewicz and co-workers suggest placing a 1 liter ask of intravenous uid transversely in line with the spines of the scapulae beneath the patient, allowing gentle extension of the neck.7 Our preference is to place a deated intravenous pressure bag underneath the patients shoulders. The bag is then inated to produce the appropriate amount of neck extension. The head should be well supported using a gelatinous head-ring, and special care must be taken, especially in the elderly, to avoid over-extension of the neck. Hyperextension of the neck may lead to increased postoperative pain and a slight risk of spinal cord damage.11 The operating table may be tilted 15 to 30 degrees in the reverse Trendelenburg position to reduce venous congestion in the neck. A headlight facilitates lighting and exposure through the limited incisions. Importantly, the anesthesiologist and surgeon must ensure perfect alignment of the head and body before marking the line of incision; any small deviation to the side may result in an inaccurately placed incision.26 Hemithyroidectomy then proceeds in systematic fashion. Cranial retraction of the skin incision reveals key structures involved in dissection of the superior pole. The superior pole of the thyroid lobe is retracted laterally, opening the avascular space and allowing for visualization of the external branch of the superior laryngeal nerve (ESLN) and superior thyroid artery. The artery is divided between silk ties or metal clips immediately adjacent to the thyroid capsule, preventing injury to the ESLN. Adjustment of skin retraction toward the midline allows for exposure of the trachea and thyroid isthmus. We expose the tracheal surface above and below the isthmus and subsequently divide the isthmus. This facilitates mobility of the thyroid lobe and allows for increased exposure during the lateral dissection. Caudal retraction allows for mobilization and dissection of the inferior pole. Care must be taken to avoid injury to the inferior parathyroid gland. Finally, the skin incision is retracted laterally; delivery of the thyroid nodule or lobe through the small incision facilitates lateral gland exposure. Careful dissection will allow for identication and protection of the recurrent laryngeal nerve (RLN). The ligament of Berry is then divided and the thyroid lobe is removed.21,23

able suture in simple or gure-of-eight fashion. The wound is closed with subcutaneous absorbable suture to the platysma and a running subcuticular non-absorbable suture for dermal approximation.
Special Postoperative Care

Postoperatively, the patient should immediately be placed in a low Fowler position with the head of the bed elevated at least 10 to 20 degrees. This position should be maintained for 12 hours to facilitate hemostasis and limit neck vein engorgement. Guidelines should be developed to address serum calcium management after total, near total, or subtotal thyroidectomies and total parathyroidectomies. On the postoperative evening, we refrain from routine use of intravenous calcium supplementation, reserving the use of 1 amp of calcium gluconate only if carpopedal spasm and/or tetany suggest severe hypocalcemia. Serum calcium levels should be measured 4 hours postoperatively and again the following morning. Calcium carbonate is given as needed for mild symptoms of hypocalcemia; patients with severe hypocalcemia are started on scheduled calcium carbonate three times per day. All patients are started and sent home on scheduled calcium carbonate twice daily beginning on postoperative day 1. We recommend patients discontinue the use of calcium supplementation at least 1 day before the follow-up clinic visit so as to assess an accurate serum calcium and PTH level at that time.
Important Complications
Several important complications may be encountered after thyroidectomy or parathyroidectomy. Complications resulting from damage to vital structures, such as the laryngeal nerves and parathyroid glands, may be avoided by maintaining a near bloodless surgical eld and performing meticulous dissection. The most important complications of thyroidectomy are:

Recurrent laryngeal nerve injury External branch of superior laryngeal nerve injury Hypocalcemia resulting from hypoparathyroidism Neck hematoma Seroma formation Infection Wound complications
Wound Closure
Meticulous hemostasis must be the standard of practice as the most serious and life-threatening complication of thryoidectomy and parathyroidectomy is postoperative airway obstruction because of excessive bleeding and hematoma formation. Although the placement of surgical suction drains may allow for drainage of a small hematoma, the routine use of surgical drains is not an alternative to hemostasis. In fact, Hurtado-Lopez and co-workers recently showed that patients in whom surgical drains were used required prolonged hospitalization compared with those without drains.29 Additionally, active suction may damage the recurrent laryngeal nerve or parathyroid glands if the drain is in close contact with these structures.30 After adequate hemostasis is obtained, the strap muscles are reapproximated with absorb-
Unilateral recurrent laryngeal nerve injury manifests as transient or permanent hoarseness in the postoperative period. Bilateral recurrent laryngeal nerve injury is much more serious, because the vocal cords may assume a median or paramedian position, often causing inspiratory stridor and the need for emergent intubation. Fortunately, bilateral recurrent laryngeal nerve palsy is an exceedingly rare complication of thyroidectomy and is most likely to be encountered with difcult reoperation when one recurrent laryngeal nerve has already been injured during a prior operation. Indeed, the identication of the recurrent laryngeal nerve throughout its course is quite fundamental if damage from thyroidectomy is to be avoided. Injury to the external branch of the superior laryngeal nerve occurs when the nerve is inadequately visualized during the dissection and ligation of the upper pole vessels.

Injury to the nerve can result in transient impairment of the ipsilateral cricothyroid muscle, making projection of ones voice or singing a high note quite difcult. Although these injuries tend to be transient and improve in the months after surgery, permanent injuries do occur. Hypocalcemia in the postoperative period is not uncommon and results from removal, injury or devascularization of the parathyroid glands resulting in mild to severe hypocalcemia. The nadir for serum calcium levels after surgery often does not occur until 48 to 72 hours postoperatively; however, symptoms consistent with mild and severe hypocalcemia must be recognized. Symptoms range from mild paresthesias to carpopedal spasm and tetany. Mild hypocalcemia may be treated with oral calcium supplementation and close observation; more profound hypocalcemia requires intravenous calcium supplementation initially, followed by oral supplementation with calcium and/or calcitriol. Perhaps the most serious and life-threatening complication of thyroidectomy and parathyroidectomy is airway obstruction resulting from postoperative bleeding and neck hematoma. Though extremely rare, the urgency of treating this condition once recognized cannot be overemphasized, especially if respiratory compromise is present. In emergency situations, treatment requires removal of the surgical dressing and reopening the wound, even if at the bedside, for evacuation of the hematoma and relief of the pressure being exerted on the upper airway. Aseptic technique should be maintained whenever possible. Pressure should be applied with a sterile sponge and the patient should immediately return to the operating room for surgical exploration and hemostasis. Wound complications can be minimized by the use of appropriate incision placement and the use of non-absorbable suture. This is especially true of keloid formation and scar granuloma. Though seroma is common with extended lymph node dissection, most resorb spontaneously and do not require further intervention. Infection is quite rare, and we do not routinely use prophylactic antibiotics preoperatively.
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References
1. Netterville JL, Aly A, Ossoff RH: Evaluation and treatment of complications of thyroid and parathyroid surgery. Otol Clin North Am 23: 529-552, 1990 2. Farrer WB: Complications of thyroidectomy. Surg Clin North Am 63: 1353-1361, 1993 3. Brunaud L, Zarnegar R, Wada N, et al: Incision length for standard thyroidectomy and parathyroidectomy: When is it minimally invasive? Arch Surg 138:1140-1143, 2003 4. Welbourn RB: The history of endocrine surgery (1st ed). New York, NY: Praeger Publishers, 1990 5. Hannan SA: The magnicent seven: A history of modern thyroid surgery. Int J Surg 4:187-191, 2006 6. Hegner CF: A history of thyroid surgery. Ann Surg 95:481-492, 1932 7. Jancewicz S, Sidhu S, Jalaludin B, et al: Optimal position for a cervical collar incision: A prospective study. ANZ J Surg 72:15-17, 2002 8. Broughan TA, Esselystyn CB: Lobectomy and subtotal thyroidectomy, in Nyhus LM, Baker RJ (eds): Mastery of surgery (2nd ed, Chapt 23). Boston, MA: Little, Brown and Company, 1992 9. Clark OH: Total thyroidectomy and lymph node dissection for cancer of the thyroid, in Nyhus LM, Baker RJ (eds): Mastery of surgery (2nd ed, Chapt 23). Boston, MA: Little, Brown and Company, 1992 10. Scott-Conner CE, Dawson DL: Operative anatomy (1st ed). Philadelphia, PA: J.B. Lippincott Company, 1993 11. Sturgeon C, Corvera C, Clark OH: The missing thyroid. J Am Coll Surg 201:841-846, 2005 12. Songun I, Kievik J, van de Velde CJ: Complications of thyroid surgery, in Clark OH, Quan-Yang D (eds): Textbook of endocrine surgery (1st ed, Ch 22). Philadelphia, PA: W.B. Saunders Company, 1997 13. Wheeler MH: The technique of thyroidectomy. [Review]. J R Soc Med 91:12-16, 1998 (suppl 33) 14. Milroy E: Parathyroid gland exploration, in Dudley H, Carter DC, Russel RC (eds): Atlas of general surgery (2nd ed). London, Thomsen Publishing Group, 1985, pp 922-929 15. Ferzli GS, Sayad P, Abdo Z, et al: Minimally invasive, nonendoscopic thyroid surgery. J Am Coll Surg 11:161-163, 2001 16. Takami HE, Ikeda Y: Minimally invasive thyroidectomy. Curr Opin Oncol 18:43-47, 2006 17. Park CS, Chung WY, Chang HS: Minimally invasive open thyroidectomy. Surg Today 31:665-669, 2001 18. Gagner M, Inabet WB: Endoscopic thyroidectomy for solitary thyroid nodules. Thyroid 11:161-163, 2001 19. Miccoli P, Berti P: Minimally invasive parathyroid surgery. Best Pract Res Clin Endocrinol Metab 15:139-147, 2001 20. Sackett WR, Barraclough BH, Sidhu S, et al: Minimal access thyroid surgery: Is it feasible, is it appropriate? ANZ J Surg 72:777-780, 2002 21. Agarwal G, Barraclough BH, Reeve TS, et al: Minimally invasive parathyroidectomy using the focused lateral approach. II. Surgical technique. ANZ J Surg 72:147-151, 2002 22. Gosnell JE, Sackett WR, Sidhu S, et al: Minimal access thyroid surgery: Technique and report of the rst 25 cases. ANZ J Surg 74:330-334, 2004 23. Palazzo FF, Sywak MS, Sidhu SB, et al: Safety and feasibility of thyroid lobectomy via a lateral 2.5-cm incision with a cohort comparison of the rst 50 cases: Evolution of a surgical approach. Langenbecks Arch Surg 390:230-235, 2005 24. Yeh MW, Sidhu SB, Sywak M, et al: Completion thyroidectomy for malignancy after minimal access thyroid surgery. ANZ J Surg 76:332334, 2006 25. Spanknebel K, Chabot JA, DiGiorgi M, et al: Thyroidectomy using local anesthesia: A report of 1,025 cases over 16 years. J Am Coll Surg 201:375-385, 2005 26. Zollinger Jr RM, Zollinger Sr RM: Subtotal thyroidectomy, in Zollingers atlas of surgical operations (8th ed). New York: McGrawHill, 2003, pp 364-372
Conclusion
Surgical incisions and exposures in the neck, particularly with regard to thyroidectomy and parathyroidectomy, have evolved drastically since the days of Kocher and Billroth. Techniques for optimally placing a neck incision have evolved to accommodate the desire for minimally invasive surgery and improved cosmesis. The transverse cervical collar incision, initially described by Kocher and altered by countless others, remains the preferred incision of choice for most surgeons based on its relative ease, adequacy of exposure, and suitable cosmetic result. In selected patients, a lateral focused approach to the parathyroid gland and thyroid lobe is feasible, safe, and effective. In the hands of a skilled surgeon familiar with the anatomic details of each surgical technique, either approach should be associated with extremely low morbidity and mortality.
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27. Skandalakis JE, Carlson GW, Colborn GL, et al: Neck, in Skandalakis JE (ed): Skandalakis surgical anatomy: The embroyologic and anatomic basis of modern surgery. Athens: Paschalidis Medical Publications, 2004, pp 1-116 28. Polluck WF: Surgical anatomy of the thyroid and parathyroid glands. Surg Clin North Am 44:1161, 1964

29. Hurtado-Lopez LM, Lopez-Romero S, Rizzo-Fuentes C, et al: Selective use of drains in thyroid surgery. Head Neck 23:189-193, 2001 (abstract only) 30. Lennquist S: Thyroidectomy, in Clark OH, Duh QY (eds): Textbook of endocrine surgery (1st ed). Philadelphia, PA: W.B. Saunders Company, 1997, pp 147-153
Thoracic Incisions
David B. Campbell, MD
ccess to chest contents and appreciation of the anatomy of the chest wall and internal anatomy are practical requisites for all general and trauma surgeons. The expediency of a clinical situation and the scope of the patients problems dictate the access options chosen. Although minimally invasive options for elective operations within the chest are evolving, small chest incisions offer less exible access than laparoscopic surgery because of xed intercostal positions, postoperative pain from involvement of multiple intercostal nerves, and immature instrumentation to address the variety of pathologies encountered. The need for adequate ventilation with endobronchial control is a unique concern for all chest operations, but a generous open exposure is required for rapid and uncompromised exposure of the heart, lung hilum, or aorta. A collaborative effort with anesthesia provides lung isolation. A double lumen endotracheal tube, an endobronchial blocker or mainstem bronchial intubation can all be effective. Abdominal incisions through soft tissues have inherent mobility, but most thoracic incisions provide limited exibility because access is limited by the rigid chest wall and overlapping muscles with different functions. A proper thoracic incision provides adequate exposure while minimizing damage to ribs, cartilage, muscle, and intercostal nerves. Options for extension should be anticipated. A limited incision provides limited exposure, and over-retraction may result in complex local rib fractures and muscle tears. The skin incision may be minimized, but the internal intercostal incision should be relatively wide from front to back to allow the ribs to separate by hinging like bucket handles. Optimal pain management begins before thoracotomy, and a variety of ancillary indwelling catheters can alleviate pain and expedite recovery.
the lung re-inated to check for air leaks. Direct suture, stapling, and applied topical adhesives and hemostatic agents should be used aggressively to minimize postoperative air leaks. Infection risks are thereby minimized, chest tube removal expedited and lengths of stay minimized. Interrupted paracostal sutures of #1 braided Dacron provide secure rib approximation. Intrathoracic dead space should be minimized and routinely two 32F chest tubes are used: a straight tube in an apical anterior position for air evacuation and a basal curved tube in the posterior recess to recover blood and uid. Tubes should exit the skin anterior to the mid axillary line to minimize discomfort when the patient lays supine. Incised muscles are re-approximated with strong running suture taking bites of fascia in front and back. Large spaces around separated muscles should be drained with soft exible catheters to prevent seroma formation. The risk of chest wall hernia after thoracotomy is low, and most incision closures are straightforward. However, pain control deserves special emphasis, as adequate analgesia allows patients to maintain adequate pulmonary toilet and to progress toward functional recovery. Epidural, paravertebral, and intercostal catheters all have proper places in postoperative management. Intercostal nerve blocks (bupivacaine 0.5% with epinephrine 1/200,000) offer excellent supplemental pain relief. Brief discussions of chest incisions useful to the general surgeon, particularly with respect to trauma, follow. Table 1 presents a summary comparison of four useful incisions.
Anterior Thoracotomy Chest Incision Closure

Hemostasis is achieved in the usual manner, but unipolar electrocautery should be used with caution in the posterior mediastinum near intervertebral foramina. After every thoracotomy, the chest should be ooded with warm saline and
Department of Cardiothoracic Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA. Address reprint requests to David B. Campbell, MD, Professor of Cardiothoracic Surgery, Penn State Milton S. Hershey Medical Center, MC H-165, 500 University Drive, Hershey, PA 17033. E-mail: dbc2@psu.edu
Emergent access to the heart for manual cardiopulmonary resuscitation or tamponade can be achieved by left anterolateral thoracotomy. Access to both ventricles, the left hilum, and the descending aorta is possible. A submammary incision is made and extended down to the superior surface of the underlying fth or sixth rib (Fig 1A). This is at the inferior margin of the pectoralis major muscle, and intercostal incision is made over the top of the underlying rib. Extension laterally follows the split bers of the serratus. Medial extension to the sternum will divide the internal mammary artery, which lies 1 cm lateral to the sternum. Limiting the medial extent avoids this trouble77
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Figure 1 Anterior thoracotomy. (A) Line of incision, left chest rotated up 30 degrees. (B) Deep exposure with pectoralis major incised medially.
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Figure 1 (Continued) Anterior thoracotomy, continued. (C) Pericardium opened, heart exposed, sutures placed in stab wound. (D) Chest closure with rib reapproximation and paracostal sutures.
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Table 1 Comparison of the Four Most Useful Incisions Incision Median sternotomy Advantages Wide mediastinal exposure Access to both hila Full cardiac access Option for cardiopulmonary bypass Little postoperative pain Augments liver and IVC exposure for difcult abdominal cases Good internal access to chest wall injuries Rapid access to heart and hila, especially on left side Vertical and/or trans-sternal extensions possible Adequate for all lung and esophageal problems Best distal arch and descending aortic exposure Conventional instruments used Intercostal ap can be harvested Extension for thoracoabdominal exposure possible Adequate for almost all lung and esophageal problems Conventional instruments used No muscle division, little to heal Cosmetically acceptable Extension to posterolateral thoracotomy possible Intercostal ap can be harvested
D.B. Campbell
Disadvantages Requires a saw Poor access to descending aorta Poor access to left lower lobe Suboptimal access to trachea and bronchi No esophageal access
Anterior thoracotomy
Posterolateral thoracotomy
Lateral muscle sparing thoracotomy
Limited access to lung No esophageal or large airway access Moderate postoperative pain Frequent rib fractures Requires muscle division and reconstruction Cosmetically undesirable Moderate postoperative pain Requires dissection and retraction (not rapid) Inadequate aortic exposure Moderate postoperative pain
some bleeding. A retractor is inserted and opened as much as needed, mindful that the anterior costal cartilages are more fragile than bone. These cartilages can be divided with rib shears to enhance the exposure (Fig 1B), although wound closure is tedious and healing is not rapid. Stout sutures are placed through the cartilages and interspace musculature, and several paracostal sutures are placed around the ribs of the interspace incision (Fig 1D). Two chest tubes (apicoanterior and posterobasal) are brought out below, and a subcutaneous drain may be prudent if large muscle aps were developed. This incision provides access to the ipsilateral hilum that is unrestricted (Fig 1C). In case of massive lung bleeding, a large hilar clamp can be applied from above downwards across the pulmonary artery, bronchus, and both veins. Emergent clamping of the descending thoracic aorta is possible by pulling the lung forward. Relief of pericardial tamponade or open cardiac message requires incision into the pericardial space, and widest exposure is possible with a longitudinal incision anterior and parallel to the phrenic nerve. Pericardiotomy should avoid phrenic nerve division. Finger pressure may be required to control bleeding from a cardiac stab wound, and traction sutures maintain exposure of the heart for suture placement. The pericardium can be loosely re-approximated with interrupted sutures to provide cardiac support. Closure should be loose enough to prevent tamponade from epicardial bleeding, but sutures should be close enough to prevent cardiac herniation through the defect. Broken costal cartilages and ribs are frequent with this emergency access. Transection of the anterior costal carti-
lages may be more prudent than applying increasing raw retraction. Nevertheless, closure is routine with paracostal sutures providing needed stabilization. This incision can be extended across the sternum with a saw or rib shears, although closure is less stable. Postoperative pain control efforts (above) will be appreciated by the patient.
Posterolateral Thoracotomy
When uncompromised access to the lung and mediastinum is necessary, the patient should be placed in full lateral position. If hemoptysis is a signicant problem, then the airway should be controlled with a double lumen tube, or at least with an intrabronchial blocker. Turning the patient into the lateral decubitus position places the good lung down, making it more vulnerable to blood and secretions in the airway. Posterolateral thoracotomy is the classic incision for lung and mediastinal surgery and on the left side this exposure is still preferred for descending aortic procedures. On the right side, it offers the best access to the intrathoracic trachea and to the mid and upper esophagus. The skin incision for posterolateral thoracotomy is generous, from behind the scapula around its inferior border to the submammary crease anteriorly (Fig 2A). The blood and nerve supplies of the latissimus dorsi originate above, so this muscle should be mobilized inferiorly and transected at a low level to maximize its functional recovery. Intercostal division is made widely from front to back, and the serratus anterior can often be left intact and re-
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Figure 2 Posterolateral thoracotomy. (A) Incision with patient in left lateral decubitus position. (B) Wide exposure with latissimus dorsi divided, 5th rib incised posteriorly. (C) Rib approximator allows secure closure with paracostal sutures.
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Figure 3 Muscle sparing lateral thoracotomy. (A) Incisions, patient in left lateral decubitus position. (B) Subcutaneous aps allow serratus anterior muscle retraction upward and chest wall access.
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Figure 3 (Continued) Muscle sparing lateral thoracotomy, continued. (C) After interior front-to-back muscle division, crossed Balfour and Tufer retractors provide exposure without rib fractures.
tracted upward and forward. If wider exposure is required, then a short length of rib can be transected posteriorly with rib shears (Fig 2B) to prevent multiple complex fractures. Closure is conducted in layers, with strong permanent paracostal sutures (Fig 2C) and running absorbable sutures for muscle re-approximation and subcutaneous layers. When this incision is made, two interspaces lower, extension across the costal margin for thoracoabdominal exposure is straightforward.
Muscle Sparing Lateral Thoracotomy

Large muscle division can be avoided for most routine thoracic exposures, including those for acute chest wall and lung trauma, and for late empyema drainage and decortication. A lateral thoracotomy of 4 to 5 inches with separation and retraction of latissimus and serratus muscles allows manual palpation of intrathoracic structures and use of conventional instruments for most elective operations. Crossed Tufer and Balfour retractors provide ample access and exposure at the level of the hila over the major ssure. Landmarks for the skin incision are a point one inch above the scapular tip and the inframammary crease (Fig 3A). The sixth rib underlies a line connecting these points, but chest entry can be an interspace higher. Skin and subcutaneous tissues are incised along this line
from just behind the midaxillary line (the anterior border of the latissimus) forward about 5 inches. The anterior border of the latissimus is mobilized above and below. This muscle is retracted posteriorly and away from the chest wall. With nger dissection, the underlying serratus is separated, taking care not to injure the long thoracic nerve on its surface. Traction is applied to the serratus in an upward and anterior direction to allow identication of its inferior border, and the fat below is cauterized and divided to expose the chest wall (Fig 3B). When access to the top of the thoracic cavity is desired (fourth intercostal space) it is often advantageous to separate the lowest insertion of the serratus from the chest wall. Maintaining upward traction on the serratus, ipsilateral ventilation is stopped and intercostal incision is made above a rib, from back to front through the three layers of intercostal muscle. Using a Kelly clamp for initial intercostal entry allows the lung to fall away from the chest wall, minimizing the chance of lung injury from cautery. The incision is enlarged anteriorly and posteriorly with electrocautery. Paraspinous muscles posteriorly and the upward sweep of the ribs (short of the internal thoracic artery pedicle) anteriorly are practical limits for intercostal division. If an intercostal ap is not required, a Tufer retractor maintains intercostal distraction, and a Balfour is opened at right angles to provide additional soft tissue retraction (Fig 3C). Rib division and fractures are avoided. This exposure allows insertion of a hand for full palpation of the lung and mediastinum, and conventional instruments and techniques are used for necessary procedures.
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Figure 4 Median sternotomy. (A) Sternum is divided in the midline with a saw. (B) Pericardium is opened and suspended, allowing full cardiac and hilar access.
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Figure 4 (Continued) Median sternotomy, continued. (C) Sternal halves impacted with interrupted wire closure.
Closure of this incision can be rapid. Chest tubes are brought out inferior to the wound and posterior intercostal nerve blocks are done internally under direct vision using a small bore spinal or long aspiration (mediastinoscopy) needle. After the chest is irrigated the lung is reinated and tested for air leaks. It is deated and paracostal sutures are placed and tied. The serratus and latissimus muscles return to normal positions when retraction is released. A soft drain above the muscles prevents seroma formation, and fat and subcutaneous layers are closed with running absorbable sutures.
Median Sternotomy
Access for hilar dissection and control through this incision is good, and median sternotomy offers optimal exposure and control for resuscitation and penetrating cardiac wounds. The dissections required for all lobectomies except the left lower lobe can be done, so lung control is excellent. Although the esophagus cannot be accessed through this anterior exposure, transpericardial incision and retraction of the aorta and vena cava offers excellent control of the distal trachea and carina. With assistance from selective lung ventilation this wide access also opens options for internal rib xation for complex blunt chest wall trauma. Upper abdominal exposure shortcomings of laparotomy are resolved if the midline incision is extended cephalad with sternotomy. Surgeons who have participated in multi-organ harvests for transplantation understand the utility of access to the inferior vena cava and
hepatic veins. One of the few downsides of this incision is that either a sternal saw or Lebsche knife and mallet must be available. Skin and subcutaneous tissue is incised to the midline of the anterior sternal table, and the suprasternal ligament is incised after palpating for anomalous neck vessels and controlling crossing veins. The sternum is divided in the middle with a saw (Fig 4A). Periosteal bleeding is arrested with electrocautery and a retractor inserted. Bone wax interferes with sternal healing, but can be used sparingly if marrow bleeding is profuse. Access to the lungs is achieved by opening the pleura, which is done most safely at the level of the 3rd or 4th interspace, above the base of the heart. The pericardium is usually opened vertically in the midline, and the incised edges can be pulled up to the wound edges to elevate and expose the heart. Manual cardiac massage is conducted without restriction through this incision, and air embolism can be addressed directly by aspiration of pulmonary artery and right ventricle. If the patients condition requires it and if massive anticoagulation can be tolerated, cardiopulmonary bypass can be instituted for resuscitation, to correct hypothermia, for massive pulmonary embolism or for irreversible airway compromise (Fig 4B). Hilar access is straightforward if the pericardium is pulled in the opposite direction, which allows manual compression or clamping. Individual pulmonary arteries and pulmonary veins can also be controlled or clamped inside the pericardium. After wound irrigation and hemostasis, closure is accomplished with circlage sternal wires and layers of absorbable sutures. Drainage tubes should be left in opened
86 pleural spaces, and anterior and posterior intrapericardial tubes are customary. The pericardium is either left open or loosely approximated by two or three interrupted sutures. Tight impaction of the sides of the sternum assures union with minimal pain and infection risk. A rule of thumb for
D.B. Campbell
closure is one wire per 10 kg patient weight, with the top three wires through the bone above the angle of Louis and the remainder of the wires passing around the sternal halves in the intercostal spaces, avoiding the internal thoracic arteries (Fig 4C).
Retroperitoneal Exposures
John Radtka III, MD, and David Han, MD, MS, FACS
he retroperitoneal approach provides exposure for a variety of general surgical procedures. In some situations, it is simply an alternative to a transperitoneal approach, in others it is the preferred method of exposure. In such cases, advantages of the retroperitoneal approach may include avoiding a hostile peritoneal cavity through which previous surgeries have occurred, better and easier exposure, and reduced uid shifts and the accompanying decreased physiologic stress. Oftentimes, the impediment to choosing a retroperitoneal exposure is a lack of surgeon experience. Two common applications of retroperitoneal exposure are for vascular reconstruction and anterior spine surgery. Familiarity with this approach provides an excellent option in performing these procedures.
Vascular Reconstructions
A left retroperitoneal approach is the approach of choice for patients with thoracoabdominal aortic aneurysms, and is also indicated in patients with a hostile abdomen because of previous surgery, inammatory abdominal aortic aneurysms, associated horseshoe kidneys, and right sided ostomies. In patients with a left sided ostomy, a right retroperitoneal approach can be used. Relative contraindications for a left retroperitoneal approach include the need for extensive right renal or right iliac artery reconstruction. In patients who require evaluation of the peritoneal contents at the time of exploration, a retroperitoneal approach with subsequent opening of the peritoneum can be done. This may also allow better exposure of the right renal and iliac arteries. Proper positioning of the patient is vital to allow appropriate exposure and to prevent postoperative complications. Exposure of the femoral arteries at the groin is often required, and so having the pelvis as close to at as possible is ideal. In the obese patient, it is often helpful to mark the femoral pulses with an indelible marker before nal positioning as the skin position relative to the femoral arteries may change depending on the size of the pannus. The torso is rotated to the right, with the left arm supported on an over-arm board
Department of Surgery and Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA. Address reprint requests to David Han, MD, MS, FACS, Associate Professor of Surgery and Radiology, Department of Surgery, Penn State Milton S. Hershey Medical Center, P.O. Box 850, M.C. H053, Hershey, PA 170330850. E-mail: dhan@hmc.psu.edu
(Fig 1). An operating table that allows exion and extension at its midpoint is also helpful, with the table extended for exposure, and exed to facilitate closure. A beanbag is placed under the patients torso for full support, and pressure points at the right axilla and left upper arm must be checked and padded. Rotation of the operating table from side to side allows better exposure of the abdominal or femoral components as needed. Depending on the amount of proximal aortic exposure required, the incision is begun in the 9th, 10th, or 11th interspace at the mid axillary line, but can be carried to the posterior axillary line if more proximal exposure is required. If the 11th interspace is used, this incision can be carried directly over the 12th rib with resection of the 12th rib to facilitate exposure. Medially, the incision is carried either to the lateral edge of the rectus muscle, or can be taken to the midline at the level of the umbilicus and extended into a midline abdominal incision. Division of the underlying oblique muscle and fascia is performed. Typically, the plane between the transverus abdominus and the peritoneum is most easily identied laterally. In some patients, however, the transversus abdominis muscle is quite attenuated, and inadvertent entry into the peritoneal sac can easily occur. In these patients, division of the anterior and posterior rectus sheath can allow easier identication of the underlying peritoneum, and subsequent development of the appropriate retroperitoneal plane (Fig 2). Proximally, division of the costal cartilage at the 9th or 10th interspace is performed (Fig 3). The intercostal muscles are divided on the superior edge of the rib. If the pleura is entered, it can be closed at the end of the procedure after placement of a single posterior tube thoracostomy. The diaphragm is left intact if possible except in the case of thoracoabdominal aortic reconstruction, where either circumferential or radial division of the diaphragm is required. Circumferential division is more cumbersome, but avoids damage to the major branches of the phrenic nerve. Completion of the proximal dissection is accomplished by sweeping the peritoneum off of the diaphragm superiorly, taking care to avoid traction injuries to the underlying spleen, which can be palpated through the peritoneum. Exposure of the perivisceral aorta is performed by opening the fascia anterior and lateral to the left kidney, and mobilizing the plane posterior to the kidney. Venous branches from the left renal vein are ligated at this point, and the kidney is swept anteriorly. The ureter should be identied medially as it courses along the peritoneal sac (Fig 4). Padded self-retaining retrac87
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Figure 1 Patient positioning: An operating table that allows exion and extension at its midpoint should be utilized. This provides extension for exposure and exion for closure. The patient is placed with the torso rotated to the right and the hips as at as possible to allow exposure of both groins if needed. The left arm is supported on an over arm board. A beanbag is placed under the torso of the patient for full support. All pressure points are checked and adequately padded. Depending on the amount of proximal aortic exposure required, the incision is begun in the 9th, 10th, or 11th interspace at the mid axillary line, but can be carried to the posterior axillary line if more proximal exposure is required. If the 11th interspace is used, this incision can be carried directly over the 12th rib with resection of the 12th rib to facilitate exposure. Medially, the incision is carried either to the lateral edge of the rectus muscle, or can be taken to the midline at the level of the umbilicus and extended into a midline abdominal incision.
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Figure 2 External oblique and latissimus dorsi dissection: The incision is continued through the subsequent layers of muscle. Initially the latissimus dorsi is incised. Then the external oblique muscle and aponeurosis are divided in the direction of their bers. m. muscle.
tors are used to hold the peritoneal contents medially. Closure of the wound in layers is performed with either continuous or interrupted suture. Choice of suture material is typically based on surgeon preference. Monolament absorbable suture such as polydioxanone is a suitable choice. If the fascial layers are closed with continuous suture, reapproximation of the transected costal margin is best performed with separate sutures, rather than as part of the fascial closure. Closed suction drainage via a tube thoracostomy is performed if the pleural space was entered. This is typically most easily accomplished by making a stab incision one or two rib spaces above the operative incision, and directing the tube posteriorly through a rib interspace one level above the stab incision. One posterior tube is generally sufcient, and can be removed in 24 to 48 hours.
Spine Exposures
Exposure of the proximal lumbar bodies and disc interspaces proceeds similar to that for vascular reconstructions. Exposure of the L4, L5, and S1 bodies and interspaces does not require extensive proximal exposure and thus can be performed with a different approach (Fig 5). The patient can be laid at on the operating table. The left arm is placed either at the side or at 90 taking care to avoid strain on the brachial plexus. A rolled towel or bump can be placed under the left ank, but in so doing, one must be careful to avoid placing additional strain at the level of the left axilla. Adequate exposure, however, can usually be obtained in patients of varying body habitus without this maneuver.
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Figure 3 Identication of the retroperitoneal plane: Division of the costal cartilage at the 9th or 10th interspace is performed. The intercostal muscles are divided on the superior edge of the rib. If the pleura is entered, it can be closed at the end of the procedure after placement of a single posterior tube thoracostomy. The diaphragm is either left intact or divided if needed, as is the case in thoracoabdominal aortic reconstruction. The transversus abdominus muscle is divided and the plane between this muscle and the peritoneum is identied. The identication of this plane is most easily accomplished in the lateral portion of the exposure. In some patients, however, the transversus abdominis muscle is quite attenuated, and inadvertent entry into the peritoneal sac can easily occur. In these patients, division of the posterior rectus sheath can allow easier identication of the underlying peritoneum, and subsequent development of the appropriate retroperitoneal plane. m. muscle.
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Figure 4 Aortic exposure: Completion of the proximal dissection is accomplished by sweeping the peritoneum off of the diaphragm superiorly, taking care to avoid traction injuries to the underlying spleen, which can be palpated through the peritoneum. The abdominal contents that are enveloped by peritoneum are retracted anteriorly and to the right. Exposure of the perivisceral aorta is performed by opening the fascia anterior and lateral to the left kidney, and mobilizing the plane posterior to the kidney. Venous branches from the left renal vein are ligated at this point, and the kidney is swept anteriorly. The ureter should be identied medially as it courses along the peritoneal sac. Padded self-retaining retractors are used to hold the peritoneal contents medially. SMA superior mesenteric artery; Ao aorta; L. left; IMA inferior mesenteric artery.
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Figure 5 Relationship between the vertebral bodies and the abdominal vasculature. Anterior exposure of the spine is most easily and safely accomplished with an understanding of the relationships between the large vessels and the corresponding lumbar bodies. Exposure of the L1 through L4 bodies and interspaces requires exposure and mobilization of the aorta through a left sided retroperitoneal approach. The vena cava is sufciently to the right to not require formal exposure, although identication of its medial (left) edge is appropriate. Exposure of the L4 and L5 bodies and interspace requires more extensive dissection of the left common iliac artery and vein. Exposure of the L5 and S1 interspace is most easily accomplished by a direct anterior approach, with identication of the right common iliac artery as well as the left common iliac artery and vein. IVC inferior vena cava; SMA superior mesenteric artery; L. left; Ao aorta; IMA inferior mesenteric artery.
Although there is typically minimal variability from patient to patient, uoroscopic examination before skin incision can help guide the exact placement of the incision. For exposure of the L5-S1 interspace, as in anterior lumbar interbody fusion, a transverse incision is created starting at the midline approximately midway between the symphysis pubis and the umbilicus. It is extended laterally just beyond the edge of the rectus sheath, although it may be extended as needed. Generous full thickness aps from the skin to the fascia are mobilized in the cephalad and caudal directions. A vertical incision is then made in the anterior rectus sheath approximately 1 to 2 cm lateral to the linea alba. Leaving a fascial edge medially facilitates closure. The underlying rectus muscle is swept laterally and the underlying posterior sheath is incised vertically. The plane between the peritoneum and the posterior rectus sheath is identied, and the peritoneum is swept medially. An important landmark here is the underlying psoas muscle,
which should remain in the posterior aspect of the wound. As the peritoneum is elevated and moved medially, the ureter is identied on the peritoneum and the left common iliac artery can be palpated. Medial to this, the left common iliac vein is identied, and the medial border skeletonized. Directly behind this lies the L5-S1 interspace, and further vessel mobilization is performed to allow adequate anterior exposure. Exposure of the L4 and L5 lumbar bodies typically requires a more lateral approach, given that the L4 body typically lies directly behind the aortic bifurcation. An oblique incision can be created, with the level determined by preoperative uoroscopy. Division through the oblique musculature and transversus abdominus is as described previously; the retroperitoneal plane is most easily identied laterally. In the medial portion of the incision, division of the lateral edge of the rectus abdominus fascia and muscle may be necessary. Mobilization of the left common iliac artery and distal aorta is
necessary, with division of the middle sacral and lumbar arteries as needed.
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Suggested Reading
Arko FR, Bohannon WT, Mettauer M, et al: Retroperitoneal approach for aortic surgery: Is it worth it? Cardiovasc Surg 9:20-26, 2001 Cinar B, Goksel O, Kut S, et al: Abdominal aortic aneurysm surgery: Retroperitoneal or transperitoneal approach? J Cardiovasc Surg (Torino) 47: 637-641, 2006 Darling C, 3rd, Shah DM, Chang BB, et al: Current status of the use of retroperitoneal approach for reconstructions of the aorta and its branches. Ann Surg 224:501-506, 1996 Ernst CB: Left ank retroperitoneal exposure: a technical aid to complex aortic reconstruction. J Vasc Surg 14:283-291, 1991 Gumbs AA, Bloom ND, Bitan FD, et al: Open anterior approaches for lumbar spine procedures. Am J Surg 194:98-102, 2007 Rob C: Extraperitoneal approach to the abdominal aorta. Surgery 53:87-89, 1963 Williams GM, Ricotta J, Zinner M: The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery 88:846-855, 1980
Conclusions
Familiarity with the retroperitoneal approach provides an additional weapon in the arsenal of approaches to abdominal pathology. A three dimensional understanding of the anatomical relationships between structures plays a vital role, and a comfort level in using this approach can be obtained with experience. Proper positioning of the patient is perhaps the most important part of the process, as attention to pressure and stretch points will help to prevent postoperative complications.
The Abdominoinguinal Incision

Constantine P. Karakousis, MD, PhD
he pivotal anatomical point in the abdominoinguinal incision is the origin of the inferior epigastric vessels as it is true for the radical groin (ilioinguinal) dissection when the latter is performed with in continuity removal of the inguinal and deep nodes. In the radical groin dissection, the anterolateral abdominal wall muscles and the inguinal ligament are divided lateral to the external iliac-femoral artery axis and the inferior epigastric vessels are approached from the lateral side as they are ligated and divided. In the abdominoinguinal incision, the inguinal ligament is divided near the pubic tubercle and the inferior epigastric vessels are approached from the medial side as they are ligated at their origin and divided. The indications for the abdominoinguinal incision are: 1. Large tumors in the iliac fossa extending anteriorly to involve the inner layers of the abdominal wall or inferiorly behind or through the inguinal ligament into the groin. 2. Tumors involving the iliac vessels requiring the in continuity exposure of the femoral vessels for their removal. 3. Tumors xed to the wall of the lesser pelvis requiring removal of the obturator internus. 4. Large tumors of the pubic bone extending into the pelvis or adductor group of muscles; or pelvic tumors extending through the obturator foramen into the adductors. 5. Large, lower abdominal tumors extending laterally and/or inferiorly so extensively that they cannot be retracted sufciently to be dissected off the external iliac vessels to which they may be loosely attached. The abdominoinguinal incision exposes in continuity the abdominal cavity with the adjacent anatomical area of the thigh (femoral triangle) and in that sense it is, for the lower quadrants of the abdomen, the equivalent of the thoracoabdominal incision for the upper quadrants.
Operative Technique
A lower midline abdominal incision is employed starting at the pubic symphysis and extending proximally to the umbi-
Department of Surgery, State University of New York at Buffalo and Kaleida Health, Buffalo, NY. Address reprint requests to Constantine P. Karakousis, MD, PhD, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209. E-mail: ckarakousis@kaleidahealth.org
licus and often above the umbilicus for a few centimeters, the proximal extension of the incision depending on the proximal extension of the tumor (Fig 1). The incision veers around the left or right side of the umbilicus depending on the location of the tumor. The linea alba is identied and incised most easily next to the umbilicus. The peritoneum is then incised. Although the linea alba is incised to the pubic symphysis, the peritoneal incision as one approaches the lower end is veered to the left or right, and often both sides of the easily palpable urinary bladder. Through the abdominal portion of the incision, one explores the entire abdominal cavity and then assesses the tumor that is to be resected. Mere xation is not a sign of unresectability as the involved soft tissues can be resected through this incision. Bone involvement, other than that of the pubic bone, can be dealt with through the incisions employed in internal hemipelvectomy. The abdominal incision is then extended at its lower end transversely to the mid-inguinal point on the side of involvement, and then vertically over the presumed course of the femoral artery for a few centimeters or to the apex of the femoral triangle (Fig 2). If the aim is to simply provide exposure in continuity of the vessels but there is no tumor actually below the inguinal ligament a short vertical incision over the femoral vessels sufces to allow for their exposure. On the other hand, if one is to perform an ilioinguinal dissection for bulky lymph nodes, which cannot be safely removed through the usual incision for radical groin dissection, the vertical portion of the incision is extended to the apex of the femoral triangle followed by development of aps. Similarly if one is to remove in continuity the pubic bone or the entire ischiopubic ramus en bloc with the adductor muscles, the vertical incision is again long to the apex of the femoral triangle but then there is no need to develop aps, but simply to expose the vessels and medial to them the adductors. The transverse portion of the incision (from the pubic symphysis to the mid-inguinal point) is deepened through the subcutaneous fat exposing laterally the spermatic cord in the male. The anterior rectus sheath and rectus abdominis are divided close to the pubic crest and the inguinal ligament divided at the pubic tubercle (Fig 3). The spermatic cord, if not involved by the tumor, can be extricated from the inguinal canal by dividing the oor of the canal from its deep aspect (Fig 4). Dividing the internal spermatic vessels deep to the internal inguinal ring, if necessary, allows the testicle to remain viable if the latter has not been mobilized off its scrotal sac that provides some blood supply to the testicle. Alter-
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95 detached off the iliac fascia completing the process of operative exposure. The operation then continues according to the location and extent of the tumor. For a tumor of the iliac fossa one exposes lateral to the external iliac artery and deep to the iliac fascia the femoral nerve that surrounded by a vessel loop is dissected from the tumor, unless it is found to be surrounded by the tumor in which case it can be divided. In the latter case, the patient is unable to actively extend the knee but he can still ambulate, after a while without any external support. When the iliofemoral vessels are involved they are exposed proximally and distally, the tumor is mobilized all the way around tethered only by the vessels, the patient is heparinized, vascular clamps are applied proximally and distally and the specimen is removed followed by vascular reconstruction. When the tumor is attached to the wall of the lesser pelvis, immediately behind the external iliac vein the fascia is incised, the bone exposed and the dissection continues on the bone, on the lateral side of the obturator internus, taking care of the internal iliac vessels, the overlying ureter and more posterolaterally of the sacral nerves forming the sciatic nerve under the piriformis. The sacral nerves constitute the limit of the resection. The obturator nerve issuing from a position lateral (behind) the internal iliac vessels and coursing on the surface of the obturator internus fascia toward the obturator foramen is expendable, since its removal does not cause any deciencies in the ordinary use of the lower extremity (Fig 8). The obturator vessels behind the nerve can also be ligated and divided. The pubic bone, when involved, is removed by dividing the pubic symphysis with a Gigli saw, the anterior pubis ramus close to the acetabulum and the posterior pubic or ischial ramus en bloc with the soft tissues involved. The closure of the incision is simple: The lateral third of the inguinal ligament is sutured to the iliac fascia (when the latter is removed, to the iliofemoral ligament of the hip joint), and the medial half of the inguinal ligament to Coopers ligament. The anterior sheath and rectus abdominis are sutured to the pubic crest and the midline abdominal incision is closed in routine fashion (Fig 9).
Figure 1 A right abdominoinguinal incision for a tumor xed to the right side of the pelvis. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
natively, the external oblique aponeurosis may be opened from the external inguinal ring and the spermatic cord extricated by incising the inguinal oor to the internal inguinal ring (Figs 5 and 6). Because the cord lies lateral to the inferior epigastric vessels at the level of the internal ring, complete freedom of the former cannot occur before ligation and division of the latter. After the inguinal ligament is divided at the pubic tubercle, the inguinal ligament and the adjacent abdominal wall are retracted anteriorly and laterally so that the inferior epigastric vein and then the artery are ligated and divided at their origin (Fig 7). The lateral third of the inguinal ligament is then
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Figure 2 The femoral vessels exposed below the inguinal ligament. m. muscle. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 3 The ipsilateral rectus abdominis is divided near the pubic crest. m. muscle. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 4 In the male, the spermatic cord may be freed by incising the inguinal oor from inside (dotted line). (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 5 The cord may be freed also by incising the external oblique aponeurosis over the inguinal canal. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 6 The oor of the inguinal canal is incised anteriorly completing the extrication of the cord. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 7 After ligation and division of the inferior epigastric vessels at their origin, and detachment of the lateral third of the inguinal ligament off the iliac fascia, the exposure provided by the abdominoinguinal incision is complete. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 8 Operative eld after incontinuity dissection of the inguinal and deep nodes (the latter still attached over the internal iliac vessels). (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 9 The fascial layer of the abdominoinguinal incision has been closed. m. muscle. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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Figure 10 In case of mesh repair of resected lower abdominal wall layers interposing sartorius between the mesh and the vessels. m. muscle. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
Modications of the Technique

In the presence of a previous inguinal incision the transverse portion of the abdominoinguinal incision may be led through or around the previous inguinal incision with an ellipse, so as to avoid two parallel, close to each other incisions, which may result in ischemia of the in between skin. When a portion of the lower abdominal wall including possibly the inguinal ligament and the overlying skin are removed, reconstruction may be effected through the use of the contralateral rectus abdominis and its posterior sheath-peritoneum based on the inferior epigastric vessels. This ap will reach easily the iliac crest and has a width of about 8 cm. After repair of the defect with the ap a skin graft may be applied to the muscle to complete the repair. If a mesh is to be used for the repair there should be no direct contact with bowel loops through the availability of peritoneum or the elongated omentum or perhaps the nonadhering surface of a dual-face Goretex patch. In any case, it is wise to mobilize the sartorius to cover the vessels (Fig 10).
Overall, it is best to avoid the placement of a mesh to repair the lower abdominal wall and inguinal ligament as the mesh can erode into the adjacent artery or vein particularly if the vessels have been or will be subject to radiation. The abdominoinguinal incision can be made bilaterally for a low, midline pelvic tumor with bilateral xation to the pelvic walls. In the latter case, however, instead of a bilateral abdominoinguinal incision it sufces to perform a simplied version, that is, a T incision, with the vertical portion of the T being the midline abdominal incision and the transverse portion the bilateral transverse extension along the pubic crests to the pubic tubercles and the bilateral division of the rectus abdominis muscles off the pubic crests (Fig 11). This T incision allows exposure of the external iliac vessels to the point they course under the inguinal ligament, exposure of the obturator foramen, of the external iliac and obturator nodes and therefore is suitable not only for resection of large, midline pelvic tumors, but also for bilateral pelvic node dissection (Fig 12).
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Figure 11 A T-incision for lower midline pelvic tumors. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
Figure 12 T-incision with transection of the rectus abdominis muscles at the pubic crest, provides exposure of the distal external iliac vessels, obturator nerve, and obturator foramen bilaterally. m. muscle. (Reprinted with permission from Bland KI, Karakousis CP, Copeland III EM (eds): Atlas of Surgical Oncology. Philadelphia, W.B. Saunders, 1995.)
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The results of tumor removal with this incision depend on the grade of the tumor and the opportunity one has to procure wide margins around the tumor, as is true of any other incision. The abdominoinguinal incision, however, renders resectable tumors in the lower quadrants of the abdomen or pelvis often considered unresectable with the ordinary incisions or subjected to external hemipelvectomy in the past.
Complications and Results

The abdominoinguinal incision is tolerated well and has no more complications than any ordinary incision. The only complication occasionally occurring specic to this incision is a slight degree of skin edge necrosis often not requiring debridement at the corner of the midline incision and the lateral transverse extension particularly if there has been undermining of the skin corner through the subcutaneous fat.
Thoracoabdominal Incision: A Forgotten Tool

Niraj J. Gusani, MD, Diego Avella, MD, Kevin F. Staveley-OCarroll, MD, PhD, and Eric T. Kimchi, MD
omplex upper gastrointestinal, hepatic, retroperitoneal, and distal thoracic aortic pathologies prove to be some of the most difcult and challenging surgical problems. Not only is the pathology of these areas/organs complicated, the anatomy and surgical approach to these lesions can often be a signicant challenge. Exposure to critical structures is often limited because they are obscured by the lower ribs and the diaphragm. Often there is a dilemma in deciding whether a procedure should be performed from a transabdominal or transthoracic approach. Each one of these has its limitations in providing optimum exposure. An excellent solution to this problem was developed in the late 19th century by Mikulicz,1 who performed the rst thoracoabdominal incision. Over the ensuing decades its use has been intermittently reported for a variety of complex pathologies and trauma of the upper abdomen, retroperitoneum, and lower thorax.2 Despite providing exceptional exposure its use has never gained widespread acceptance. Concerns of chest wall instability, pain from costochodritis, phrenic nerve injury, and the complexity of the closure have certainly played a role in the underutilization of this incision. We use the thoracoabdominal incision for access to complex retroperitoneal sarcomas that will likely require multi-visceral resection and may possibly involve the diaphragm. In addition, this approach is useful for treatment of lower esophageal and gastroesophageal (GE) junction pathologies, especially in the re-operative setting. The intent of this chapter is to provide a straightforward approach to this incision for the general surgeon with tips to help avoid common pitfalls. The illustrations provide details for a left thoracoabdominal incision, which is more commonly used, but certainly one may apply the same principles and techniques in a right-sided approach.
Technique
All patients, after successful induction of general anesthesia, are placed in the appropriate lateral decubitus position. Single lung ventilation aids exposure, but it is not strictly required as the lung can be adequately packed and retracted.
Section of Surgical Oncology, Department of Surgery, Penn State College of Medicine, Hershey, PA. Address reprint requests to Eric T. Kimchi, MD, Assistant Professor of Surgery, Section of Surgical Oncology, Department of Surgery, Penn State Milton S. Hershey Medical Center, P.O. Box 850, 500 University Drive, H070, Hershey, PA 17033. E-mail: ekimchi@psu.edu
Safety measures to minimize the chance of nerve injury with the patient in this position must not be overlooked. An axillary roll made up of a rolled bedsheet, towel, wrapped saline bag, or silicone bump, are all appropriate choices. A suctionenabled collapsible beanbag aids in maintaining the patients torso in the ideal position. In addition, it is important to position the patients lower extremities with the bottom leg bent at the knee and the top leg straightened with a pillow between the legs. To optimize exposure, we maximally ex the bed at the level of the patients iliac crest. It is essential to prepare the operative eld so that the abdomen is exposed as far as possible past the midline of the abdomen and back to allow for the proper incision. Once sterile towels are placed to square off the operative eld, an adhesive drape is placed over the operative site and then the nal drapes are placed. Others have advocated use of the semilateral position with a thoracoabdominal incision,3 but we favor the straight lateral approach because it provides the best exposure of the distal thoracic esophagus and GE junction. An incision is performed from a point 2 cm below the tip of the scapula to a point in the midline of the abdomen equidistant from the xiphoid process and the umbilicus (Fig 1). The incision is deepened preserving the latissimus and incising the serratus anterior muscle. The chest is entered at the eighth intercostal space. The pulmonary ligament is divided and the lung mobilized and retracted cephalad and medially out of the eld, allowing for exposure of the intrathoracic aorta and esophagus for a left sided approach or the inferior vena cava for a right sided approach. Subsequently, the abdominal cavity is entered by dividing the diaphragm peripherally, 2 to 4 cm from its lateral and anterior attachments to the ribs, using electrocautery (Fig 2). Periodic placement of marking stitches on the divided diaphragm is very helpful when aligning the diaphragm at closure. Typically, a portion of the costochondral cartilage is excised to prevent postoperative costochondritis. The abdominal incision is opened to the linea alba at a point equidistant from the xiphoid process to the umbilicus. The abdominal wall muscles are divided and the peritoneum entered. Exposure is aided by placement of a segmental self-retaining retractor. This provides excellent exposure to the intrathoracic esophagus, GE junction, and the abdominal viscera (Fig 3). Closure is aided by taking the bed out of the exed position. The diaphragmatic repair is performed rst using #1 PDS suture; appropriate alignment of the diaphragm is facilitated by the marking stitches placed earlier. A troublesome 107
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Figure 1 Patient placed in the right lateral decubitus position. Thoracoabdominal incision is depicted extending from a point 2 cm below the tip of the left scapula to a point in the midline equidistant from the xiphoid process and the umbilicus.
Thoracoabdominal incision
109
Figure 2 Viewing from above the cross section of the diaphragm, the hatched line represents the circumferential incision made along the peripheral edge of the diaphragm, approximately 2 to 4 cm from its lateral attachment to the ribs. This avoids injury to the phrenic nerve and allows entry from the thoracic cavity into the abdominal cavity to create a common cavity for the thorax and peritoneum. IVC inferior vena cava.
area is encountered at the junction of the diaphragm and the abdominal fascia; this inherently weak area is difcult to reapproximate and may lead to an abdominal wall or diaphragmatic hernia. An en masse closure incorporating the ribs, diaphragm, and abdominal wall muscle with a #2 Vicryl gure-of-eight suture can be helpful in strengthening this area. Similarly, the ribs are re-approximated using interrupted #2 Vicryl gure-of-eight sutures. The abdominal wound is closed by re-approximating the abdominal wall muscle and fascia en mass using a running #1 PDS suture. The chest wall musculature is closed in two layers using running #1 Vicryl sutures, and the skin is approximated with surgical clips.4
Discussion
General surgeons routinely perform procedures involving the upper GI tract, such as gastric bypass surgery, Nissen fundoplication, gastric resections, and a variety of emergent procedures. These surgical procedures, especially in the emergent setting, can carry signicant morbidity, sometimes requiring multiple re-operations. Operative intervention in these challenging patients is often quite difcult, as a result of previous abscess formation, adhesive disease, or other pathologic processes involving both the thoracic and abdominal cavities.5
Periodically, when adequate visualization of the upper abdomen and distal esophagus from a midline incision cannot be obtained, the incision is extended from the xiphoid process through the costochondral cartilage and into an upper intercostal space to create a thoracoabdominal incision. We do not advocate this approach for upper GI or lower thoracic procedures as the heart continues to impede access to the posterior mediastinum in the supine position. When faced with this situation we suggest that the upper aspect of the midline incision should be closed to a point midway between the umbilicus and the xiphoid process, an adhesive dressing is then placed over the wound, and the patient may be repositioned in the lateral decubitus position. The thoracoabdominal incision described above may then be performed allowing for proper exposure. Although the thoracoabdominal incision is occasionally used by surgical oncologists and thoracic surgeons, it has largely been abandoned by general surgeons.6 This exposure, as described above, allows for excellent visualization of the upper abdominal GI tract and lower thoracic esophagus; as such, it is a useful tool that should be maintained in the repertoire of general surgeons performing upper GI procedures. We feel that this technique is particularly useful in the subset of patients who develop complex upper GI tract complications. In addition, we propose that this incision can be employed with acceptably low morbidity.
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Figure 3 This exposure is achieved from a thoracoabdominal incision with a patient in the right lateral decubitus position. The diaphragm has been incised circumferentially and retracted cephalad, allowing for exposure of the GE junction, intraabdominal viscera, and intrathoracic esophagus. Ao aorta; Esoph esophagus.
References
1. Mikulicz M: Grenzgeb Med Chir, vol 8, in Garlock JH: Combined abdominothoacic approach for carcinoma of the cardiac and lower esophagus. Surg Gynecol Obstet 83:737, 1946 2. Heitmiller RF: The left thoracoabdominal incision. Ann Thorac Surg 46:250-253, 1988 3. Lumsden AB, Colborn GL, Sreeram S, Skandalakis LJ: The surgical anatomy and technique of the thoracoabdominal incision. Surg Clin North Am 73:633-644, 1993
4. Cameron J: Atlas of surgery: The Esophagus, the Stomach, the Duodenum, the Spleen, Laparoscopic Cholecystectomy. Baltimore: Williams and Wilkins, 1991, pp 28-44 5. Koniaris LG, Spector SA, Staveley-OCarroll KF: Complete esophageal diversion: A simplied, easily reversible technique. J Am Coll Surg 199: 991-993, 2004 6. Forshaw MJ, Gossage JA, Ockrim J, et al: Left thoracoabdominal esophagogastrectomy: Still a valid operation for carcinoma of the distal esophagus and esophagogastric junction. Dis Esophagus 19: 340-345, 2006

2008, Vol.10, No.2, Incisions and Operative Exposures

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2008, Vol.10, No.2, Incisions and Operative Exposures

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Volume 10, Number 2

Volume 10, Number 2

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