operative technique in general surgery

for Thyroidectomy and ParathyroidectomyScott Pinchot, MD, Herbert Chen, MD, and Rebecca Sippel, MD W hile many articles in the medical literature focus on the complications of thyroid an

In 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

con-ventional 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

preoper-ative 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

significant morbidity This is especially true for surgical

ex-posures 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 bymost general surgeons but, when needed, familiarity with theanatomy and technique of reconstructive closure is critical.Cervical exposures are needed for more than just thyroiddisease and clearly a meticulously performed incision in thisrelatively cosmetic area of the body is important for patientsatisfaction as well as for minimizing complications.The present collection of operative incisional techniquesprovides the detail and description necessary for the generalsurgeon who may be somewhat less practiced in these moreunusual exposures to perform them in a fashion that willprovide the greatest operative success with minimal subse-quent morbidity

Walter A Koltun, MD

Professor of Surgery Peter and Marshia Carlino Professor of Inflammatory Bowel Disease Chief, Section of Colon and Rectal Surgery

Penn State College of Medicine Milton S Hershey Medical Center

Editor-in-Chief

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doi:10.1053/j.optechgensurg.2008.05.004

Adequate exposure is the key to successful surgery

Al-though the abdominal incision has become the mainstay

of the general surgeon’s exposure, there are a number of other

incisions that are critical to the general surgeon’s

armamen-tarium In this issue, we describe in detail the following

ex-posures: cervical, retroperitoneal, thoracic,

thoraco-abdomi-nal, 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 geon who is unfamiliar with the incision to perform the tech-nique

sur-One of the beauties of general surgery is the variability inthe clinical and operative challenges that it presents By beingwell versed in a variety of exposures, the surgeon is muchbetter equipped to successfully meet these challenges It is

my sincere hope that this issue will increase the practicinggeneral surgeon’s versatility It was a pleasure preparing thisissue and seeing it come together in its final form I’m verygrateful to the authors for their hard work

Kevin F Staveley-O’Carroll, MD, PhD, FACS

Guest Editor

62 1524-153X/08/$-see front matter © 2008 Elsevier Inc All rights reserved.

doi:10.1053/j.optechgensurg.2008.05.003

for Thyroidectomy and Parathyroidectomy

Scott Pinchot, MD, Herbert Chen, MD, and Rebecca Sippel, MD

W hile many articles in the medical literature focus on

the complications of thyroid and parathyroid surgery

such as nerve injury and hypoparathyroidism, very little

at-tention has been directed toward incision length and location

as they relate to conventional open thyroidectomy and

para-thyroidectomy.1,2 Current techniques for open

thyroidec-tomy and parathyroidecthyroidec-tomy 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

briefly outline the historical background as it pertains to the

cervical incision for these procedures, and we hope to

pro-vide a thorough review of current methodological

ap-proaches to thyroidectomy and parathyroidectomy

Historical Background

Some of the first descriptions of operations for “lumps in the

neck” may be found within the writings of The School of

Sal-erno, 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

treat-ment of a single, large goiter; he writes, “two setons were

in-serted at right angles, with the help of a hot iron, and

manipu-lated toward the surface [of the skin] twice daily until they had

cut through the flesh.”4 It is little wonder why (based on these

writings) the mid-19th century English surgeon Gross

de-nounced thyroid surgery as “horrid butchery deserving

of rebuke and condemnation.”5 Less barbaric means of

per-forming 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 first

well-doc-umented 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

govern-ing cervical incisions for thyroidectomy usually included

ei-ther a longitudinal or oblique incision, although Y-shaped

and cruciate incisions were still documented in the ture.4 However, thyroid surgery would truly come of ageduring the 1850s, largely through the efforts of outstandingsurgeons like Theodor Billroth of Vienna and TheodorKocher of Berne Before settling in Austria, Billroth held theChair of Surgery in Zürich, where he instituted surgery forcompressive symptoms of endemic goiter While in Switzer-land, Billroth used a lateral incision parallel to the inner bor-der of the sternocleidomastoid muscle to gain access to thethyroid.6 Unfortunately, disheartened by a nearly 40% mor-tality among his thyroidectomy patients, Billroth abandonedthyroid surgery for some time, though not before passing thebaton to Theodor Kocher, a surgeon 12 years his junior.4,5

litera-Kocher, who would later be lauded as the “Father of ThyroidSurgery,” initially performed his thyroidectomy through anincision along the anterior border of the sternocleidomas-toid.5 His technique would later evolve to include a midlineand vertical component, adding his oblique extension to theanterior border of the sternocleidomastoid (“Winkelschnitt”)only when he needed better access.4 By 1895, Kocher hadreduced 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 sion that would later bear his name, Kocher popularized anapproach that would last well into the 20th century (Fig 1)

inci-Central Incisions in Modern Thyroid Surgery

The cervical collar incision is generally regarded in moderntexts of surgery as the appropriate neck incision for thyroid-ectomy.7-10 However, unlike the long transverse incisionpopularized by Kocher, current techniques in thyroid inci-sions have evolved, enabling surgeons to minimize the size oftheir surgical incision.3 Although this transition towardsmaller incisions has been readily put to practice, very littlehas been published with regard to the optimal position andlength of the cervical collar incision

Positioning of the collar incision during thyroidectomy is

of critical importance, as an inappropriately placed incisionmay lead to needless scarring or unusual prominence Inci-sions placed less than 2 cm or one finger breadth from thesternal notch frequently lead to hypertrophic scarring, espe-cially when the scar overlies the manubrium.10Furthermore,appropriate placement of the surgical incision may allow

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

63

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doi:10.1053/j.optechgensurg.2008.03.001

scarring to be hidden by clothing.12Several 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

sternomas-toid 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

pro-posed the optimal position for marking the midpoint of a

collar incision is one finger-breadth above the sternal notch

in the neutral upright neck position, or two finger-breadths

above the sternal notch in the supine, extended neck.7These

suggestions were reached after performing a thorough study

of incision migration in the supine and hyperextended neckand after evaluating the influence of the degree of neck pa-thology (factors such as goiter size, patient body mass index,neck circumference, and type of surgery) on incision posi-tion.7More recently, Sturgeon and colleagues disputed thisclaim after an evaluation of several patients referred to theirpractice for a “missed thyroid” during initial operation.11

They noted one of the main reasons for failure at the initialoperation to locate the thyroid was that the incision wasmade too low on the neck of patients with subjectively longnecks.11Based on their recommendations, the cricoid carti-lage should be palpated and the incision made approximately

1 cm inferior to this site because it centers the incision rectly over the mid portion of the thyroid gland.11This ap-proach also gives the surgeon better exposure of the superior

di-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.

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

contemporar-ies, several studies now indicate that thyroidectomy may be

accomplished through a much smaller incision.3Much of the

decrease in incision length can be attributed to a higher

placement of the incision, which allows better and safer

ex-posure 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.”15Similarly,

Takami16outlined the use of a 3 cm skin incision, and Park

and co-workers described a minimally invasive open

thyroid-ectomy technique through a 3 to 3.5 cm incision.17Brunaud

and colleagues at the University of California, San Francisco

clarified the demarcation between conventional

thyroidec-tomy and its minimally invasive counterpart.3 After

deter-mining the minimum incision length in over 200 consecutive

operations, this group proposed the term “minimally

inva-sive” should be associated with an incision shorter than 3 cm

for thyroidectomy and 2.5 cm for parathyroidectomy.3

Sev-eral studies identify the only limiting factor to

mini-thyroid-ectomy is the size of the gland; glands larger than 7 cm

frequently required extension of the incision beyond 4

cm.15,16Brunaud 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

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

significant increase in the use of a lateral incision to approach

the central neck It has been recently shown that neck

sur-gery, either parathyroidectomy or hemithyroidectomy,

may be feasibly performed through a 2 cm lateral incision

and is safe.20We find the lateral approach is especially useful

for focused parathyroidectomies and for reoperative neck

surgery The lateral approach has also been applied to

pri-mary 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-tive surgery, the lateral approach allows dissection through arelatively unspoiled tissue plain.23-24

Park and co-workers initially described the use of a lateralincision for hemithyroidectomy in a cohort of 466 patients;compared with historical controls, these patients had no dif-ference in demographics, complications, or extent of surgeryincluding central compartment lymph node dissections butexhibited smaller scar size, operative time, blood loss, andanalgesia requirements.17 Stemming from the study of over

500 minimally invasive parathyroidectomies, Delbridge andcolleagues from the University of Sydney Endocrine SurgicalUnit have extensively described their ‘focused’ lateral approach

to thyroidectomy/(MATS).20-23Delbridge and co-workers haveshown MATS utilizing a 2 cm lateral incision may be a superiorapproach and is especially suited to patients with a single follic-ular thyroid nodule⬍2 cm in diameter.20Some contraindica-tions to the focused lateral approach to thyroidectomy include ahistory of neck irradiation, history of prior neck surgery, multi-nodular goiter, a diagnosis or family history of multiple endo-crine neoplasia, proven autoimmune thyroiditis, significant co-morbidity such as pregnancy, a nodule size⬎3 cm, fine needleaspiration biopsy confirmation of carcinoma, and anatomic con-siderations such as extreme obesity.21,23

Indeed, a thorough understanding of the anatomy andembryology of the thyroid and parathyroid glands is of par-amount importance when performing a lateral approach An-atomic considerations will be detailed later in this paper.Delbridge and co-workers have clearly shown that with suf-ficient light and retraction, key anatomical structures in theneck may be safely dissected through a small lateral inci-sion.21,23

Perioperative Care

Anesthesia

Most thyroid and parathyroid operations are performed der general anesthesia; however, it is possible to perform theprocedure under local anesthesia In fact, Spenknabel andco-workers recently reported prospective data on 1,025 con-secutive thyroidectomies performed under local anesthesiaand noted that this method appears safe and applicable to awide range of patients.25Confounding factors, including pa-tient anxiety and comfort, suggest this approach may be bestfor high-risk patients in whom general anesthesia is ‘contra-indicated’ or in remote areas where an anesthetist is unavail-able More commonly, general inhalation anesthetic agentsare utilized via endotracheal intubation; this airway is espe-cially preferred for those in whom large goiters exert chronicpressure against the trachea or in those with large substernalgoiters

un-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 neck’s 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 “Adam’s 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 identification 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%.

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

pro-nounced scar formation, difficulty in dissecting the superior pole, or perhaps missing the thyroid entirely Incisions

made too high will make it difficult 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

inflammation 26 The incision is deepened to the areolar tissue plane just deep to the platysma muscle where an

avascular plane is reached.

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 fibers and the anterior jugular veins Utilizing a combination of blunt

and sharp dissection within this plane—alternatively, bipolar electrocautery is acceptable to raise the skin flap in the hands

of an experienced surgeon—the upper skin flap is freed to the level of the thyroid notch The inferior edge of the platysma is

then grasped and an inferior flap is created in similar fashion Dissection should be carried down to the level of the suprasternal

notch.

The anterior jugular veins symmetrically flank 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

Figure 5 Exposing the thyroid gland The skin flaps 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 identified 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 reflection 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

Figure 6 Central approach to thyroidectomy Before lateral dissection, the isthmus should be identified 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 fibrous 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 identified The thyroid lobe is retracted

anterome-dially 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 identified 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 identified, 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.

Figure 7 Focused lateral approach to the neck The lateral approach was developed for minimal-access

parathyroid-ectomy, 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

anatom-ical landmarks in the neck is critanatom-ical 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

rela-tively 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 identification 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 fiber optic operating headlight is used for optimal viewing of the surgical field.

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 identified 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 finger 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 flaps 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 identified 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.

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 finger 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

Following induction of general anesthesia, the patient

should be placed in a supine, semierect position on a

stan-dard 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 flask of

intravenous fluid transversely in line with the spines of the

scapulae beneath the patient, allowing gentle extension of the

neck.7Our preference is to place a deflated intravenous

pres-sure bag underneath the patient’s shoulders The bag is then

inflated to produce the appropriate amount of neck

exten-sion 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.11The operating table may

be tilted 15 to 30 degrees in the reverse Trendelenburg

posi-tion to reduce venous congesposi-tion in the neck A headlight

facilitates lighting and exposure through the limited

inci-sions Importantly, the anesthesiologist and surgeon must

ensure perfect alignment of the head and body before

mark-ing 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

avascu-lar 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

in-jury to the ESLN Adjustment of skin retraction toward the

midline allows for exposure of the trachea and thyroid

isth-mus 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

expo-sure 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 identification and protection of the recurrent laryngeal

nerve (RLN) The ligament of Berry is then divided and the

thyroid lobe is removed.21,23

Wound Closure

Meticulous hemostasis must be the standard of practice as the

most serious and life-threatening complication of

thryoidec-tomy and parathyroidecthryoidec-tomy is postoperative airway

ob-struction because of excessive bleeding and hematoma

for-mation 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

pa-tients in whom surgical drains were used required prolonged

hospitalization compared with those without drains.29

Addi-tionally, 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

ob-tained, the strap muscles are reapproximated with

absorb-able suture in simple or figure-of-eight fashion The wound isclosed with subcutaneous absorbable suture to the platysmaand a running subcuticular non-absorbable suture for dermalapproximation

Special Postoperative Care

Postoperatively, the patient should immediately be placed in

a low Fowler position with the head of the bed elevated atleast 10 to 20 degrees This position should be maintained for

12 hours to facilitate hemostasis and limit neck vein ment

engorge-Guidelines should be developed to address serum calciummanagement after total, near total, or subtotal thyroidecto-mies and total parathyroidectomies On the postoperativeevening, we refrain from routine use of intravenous calciumsupplementation, reserving the use of 1 amp of calcium glu-conate only if carpopedal spasm and/or tetany suggest severehypocalcemia Serum calcium levels should be measured 4hours postoperatively and again the following morning Cal-cium carbonate is given as needed for mild symptoms ofhypocalcemia; patients with severe hypocalcemia are started

on scheduled calcium carbonate three times per day All tients are started and sent home on scheduled calcium car-bonate twice daily beginning on postoperative day 1 Werecommend patients discontinue the use of calcium supple-mentation at least 1 day before the follow-up clinic visit so as

pa-to assess an accurate serum calcium and PTH level at thattime

Important Complications

Several important complications may be encountered afterthyroidectomy or parathyroidectomy Complications result-ing from damage to vital structures, such as the laryngealnerves and parathyroid glands, may be avoided by maintain-ing a near bloodless surgical field and performing meticulousdissection The most important complications of thyroidec-tomy are:

● Recurrent laryngeal nerve injury

● External branch of superior laryngeal nerve injury

● Hypocalcemia resulting from hypoparathyroidism

● Neck hematoma

● Seroma formation

● Infection

● Wound complicationsUnilateral recurrent laryngeal nerve injury manifests as tran-sient or permanent hoarseness in the postoperative period Bi-lateral recurrent laryngeal nerve injury is much more serious,because the vocal cords may assume a median or paramedianposition, often causing inspiratory stridor and the need foremergent intubation Fortunately, bilateral recurrent laryngealnerve palsy is an exceedingly rare complication of thyroidec-tomy and is most likely to be encountered with difficult reop-eration when one recurrent laryngeal nerve has already beeninjured during a prior operation Indeed, the identification ofthe recurrent laryngeal nerve throughout its course is quite fun-damental if damage from thyroidectomy is to be avoided.Injury to the external branch of the superior laryngealnerve occurs when the nerve is inadequately visualized dur-ing 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 one’s

voice or singing a high note quite difficult 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

un-common and results from removal, injury or

devascular-ization of the parathyroid glands resulting in mild to

se-vere 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

cal-cium supplementation and close observation; more

pro-found hypocalcemia requires intravenous calcium

supple-mentation initially, followed by oral supplesupple-mentation with

calcium and/or calcitriol

Perhaps the most serious and life-threatening

complica-tion of thyroidectomy and parathyroidectomy is airway

ob-struction resulting from postoperative bleeding and neck

he-matoma Though extremely rare, the urgency of treating this

condition once recognized cannot be overemphasized,

espe-cially if respiratory compromise is present In emergency

sit-uations, treatment requires removal of the surgical dressing

and reopening the wound, even if at the bedside, for

evacu-ation of the hematoma and relief of the pressure being

ex-erted 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-absorb-able 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

preopera-tively

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

col-lar 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

expo-sure, and suitable cosmetic result In selected patients, a

lat-eral 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

ex-tremely low morbidity and mortality

References

1 Netterville JL, Aly A, Ossoff RH: Evaluation and treatment of cations of thyroid and parathyroid surgery Otol Clin North Am 23: 529-552, 1990

compli-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 magnificent seven: A history of modern thyroid gery Int J Surg 4:187-191, 2006

sur-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 vical collar incision: A prospective study ANZ J Surg 72:15-17, 2002

cer-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) phia, PA: J.B Lippincott Company, 1993

Philadel-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, Thom- sen 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 tomy Surg Today 31:665-669, 2001

thyroidec-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 thyroidectomy using the ‘focused’ lateral approach II Surgical tech- nique ANZ J Surg 72:147-151, 2002

para-22 Gosnell JE, Sackett WR, Sidhu S, et al: Minimal access thyroid surgery: Technique and report of the first 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 first 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 76:332-

334, 2006

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26 Zollinger Jr RM, Zollinger Sr RM: Subtotal thyroidectomy, in Zollinger’s atlas of surgical operations (8th ed) New York: McGraw- Hill, 2003, pp 364-372

27 Skandalakis JE, Carlson GW, Colborn GL, et al: Neck, in Skandalakis

JE (ed): Skandalakis’ surgical anatomy: The embroyologic and

ana-tomic basis of modern surgery Athens: Paschalidis Medical

Publica-tions, 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 (ab- stract 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

David B Campbell, MD

Access to chest contents and appreciation of the anatomy

of the chest wall and internal anatomy are practical

req-uisites for all general and trauma surgeons The expediency of

a clinical situation and the scope of the patient’s problems

dictate the access options chosen Although minimally

inva-sive options for elective operations within the chest are

evolv-ing, small chest incisions offer less flexible access than

lapa-roscopic surgery because of fixed intercostal positions,

postoperative pain from involvement of multiple intercostal

nerves, and immature instrumentation to address the variety

of pathologies encountered The need for adequate

ventila-tion 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

pro-vides 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

lim-ited flexibility because access is limlim-ited by the rigid chest wall

and overlapping muscles with different functions A proper

thoracic incision provides adequate exposure while

minimiz-ing damage to ribs, cartilage, muscle, and intercostal nerves

Options for extension should be anticipated A limited

inci-sion provides limited exposure, and over-retraction may

re-sult in complex local rib fractures and muscle tears The skin

incision may be minimized, but the internal intercostal

inci-sion 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

expe-dite recovery

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

thora-cotomy, the chest should be flooded with warm saline and

the lung re-inflated to check for air leaks Direct suture, pling, and applied topical adhesives and hemostatic agentsshould be used aggressively to minimize postoperative airleaks Infection risks are thereby minimized, chest tuberemoval expedited and lengths of stay minimized Inter-rupted paracostal sutures of #1 braided Dacron providesecure rib approximation Intrathoracic dead space should

sta-be minimized and routinely two 32°F chest tusta-bes are used:

a straight tube in an apical anterior position for air ation and a basal curved tube in the posterior recess torecover blood and fluid Tubes should exit the skin ante-rior to the mid axillary line to minimize discomfort whenthe patient lays supine Incised muscles are re-approxi-mated with strong running suture taking bites of fascia infront and back Large spaces around separated musclesshould be drained with soft flexible catheters to prevent se-roma formation

evacu-The risk of chest wall hernia after thoracotomy is low, andmost incision closures are straightforward However, paincontrol deserves special emphasis, as adequate analgesia al-lows patients to maintain adequate pulmonary toilet and toprogress toward functional recovery Epidural, paravertebral,and intercostal catheters all have proper places in postoperativemanagement Intercostal nerve blocks (bupivacaine 0.5% withepinephrine 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 usefulincisions

Anterior Thoracotomy

Emergent access to the heart for manual cardiopulmonaryresuscitation or tamponade can be achieved by left antero-lateral thoracotomy Access to both ventricles, the left hi-lum, and the descending aorta is possible A submammaryincision is made and extended down to the superior sur-face of the underlying fifth or sixth rib (Fig 1A) This is atthe inferior margin of the pectoralis major muscle, andintercostal incision is made over the top of the underlyingrib Extension laterally follows the split fibers of the ser-ratus Medial extension to the sternum will divide theinternal mammary artery, which lies 1 cm lateral to thesternum Limiting the medial extent avoids this trouble-

Department of Cardiothoracic Surgery, Penn State Milton S Hershey

Med-ical Center, Hershey, PA.

Address reprint requests to David B Campbell, MD, Professor of

Cardiotho-racic Surgery, Penn State Milton S Hershey Medical Center, MC H-165,

500 University Drive, Hershey, PA 17033 E-mail: dbc2@psu.edu

77

1524-153X/08/$-see front matter © 2008 Elsevier Inc All rights reserved.

doi:10.1053/j.optechgensurg.2008.06.001

Figure 1 Anterior thoracotomy (A) Line of incision, left chest rotated up 30 degrees (B) Deep exposure with pectoralis

major incised medially.

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.

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 flaps 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

pos-sible by pulling the lung forward Relief of pericardial

tam-ponade 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

divi-sion 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

pericar-dium can be loosely re-approximated with interrupted

su-tures 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 rawretraction Nevertheless, closure is routine with paracostalsutures providing needed stabilization This incision can beextended across the sternum with a saw or rib shears, al-though closure is less stable Postoperative pain control ef-forts (above) will be appreciated by the patient

Posterolateral Thoracotomy

When uncompromised access to the lung and num is necessary, the patient should be placed in fulllateral position If hemoptysis is a significant problem,then the airway should be controlled with a double lumentube, or at least with an intrabronchial blocker Turningthe patient into the lateral decubitus position places the

mediasti-“good” lung down, making it more vulnerable to bloodand secretions in the airway Posterolateral thoracotomy isthe classic incision for lung and mediastinal surgery and

on the left side this exposure is still preferred for ing aortic procedures On the right side, it offers the bestaccess to the intrathoracic trachea and to the mid andupper esophagus

descend-The skin incision for posterolateral thoracotomy isgenerous, from behind the scapula around its inferior bor-der to the submammary crease anteriorly (Fig 2A) Theblood and nerve supplies of the latissimus dorsi originateabove, so this muscle should be mobilized inferiorly andtransected at a low level to maximize its functional recov-ery Intercostal division is made widely from front to back,and the serratus anterior can often be left intact and re-

Table 1 Comparison of the Four Most Useful Incisions

Incision Advantages Disadvantages

Median sternotomy Wide mediastinal exposure

Access to both hila Full cardiac access Option for cardiopulmonary bypass Little postoperative pain

Augments liver and IVC exposure for difficult abdominal cases

Good internal access to chest wall injuries

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 Rapid access to heart and hila, especially on left side

Vertical and/or trans-sternal extensions possible

Limited access to lung

No esophageal or large airway access Moderate postoperative pain

Posterolateral

thoracotomy

Adequate for all lung and esophageal problems Best distal arch and descending aortic exposure Conventional instruments used

Intercostal flap can be harvested Extension for thoracoabdominal exposure possible

Frequent rib fractures Requires muscle division and reconstruction

Cosmetically undesirable Moderate postoperative pain Lateral muscle sparing

Requires dissection and retraction (not rapid)

Inadequate aortic exposure Moderate postoperative pain

Figure 2 Posterolateral thoracotomy (A)

In-cision 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.

Figure 3 Muscle sparing lateral thoracotomy (A) Incisions, patient in left lateral decubitus position (B) Subcutaneous

flaps allow serratus anterior muscle retraction upward and chest wall access.

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

frac-tures Closure is conducted in layers, with strong

perma-nent 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

de-cortication A lateral thoracotomy of 4 to 5 inches with

separation and retraction of latissimus and serratus

mus-cles allows manual palpation of intrathoracic structures

and use of conventional instruments for most elective

op-erations Crossed Tuffier and Balfour retractors provide

ample access and exposure at the level of the hila over the

major fissure 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 anteriorborder of the latissimus is mobilized above and below.This muscle is retracted posteriorly and away from thechest wall With finger dissection, the underlying serratus

is separated, taking care not to injure the long thoracicnerve on its surface Traction is applied to the serratus in

an upward and anterior direction to allow identification ofits inferior border, and the fat below is cauterized anddivided to expose the chest wall (Fig 3B) When access tothe top of the thoracic cavity is desired (fourth intercostalspace) it is often advantageous to separate the lowest in-sertion of the serratus from the chest wall Maintainingupward traction on the serratus, ipsilateral ventilation isstopped and intercostal incision is made above a rib, fromback to front through the three layers of intercostal mus-cle Using a Kelly clamp for initial intercostal entry allowsthe lung to fall away from the chest wall, minimizing thechance of lung injury from cautery The incision is en-larged anteriorly and posteriorly with electrocautery.Paraspinous muscles posteriorly and the upward sweep ofthe ribs (short of the internal thoracic artery pedicle) an-teriorly are practical limits for intercostal division If anintercostal flap is not required, a Tuffier retractor main-tains intercostal distraction, and a Balfour is opened atright angles to provide additional soft tissue retraction (Fig

3C) Rib division and fractures are avoided This exposureallows insertion of a hand for full palpation of the lung andmediastinum, and conventional instruments and tech-niques are used for necessary procedures

Figure 3 (Continued) Muscle sparing lateral thoracotomy, continued (C) After interior front-to-back muscle division,

crossed Balfour and Tuffier retractors provide exposure without rib fractures.

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.