Modified French Window as an Alternative to Thoracotomy for Complex Intrathoracic Pathology

If post-thoracotomy pain is the target, Integrated Thoracotomy is the choice

OBJECTIVES

Despite the overgrowth of procedures done by VATS, there are still needs for thoracotomy. Post-thoracotomy pain plays an important role in many post-operative morbidities. Surgeons should make efforts to evolve new techniques to reduce post-thoracotomy pain with its associated morbidities. This trial aimed to study the impact of combining lack of rib retraction with protection of both intercostal nerves on post-operative pain.

METHODS

This was a prospective study of 57 patients who had Integrated thoracotomy (I group) which consists of modified French window with Double-Edge closure. The results of I group were compared to our previous study that contained two groups 60 patients each, double edge (DE group) in which standard thoracotomy was closed using double-edge technique and (PC group) in which pericostal sutures was used for closure of thoracotomy. Outcomes assessed were operative time, time to ambulation, doses of analgesics injected in the epidural catheter, post-operative complications, chest tube drainage, hospital stay, and pain score and use of analgesics during the first post-operative year.

RESULTS

All groups had similar demographics, operative time, and incisions length, but in I group, there were significantly a smaller number of lobectomies and pneumonectomies. Patients in I group had significantly lower time to ambulation, epidural doses and post-operative pain score throughout the first week. Patients in the (I group) had a significantly lower pain score throughout the first 9 months post-operatively. Up to 6 months post-operatively, there was significantly less use of analgesics among the I group.

CONCLUSION

The combination of retractor-free exposures and neurovascular exclusion sutures for thoracotomy is safe and effective in decreasing post-thoracotomy pain and use of analgesics.

Video-assisted paraspinal approach for the stabilization of the complex spine

Access to complex conditions of the thoracic spine and of the posterior mediastinum offers significant challenges, especially if the surgeon wishes to comply with the principles of minimal invasiveness. We report a successful vertical, paraspinal incision along with the subperiosteal removal of the overlying 2-cm rib segments combined with video assistance through single-access video-assisted thoracic surgery to perform a total T6 and partial T7 corpectomy for a metastatic multiple myeloma in a 50-year old man. This approach appears to provide excellent exposure and minimal morbidity when a reliable approach to the complex spine is needed.

Posterolateral thoracotomy without muscle division: a new approach to complex procedures

Today, there is a strong increase in video-assisted thoracic surgery; however, there are still some diseases and interventions that need a wide pleural cavity exposure (i.e. sulcus tumours and extended resections). These complex procedures are usually performed via a standard posterolateral thoracotomy, which is a good approach but has significant disadvantage due to pain and difficulty coughing. We propose a new thoracotomy that avoids a dorsal muscle division but has the same intrathoracic exposure as a posterolateral thoracotomy.

Modifications to Ivor Lewis esophagectomy

The surgical approach to esophagectomy is variable. A number of factors are considered when determining the optimal approach to esophagectomy: location and extent of disease, fibrosis, additional patient factors and surgeon preference. One of the disadvantages to some approaches is the need for a change in position, which increases operative time. Also, because typically the abdomen is initially explored, patients may later be deemed unresectable at thoracotomy. We describe time saving modifications to the standard Ivor Lewis esophagectomy that eliminate the need for repositioning and facilitate a stapled end-to-end anastomosis.