How to approach intrathoracic pathology? a 5-year survey of thoracic incisions

D. Van Raemdonck, P. De Leyn, W. Coosemans, G. Deneffe, T. Leru

Department of Thoracic Surgery, University Hospital Gasthuisberg, Leuven, Belgium.

Objective : The presence of a rigid, ribbed chest wall makes the selection of a specific incision crucial to the ease and safety of a given thoracic procedure. The purpose of this study was to review the type and the number of thoracic incisions used in our institution over the past 5 years and to analyze the possible changes that have occurred during this period.

Methods : Between 1995 and 1999, the type of incision was prospectively registered into our thoracic database at the end of the operation for all types of intrathoracic, non-cardiac pathology (lung, intrathoracic esophagus, mediastinum, chest wall, and diaphragm). Data were analyzed on a yearly basis.

Results : The number of mediastinotomies for staging of bronchial carcinoma has drastically dropped over the last three years. This results from the systematic implementation of PET-scanning as a non-invasive diagnostic tool with >90% accuracy in excluding mediastinal lymph node involvement. In our institution, a (posterolateral) thoracotomy remains the most frequently used incision to deal with intrathoracic pathology. The thoraco-sternotomy (clam shell) incision has increasingly been utilized for simultaneous, bilateral pulmonary operations (e.g. lung transplantation, metastasectomy). The number of incisions per year is listed in table.

Conclusions : Surgical approach to the chest is continuously evolving as a result of new developments. Surgeons dealing with intrathoracic pathology should therefore be familiar with the wide armamentarium of thoracic incisions in order to master the technique, indications, advantages and disadvantages of each individual approach. A minimum number of thoracic operations performed annually in one thoracic unit may improve the quality of care.