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

7/27/2019 2008, Vol.10, No.2, Incisions and Operative Exposures

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Introduction

Adequate exposure is the key to successful surgery. Al-though the abdominal incision has become the mainstayof thegeneral surgeonsexposure, there area numberof otherincisions that are critical to the general surgeons 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 criticalnuances that make the exposures successful. As a result, theyhave been able to detail in a stepwise fashion the indicationsfor each incision, the positioning of the patient, the surgicalanatomy, the appropriate retraction systems, and the closureof the surgical wound. The anatomical exposures are care-

fully illustrated with the aim of allowing an experienced sur-geon who is unfamiliar with the incision to perform the tech-nique.

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 ismy sincere hope that this issue will increase the practicing

general surgeons versatility. It was a pleasure preparing thisissue and seeing it come together in its final form. Im verygrateful to the authors for their hard work.

Kevin F. Staveley-OCarroll, MD, PhD, FACSGuest Editor

Volume 10, Number 2 June 2008

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

doi:10.1053/j.optechgensurg.2008.05.003


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Incisions and Exposure of the Neck

for Thyroidectomy and ParathyroidectomyScott Pinchot, MD, Herbert Chen, MD, and Rebecca Sippel, MD

While many articles in the medical literature focus onthe complications of thyroid and parathyroid surgerysuch 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 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 tobriefly 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 ofThe 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 hadcut 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 . . . deservingof rebuke and condemnation.5 Less barbaric means of per-

forming a cervical incision for thyroidectomy were detailedin 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 litera-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 Zrich, 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

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 aspectsof his surgical incision. Employing an 8 to 10 cm collar inci-sion that would later bear his name, Kocher popularized anapproach that would last well into the 20th century (Fig 1).

Central Incisions inModern 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 of

their 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 isof 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.10 Furthermore,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:[email protected]

631524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved.

mailto:[email protected]:[email protected]:[email protected]


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scarring to be hidden by clothing.12 Several techniques have

been described to aid in optimal incision placement. Theyinclude (1) 1.5 to 2.0 cm superior to the sternoclavicularjoints,9 (2) 1 cm caudal to the cricoid cartilage,3,10,11 (3) 3 to4 cm above the sternum extending laterally to thesternomas-toidmuscles,13 (4)midwaybetween thesternal notch andthenotch of the thyroid cartilage.14

Of note, all techniques recommendincisionplacementin apre-existing neck crease whenever possible. In 2002, in adetailed prospective study, Jancewicz and co-workers pro-posed the optimal position for marking the midpoint of acollar incision is one finger-breadth above the sternal notchin the neutral upright neck position, or two finger-breadthsabove 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 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.7 More 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.11 Based on their recommendations, the cricoid carti-lage shouldbe palpated andthe incision made approximately1 cm inferior to this site because it centers the incision di-rectly over the mid portion of the thyroid gland.11 This ap-

proach also gives the surgeon better exposure of the superior

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.

64 S. Pinchot, H. Chen, and R. Sippel


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pole vessels, allowing an overall smaller incision length. Thisis our current procedure of choice.

Drivenby patient demandfor less pain andbetter cosmeticresults, the length of incision for thyroid surgery has beendecreasing in size.3,15-19 Unlike the traditional 8 to 10 cmcollar incision popularized by Kocher and his contemporar-

ies, several studies now indicate that thyroidectomy may beaccomplished through a muchsmaller incision.3 Much of thedecrease in incision length can be attributed to a higherplacement of the incision, which allows better and safer ex-posure of the superior pole vessels through a much smallerincision. Ferzli and colleagues described the use of a 2.5 cmto 3 cm incision, termeda mini-thyroidectomy.15 Similarly,

Takami16 outlined the use of a 3 cm skin incision, and Parkandco-workersdescribeda minimally invasive openthyroid-ectomy technique through a 3 to 3.5 cm incision.17 Brunaudand colleagues at the University of California, San Franciscoclarified the demarcation between conventional thyroidec-tomy and its minimally invasive counterpart.3 After deter-miningtheminimum incision length in over 200 consecutive

operations, this group proposed the term minimally inva-sive should be associated with an incision shorter than 3 cmfor 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 cmfrequently required extension of the incision beyond 4

cm.15,16 Brunaud and colleagues suggest patient BMI, extentof the planned exploration, and the resident clinical trainingstage should also be taken into account before performing aminimally invasive thyroidectomy or parathyroidectomy.3

Lateral Focused Incision

for Minimal Access ThyroidSurgery and Parathyroidectomy

While historically the traditional approach to the centralneck has been a central incision, recently there has been asignificant increase in theuse 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 incisionand is safe.20We find the lateral approach is especially usefulfor focused parathyroidectomies and for reoperative necksurgery. The lateral approach has also been applied to pri-mary thyroidectomy for Minimal Access Thyroid Surgery

(MATS).20-24

For parathyroidectomies, the lateral approachgives excellent exposure for an upper gland, especially iflocated 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 over500 minimally invasive parathyroidectomies, Delbridge andcolleagues from the University of Sydney Endocrine SurgicalUnit have extensively described their focused lateral approachto thyroidectomy/(MATS).20-23 Delbridge and co-workers haveshown MATS utilizing a 2 cm lateral incision may be a superiorapproachand is especially suited to patientswith a single follic-ular thyroid nodule 2 cm in diameter.20 Some contraindica-tions to thefocusedlateral approach to thyroidectomyinclude 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 needleaspirationbiopsyconfirmationof carcinoma,andanatomic 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 importancewhen 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

AnesthesiaMost thyroid and parathyroid operations are performed un-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.25 Confounding 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.

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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 techniquefor 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 surfaceanatomy will facilitateplacementof cosmeticallydesirable incisions whereas minimizingcomplications relating to poor

wound healing, such as scar widening or keloid formation. Prominentlandmarks of thenecks surface anatomy includethe 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 thethyroid 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 atthe level of the 3rd cervical vertebra. Likewise, the arch of the cricoid cartilage, the only complete cartilaginous ringaround 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 rarelyfound 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 cmat its greatest width, and 2 to 3 cm thick,28 though one lobe may be smaller than the other or may be congenitallyabsent. 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 inabout 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 andthe neck is gently extended. Perfect alignmentof thehead andbody 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 cricoidcartilage 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 skinlines 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. Incisionsmade 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

warrantedbasedon thesize of thegland. Factors that affectthe size of theincisioninclude gland size, patient body massindex, 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, largerbleeding subcutaneous vesselsmay 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 andinflammation.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, thesuperior andinferior subplatysmalplanes aredeveloped.Usingtwo Alice clampsor 3 to5 straight Kellyclamps, thesuperior

edge of the platysma muscle or dermis is grasped and placed under tension. Ideally, dissection should proceed within the

relativelyavascularplane betweentheplatysmamuscle fibers andtheanterior jugularveins. Utilizinga combination of bluntand sharp dissection within this planealternatively, bipolar electrocautery is acceptable to raise the skin flap in the hands

of an experienced surgeonthe upper skin flap is freed to the level of the thyroid notch. Theinferior edgeof the platysmaisthen grasped and an inferior flap is created in similar fashion. Dissection should be carried down to the level of the suprasternal

notch.

Theanterior jugular veins symmetrically flank themidline raphe of theneck. Special care must be taken to avoid injurytothese veins, as active bleedingand danger of air embolushave beenreported with openingsmade into the anterior jugular vein.26



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Figure 5 Exposing the thyroid gland. The skin flaps are held apart with a self-retaining retractor. With a scalpel or

bipolar electrocauterydevice, the cervical fascia investing the paired sternohyoidmuscles is then incised, separating thestrap 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 theuse of a peanutdissectoror blunt forceps. Theblunthandle of theforceps maybe inserted beneath thepaired 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 andincised with a scalpel to develop the appropriate cleavage plane.26 Development of thepropercleavage plane willallow

lateral mobilization of the sternohyoid and sternothyroid muscles. Complete incision and reflection of the fascia of thesternothyroid 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 glandvia 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 shouldbe identifiedand mobilized

both superiorly and inferiorly just anterior to the trachea. The isthmus is divided at this point if a lobectomy isindicated; alternatively, if a total thyroidectomy is to be done, ourpreference is to removethe gland in onepiece. Duringthis medialdissection, thepyramidal lobe, if present, is dissectedfree from thesurrounding tissues with electrocautery.

The superior extentof this lobe is divided atthe point in which the gland tapers to a fibrous band, usually near the levelof 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 andthe carotid is retractedlaterally, placing themiddlethyroid vein on tension. Thevein 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 freemedially, between the cricothyroid muscle and the thyroid capsule. The space medial to the superior thyroid artery is

carefully openedto exposethe externalbranchof thesuperior laryngealnerve(ESLN).Using right angle clampsfrommedialto lateral, the superiorpole vessels aredissectedanddoublyclamped andtiedwith2-0 silk ties.Thesevascularbranchesmust

betied close tothe thyroidglandto prevent injuryto theESLN.With thesuperiorpole mobilized,the upperparathyroidgland 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) isvisualized. 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 avoidinjuring 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 parathyroid-

ectomy, but after much success has also been applied to minimal access thyroidectomy.23A thorough understandingof the anatomical details of normal and pathological thyroid and parathyroid glands and their relationship to anatom-

ical landmarks in the neck is critical. As thyroid gland anatomy hasbeen previously reviewed, emphasis will be placedon

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

groveandmaybefoundin a relatively posterior planein the lowerpart of theneck.21 The inferiorparathyroid glands developfrom 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 laryngealnerve (RLN).21 Deformities fromlarge 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 headsupport. Thebed is placed in 15 to 30 degrees of thereverse Trendelenburg position to lessen venouscongestion in the

neck veins. A fiber optic operating headlight is used for optimal viewing of the surgical field.



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Figure 8 Incision and exposure during lateral approach. The site of the incision depends on the location of thethyroid 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 sweepof 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 maybe ligatedor clipped with metal clips.For parathyroidectomy, minimal subplatysmalplaneis needed.

However, for thyroidectomy adequate development of the subplatysmal plane will allow mobility of the skin incisionover 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.



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Figure 9 With the SCM retracted laterally, the investing fascia of the strap muscles is incised. Exposure of the thyroidgland is facilitated bycareful dissection of thespaceposterior to thestrapmuscles.Adequatedissection 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 l igated with 2-0silkties or metal clips. Thespace medial to thecommoncarotid artery is then dissecteddown to theprevertebral fascial

plane.Gentle finger dissection facilitates thedevelopmentof thespacebetween theposterior aspectof thethyroid glandand prevertebral fascia. This essentially frees up the entire parathyroid-bearing region of that side of the neck.21,23



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Following induction of general anesthesia, the patientshould be placed in a supine, semierect position on a stan-dard operating table. Neck extension is facilitated by placinga folded sheet, pillow, or sandbag beneath the shoulders.Jancewicz and co-workers suggest placing a 1 liter flask ofintravenous fluid transversely in line with the spines of the

scapulae beneath thepatient, allowing gentleextensionof theneck.7 Our preference is to place a deflated intravenous pres-sure bag underneath the patients shoulders. The bag is theninflated to produce the appropriate amount of neck exten-sion. The head should be well supported using a gelatinoushead-ring, and special care must be taken, especially in theelderly, to avoid over-extension of the neck. Hyperextensionof the neck may lead to increased postoperative pain and aslight risk of spinal cord damage.11 The operating table maybe tilted 15 to 30 degrees in the reverse Trendelenburg posi-tion to reduce venous congestion in the neck. A headlightfacilitates lighting and exposure through the limited inci-sions. Importantly, the anesthesiologist and surgeon mustensure perfect alignment of the head and body before mark-

ing the line of incision; any small deviation to the side mayresult in an inaccurately placed incision.26

Hemithyroidectomy then proceeds in systematic fashion.Cranial retraction of the skin incision reveals key structuresinvolved in dissection of the superior pole. The superior poleof the thyroid lobe is retracted laterally, opening the avascu-lar space andallowing forvisualization of theexternal branchof the superior laryngeal nerve (ESLN) and superior thyroidartery. The artery is divided between silk ties or metal clipsimmediately adjacent to the thyroid capsule, preventing in-jury to the ESLN. Adjustment of skin retraction toward themidline 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 facilitatesmobility of the thyroid lobe and allows for increased expo-sure during the lateral dissection. Caudal retraction allowsfor mobilization and dissection of the inferior pole. Caremust be taken to avoid injury to the inferior parathyroidgland. Finally, the skin incision is retracted laterally; deliveryof the thyroid nodule or lobe through the small incisionfacilitates lateral glandexposure. Careful dissectionwill allowfor identification and protection of the recurrent laryngealnerve (RLN). The ligament of Berry is then divided and thethyroid lobe is removed.21,23

Wound Closure

Meticulous hemostasis must be thestandardof practice as themost serious and life-threatening complication of thryoidec-tomy and parathyroidectomy is postoperative airway ob-struction because of excessive bleeding and hematoma for-mation. Although the placement of surgical suction drainsmay allow for drainage of a small hematoma, the routine useof surgical drains is not an alternative to hemostasis. In fact,Hurtado-Lopez and co-workers recently showed that pa-tients in whom surgical drainswere used required prolongedhospitalization compared with those without drains.29Addi-tionally, active suction may damage the recurrent laryngealnerve or parathyroid glands if the drain is in close contactwith these structures.30 After adequate hemostasis is ob-

tained, the strap muscles are reapproximated with absorb-

able suture in simpleor figure-of-eight fashion. Thewound 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 ina low Fowler position with the head of the bed elevated atleast 10 to 20 degrees. This position shouldbe maintained for12 hours to facilitate hemostasis andlimit neck vein engorge-ment.

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 startedon scheduled calcium carbonate three times per day. All pa-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 asto assess an accurate serum calcium and PTH level at thattime.

Important ComplicationsSeveral important complications may be encountered afterthyroidectomy or parathyroidectomy. Complications result-ing from damage to vital structures, such as the laryngeal

nerves and parathyroid glands, may be avoided by maintain-ing a near bloodless surgical field andperforming 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 complications

Unilateral 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 itscourse 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.



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Injury to the nerve can result in transient impairment of theipsilateral cricothyroid muscle, making projection of onesvoice or singing a high note quite difficult. Although theseinjuries tend to be transient and improve in the months aftersurgery, 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 levelsafter surgery often does not occur until 48 to 72 hourspostoperatively; however, symptoms consistent with mildand severe hypocalcemia must be recognized. Symptomsrange from mild paresthesias to carpopedal spasm andtetany. 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 supplementation withcalcium 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 thiscondition once recognized cannot be overemphasized, espe-cially if respiratory compromise is present. In emergency sit-uations, treatment requires removal of the surgical dressingand 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 bemaintained whenever possible. Pressure should be appliedwith a sterile sponge and the patient should immediatelyreturn to the operating room for surgical exploration andhemostasis.

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 andscar granuloma. Though seroma is common with extendedlymph node dissection, most resorb spontaneously and donot require further intervention. Infection is quite rare, andwe do not routinely use prophylactic antibiotics preopera-tively.

Conclusion

Surgical incisions and exposures in the neck, particularlywith regard to thyroidectomy and parathyroidectomy, haveevolved drastically since the days of Kocher and Billroth.Techniques for optimally placing a neck incision have

evolved to accommodate the desire for minimally invasivesurgery and improved cosmesis. The transverse cervical col-lar incision, initially described by Kocher and altered bycountless others, remains the preferred incision of choice formost 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 thyroidlobe is feasible, safe, and effective. In the hands of a skilledsurgeon familiar with the anatomic details of each surgicaltechnique, either approach should be associated with ex-tremely low morbidity and mortality.

References1. Netterville JL, Aly A, Ossoff RH: Evaluation and treatment of compli-

cations 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 magnificent seven: A history of modern thyroid sur-

gery. 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 cer-

vical 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

ofthe thyroid, in NyhusLM, BakerRJ (eds):Masteryof surgery (2nd ed,

Chapt 23). Boston, MA: Little, Brown and Company, 199210. Scott-Conner CE, Dawson DL: Operative anatomy (1st ed). Philadel-

phia, PA: J.B. Lippincott Company, 1993

11. SturgeonC, Corvera C, Clark OH: The missingthyroid. 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, 200617. Park CS, Chung WY, Chang HS: Minimally invasive open thyroidec-

tomy. 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 para-

thyroidectomy using the focused lateral approach. II. Surgical tech-

nique. 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 first 25 cases. ANZ J Surg 74:330-334,

2004

23. Palazzo FF, Sywak MS, Sidhu SB, et al: Safety and feasibility of thyroidlobectomyvia a lateral 2.5-cmincision with a cohortcomparison of the

first 50 cases:Evolutionof a surgical approach.LangenbecksArch 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

25. Spanknebel K, ChabotJA, 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: McGraw-

Hill, 2003, pp 364-372



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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 (1sted). Philadelphia, PA: W.B. Saunders Company,

1997, pp 147-153



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Thoracic Incisions

David B. Campbell, MD

Access to chest contents and appreciation of the anatomyof the chest wall and internal anatomy are practical req-uisites for all general and trauma surgeons. The expediency ofa clinical situation and the scope of the patients problemsdictate 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 intercostalnerves, and immature instrumentation to address the variety

of pathologies encountered. The need for adequate ventila-tion with endobronchial control is a unique concern for allchest operations, but a generous open exposure is requiredfor rapid and uncompromised exposure of the heart, lunghilum, or aorta. A collaborative effort with anesthesia pro-vides lung isolation. A double lumen endotracheal tube, anendobronchial blocker or mainstem bronchial intubation canall be effective. Abdominal incisions through soft tissues haveinherent mobility, but most thoracic incisions provide lim-ited flexibility because access is limited by the rigid chest walland overlapping muscles with different functions. A properthoracic 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 skinincision may be minimized, but the internal intercostal inci-sion should be relatively wide from front to back to allow theribs to separate by hinging like bucket handles. Optimalpain management begins before thoracotomy, and a varietyof ancillary indwelling catheters can alleviate pain and expe-dite recovery.

Chest Incision Closure

Hemostasis is achieved in the usual manner, but unipolarelectrocautery should be used with caution in the posteriormediastinum 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, sta-

pling, and applied topical adhesives and hemostatic agentsshould be used aggressively to minimize postoperative air

leaks. 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

be minimized and routinely two 32F chest tubes are used:a straight tube in an apical anterior position for air evacu-ation and a basal curved tube in the posterior recess to

recover blood and fluid. Tubes should exit the skin ante-rior to the mid axillary line to minimize discomfort when

the patient lays supine. Incised muscles are re-approxi-mated with strong running suture taking bites of fascia in

front and back. Large spaces around separated musclesshould be drained with soft flexible catheters to prevent se-

roma formation.The risk of chest wall hernia after thoracotomy is low, and

most 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 postoperative

management. 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 cardiopulmonary

resuscitation 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 submammary

incision 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, and

intercostal 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:[email protected]




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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 stabwound. (D) Chest closure with rib reapproximation and paracostal sutures.

Thoracic incisions 79


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some bleeding. A retractor is inserted and opened as muchas needed, mindful that the anterior costal cartilages aremore fragile than bone. These cartilages can be divided

with rib shears to enhance the exposure (Fig 1B), althoughwound closure is tedious and healing is not rapid. Stoutsutures are placed through the cartilages and interspacemusculature, and several paracostal sutures are placedaround the ribs of the interspace incision (Fig 1D). Twochest tubes (apicoanterior and posterobasal) are broughtout below, and a subcutaneous drain may be prudent iflarge muscle flaps were developed.

This incision provides access to the ipsilateral hilum that isunrestricted (Fig 1C). In case of massive lung bleeding, alarge hilar clamp can be applied from above downwardsacross 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 thepericardial space, and widest exposure is possible with alongitudinal incision anterior and parallel to the phrenicnerve. Pericardiotomy should avoid phrenic nerve divi-sion. Finger pressure may be required to control bleedingfrom a cardiac stab wound, and traction sutures maintainexposure 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 looseenough to prevent tamponade from epicardial bleeding, butsutures should be close enough to prevent cardiac herniationthrough 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 be

extended 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 mediasti-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 thegood lung down, making it more vulnerable to blood

and secretions in the airway. Posterolateral thoracotomy isthe classic incision for lung and mediastinal surgery andon the left side this exposure is still preferred for descend-ing aortic procedures. On the right side, it offers the bestaccess to the intrathoracic trachea and to the mid andupper esophagus.

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 painAugments 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

bronchiNo 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


Lateral muscle sparing

thoracotomy

Adequate for almost all lung and esophageal problems

Conventional instruments used

No muscle division, little to heal

Cosmetically acceptableExtension to posterolateral thoracotomy possible

Intercostal flap can be harvested

Requires dissection and retraction

(not rapid)

Inadequate aortic exposure


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Figure 2 Posterolateral thoracotomy. (A) In-cision with patient in left lateral decubitus

position. (B) Wide exposure with latissimusdorsi divided, 5thrib incised posteriorly. (C)

Rib approximator allows secure closure withparacostal sutures.



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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.

82 D.B. Campbell


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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 absorbablesutures for muscle re-approximation and subcutaneouslayers. When this incision is made, two interspaces lower,extension across the costal margin for thoracoabdominalexposure is straightforward.

Muscle SparingLateral Thoracotomy

Large muscle division can be avoided for most routinethoracic exposures, including those for acute chest walland lung trauma, and for late empyema drainage and de-cortication. A lateral thoracotomy of 4 to 5 inches withseparation and retraction of latissimus and serratus mus-cles allows manual palpation of intrathoracic structuresand use of conventional instruments for most elective op-erations. Crossed Tuffier and Balfour retractors provideample access and exposure at the level of the hila over themajor fissure. Landmarks for the skin incision are a pointone inch above the scapular tip and the inframammarycrease (Fig 3A). The sixth rib underlies a line connectingthese 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 borderof 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 thechest wall. With finger dissection, the underlying serratusis separated, taking care not to injure the long thoracicnerve on its surface. Traction is applied to the serratus inan 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 (Fig3C). 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.



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Figure 4 Median sternotomy. (A) Sternum is divided in the midline with a saw. (B) Pericardium is opened andsuspended, allowing full cardiac and hilar access.

84 D.B. Campbell


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Closure of this incision can be rapid. Chest tubes arebrought out inferior to the wound and posterior intercostalnerve blocks are done internally under direct vision using asmall bore spinal or long aspiration (mediastinoscopy)

needle.After the chest is irrigated the lung is reinflated andtested for air leaks. It is deflated and paracostal sutures areplaced and tied. The serratus and latissimus muscles re-turn to normal positions when retraction is released. A softdrain above the muscles prevents seroma formation, and fatand subcutaneous layers are closed with running absorbablesutures.

Median Sternotomy

Access for hilar dissection and control through this incision is

good, and median sternotomy offers optimal exposure andcontrol for resuscitation and penetrating cardiac wounds.The dissections required for all lobectomies except the leftlower lobe canbe done, so lung control is excellent. Althoughthe esophagus cannot be accessed through this anterior ex-posure, transpericardial incision and retraction of the aortaandvena cava offersexcellent control of thedistal trachea andcarina. With assistance from selective lung ventilation thiswide access also opens options for internal rib fixation forcomplex bluntchest wall trauma.Upper abdominalexposureshortcomings of laparotomy are resolved if the midline inci-sion is extended cephalad with sternotomy. Surgeons whohave 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 ligamentis 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 car-

diac massage is conducted without restriction through this

incision, and air embolism can be addressed directly byaspiration of pulmonary artery and right ventricle. If the

patients condition requires it and if massive anticoagula-

tion can be tolerated, cardiopulmonary bypass can be in-

stituted for resuscitation, to correct hypothermia, for mas-

sive pulmonary embolism or for irreversible airway

compromise (Fig 4B). Hilar access is straightforward if the

pericardium is pulled in the opposite direction, whichallows manual compression or clamping. Individual pul-

monary arteries and pulmonary veins can also be con-

trolled or clamped inside the pericardium.

After wound irrigation and hemostasis, closure is ac-

complished with circlage sternal wires and layers of ab-

sorbable sutures. Drainage tubes should be left in opened

Figure 4 (Continued) Median sternotomy, continued. (C) Sternal halves impacted with interrupted wire closure.



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pleural spaces, and anterior and posterior intrapericardialtubes are customary. The pericardium is either left open orloosely approximated by two or three interrupted sutures.Tight impaction of the sides of the sternum assures unionwith minimal pain and infection risk. A rule of thumb for

closure is one wire per 10 kg patient weight, with the topthree wires through the bone above the angle of Louis andthe remainder of the wires passing around the sternalhalves in the intercostal spaces, avoiding the internal tho-racic arteries (Fig 4C).

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Retroperitoneal Exposures

John Radtka III, MD, and David Han, MD, MS, FACS

The retroperitoneal approach provides exposure for a va-riety of general surgicalprocedures. In some situations, itis simply an alternative to a transperitoneal approach, in oth-ers it is the preferred method of exposure. In such cases,advantages of the retroperitoneal approach may includeavoiding a hostile peritoneal cavity through which previoussurgeries have occurred, better and easier exposure, and re-duced fluid shifts and the accompanying decreased physio-logic stress. Oftentimes, the impediment to choosing a retro-peritoneal exposure is a lack of surgeon experience. Two

common applications of retroperitoneal exposure are for vas-cular reconstruction and anterior spine surgery. Familiaritywith this approach provides an excellent option in perform-ing these procedures.

Vascular Reconstructions

A left retroperitoneal approach is the approach of choicefor patients with thoracoabdominal aortic aneurysms, andis also indicated in patients with a hostile abdomen be-cause of previous surgery, inflammatory abdominal aorticaneurysms, associated horseshoe kidneys, and right sidedostomies. In patients with a left sided ostomy, a right

retroperitoneal approach can be used. Relative contrain-dications for a left retroperitoneal approach include theneed for extensive right renal or right iliac artery recon-struction. In patients who require evaluation of the peri-toneal contents at the time of exploration, a retroperito-neal approach with subsequent opening of the peritoneumcan be done. This may also allow better exposure of theright renal and iliac arteries.

Proper positioning of the patient is vital to allow appropri-ate exposure and to prevent postoperative complications.Ex-posure of the femoral arteries at the groin is often required,and so having the pelvis as close to flat as possible is ideal. Inthe obese patient, it is often helpful to mark the femoralpulses with an indeliblemarkerbefore final positioning as theskin position relative to the femoral arteries may change de-pending on the size of the pannus. The torso is rotated to theright, with the left arm supported on an over-arm board

(Fig 1). An operating table that allows flexion and extension

at its midpoint is also helpful, with the table extended forexposure,andflexed to facilitate closure. A beanbag is placedunder the patients torso for full support, andpressure points

at the right axilla and left upper arm must be checked andpadded. Rotation of the operating table from side to side

allows better exposure of the abdominal or femoral compo-nents 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 theposterior axillary line if more proximal exposure is required.If the 11th interspace is used, this incision can be carrieddirectly over the 12th rib with resection of the 12th rib to

facilitate exposure. Medially, the incision is carried either tothe lateral edge of the rectus muscle, or can be taken to themidline at the level of the umbilicus and extended into a

midline abdominal incision. Division of the underlyingoblique muscle and fascia is performed. Typically, the plane

between the transverus abdominus and the peritoneum ismost easily identified 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 rectussheath can allow easier identification of the underlying peri-toneum, and subsequent development of the appropriate ret-roperitoneal plane (Fig 2).

Proximally, division of the costal cartilage at the 9th or10th interspace is performed (Fig 3). The intercostal musclesare divided on the superior edge of the rib. If the pleura isentered, it can be closed at the end of the procedure after

placement of a single posterior tube thoracostomy. The dia-phragm is left intact if possible except in the case of thoraco-abdominal aortic reconstruction, where either circumferential

or radial division of the diaphragm is required. Circumferentialdivision ismorecumbersome, but avoidsdamage to the major

branches of the phrenic nerve.Completion of the proximal dissection is accomplished bysweeping the peritoneum off of the diaphragm superiorly,takingcare toavoid traction injuries to theunderlying spleen,

which can be palpated through the peritoneum. Exposure ofthe perivisceral aorta is performed by opening the fascia an-terior and lateral to the left kidney, and mobilizing the plane

posterior to the kidney. Venous branches from the left renalvein are ligated at this point, and the kidney is swept anteri-orly. The ureter should be identified medially as it coursesalong the peritoneal sac (Fig 4). Padded self-retaining retrac-

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 17033-

0850. E-mail:[email protected]




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Figure 1 Patient positioning: An operatingtablethat allowsflexionand extensionat itsmidpointshouldbe utilized.This

provides extension for exposure and flexion for closure. The patient is placedwith thetorso rotated to the right and the

hips as flat 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. Dependingon theamount of proximal aorticexposure required,the incision is begun in the9th, 10th, or 11thinterspace at themid axillary line, butcan be carried to theposterioraxillary 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 tofacilitate exposure. Medially, the incision is carried either to the lateral edge of therectus muscle, or canbe taken to the

midline at the level of the umbilicus and extended into a midline abdominal incision.

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tors are used to hold the peritoneal contents medially. Clo-

sure of the wound in layers is performed with either contin-uous or interrupted suture. Choice of suture material istypicallybasedon surgeon preference. Monofilament absorb-able suture such as polydioxanone is a suitable choice. If thefascial layers are closed with continuous suture, reapproxi-mation of the transected costalmargin is best performedwithseparate sutures, rather than as part of the fascial closure.Closed suction drainage via a tube thoracostomy is per-formed if thepleural space wasentered. This is typicallymosteasily accomplished by making a stab incision one or two ribspaces above the operative incision, and directing the tubeposteriorly through a rib interspace one level above the stabincision. One posterior tube is generally sufficient, and can

be removed in 24 to 48 hours.

Spine Exposures

Exposure of the proximal lumbar bodies and disc in-

terspaces proceeds similar to that for vascular reconstruc-

tions. Exposure of the L4, L5, and S1 bodies and in-

terspaces does not require extensive proximal exposure

and thus can be performed with a different approach (Fig

5). The patient can be laid flat 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 flank, 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.

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 fibers. m. muscle.

Retroperitoneal exposures 89


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Figure 3 Identification 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 closedat 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 isdivided and the plane between this muscle and the peritoneum is identified. The identification of this plane is most

easilyaccomplished in thelateral portion of theexposure. In somepatients, however, thetransversusabdominismuscleis quite attenuated, and inadvertent entry into the peritoneal sac can easily occur. In these patients, division of the

posterior rectus sheath can allow easier identification of the underlying peritoneum, and subsequent development ofthe appropriate retroperitoneal plane. m. muscle.



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Figure 4 Aortic exposure:Completion of theproximal dissection is accomplished by sweeping theperitoneum offof thediaphragm 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 identified medially as it courses along the peritoneal sac. Paddedself-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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Although there is typically minimal variability from pa-tient to patient, fluoroscopic examination before skin in-cision 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 atthe midline approximately midway between the symphy-sis pubis and the umbilicus. It is extended laterally justbeyond the edge of the rectus sheath, although it may beextended as needed. Generous full thickness flaps from theskin to the fascia are mobilized in the cephalad and caudaldirections. A vertical incision is then made in the anteriorrectus sheath approximately 1 to 2 cm lateral to the lineaalba. Leaving a fascial edge medially facilitates closure.The underlying rectus muscle is swept laterally and theunderlying posterior sheath is incised vertically. The planebetween the peritoneum and the posterior rectus sheath isidentified, and the peritoneum is swept medially. An im-

portant 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, theureter is identified on the peritoneum and the left commoniliac artery can be palpated. Medial to this, the left com-

mon iliac vein is identified, and the medial border skele-tonized. Directly behind this lies the L5-S1 interspace, andfurther vessel mobilization is performed to allow adequateanterior exposure.

Exposure of the L4 and L5 lumbar bodies typically re-quires a more lateral approach, given that the L4 body typi-cally lies directly behind the aortic bifurcation. An obliqueincision can be created, with the level determined by preop-erative fluoroscopy. Division through the oblique muscula-ture and transversus abdominus is as described previously;the retroperitoneal plane is most easily identified laterally. Inthe medial portion of the incision, division of the lateral edgeof the rectus abdominus fascia and muscle may be necessary.

Mobilizationof the left commoniliac arteryanddistal aorta is

Figure 5 Relationship between the verte-

bral bodies and the abdominal vascula-ture. Anterior exposure of the spine is

most easily and safely accomplished withan understanding of the relationships be-

tween the large vessels and the corre-sponding lumbarbodies. Exposure of the

L1 through L4 bodies and interspaces re-quires exposure and mobilization of the

aorta through a left sided retroperitoneal

approach. The vena cava is sufficiently tothe right to not require formal exposure,

although identification of its medial (left)edge is appropriate. Exposure of the L4

and L5 bodies and interspace requiresmore extensive dissectionof theleft com-

moniliac arteryand vein. Exposure of theL5 and S1 interspace is most easily ac-

complished by a direct anterior ap-

proach, with identification of the rightcommon iliac artery as well as the left

common iliac artery and vein. IVC in-ferior vena cava; SMA superior mesen-

teric artery; L. left; Ao aorta; IMAinferior mesenteric artery.



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necessary, with division of the middle sacral and lumbar

arteries as needed.

Conclusions

Familiarity with the retroperitoneal approach provides an

additional weapon in the arsenal of approaches to abdominal

pathology. A three dimensional understanding of the ana-

tomical 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 pres-

sure and stretch points will help to prevent postoperative

complications.

Suggested ReadingArko 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: Retro-

peritoneal 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 flank retroperitoneal exposure: a technical aid to complex

aortic reconstruction. J Vasc Surg 14:283-291, 1991

Gumbs AA,Bloom ND,BitanFD, etal: Open anterior approaches forlumbar

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



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The Abdominoinguinal Incision

Constantine P. Karakousis, MD, PhD

The pivotal anatomical point in the abdominoinguinal in-cision is the origin of the inferior epigastric vessels as it istrue for the radical groin (ilioinguinal) dissection when thelatter is performed with in continuity removal of the inguinaland deep nodes. In the radical groin dissection, the antero-lateral abdominal wall muscles and the inguinal ligament aredivided lateral to the external iliac-femoral artery axis and theinferior epigastric vessels are approached from the lateral sideas they are ligated and divided. In the abdominoinguinalincision, the inguinal ligament is divided near the pubic tu-

bercle and the inferior epigastric vessels are approached fromthe 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 toinvolve the inner layers of the abdominal wall or infe-riorly behind or through the inguinal ligament into thegroin.

2. Tumors involving the iliac vessels requiring the in con-tinuity exposure of the femoral vessels for their re-moval.

3. Tumors fixed to the wall of the lesser pelvis requiringremoval of the obturator internus.

4. Large tumors of the pubic bone extending into the pel-

vis or adductor group of muscles; or pelvic tumorsextending through the obturator foramen into the ad-ductors.

5. Large, lower abdominal tumors extending laterallyand/or inferiorly so extensively that they cannot be re-tracted sufficiently to be dissected off the external iliacvessels to which they may be loosely attached.

The abdominoinguinal incision exposes in continuity theabdominal cavity with the adjacent anatomical area of thethigh (femoral triangle) and in that sense it is, for the lowerquadrants of the abdomen, the equivalent of the thoracoab-dominal incision for the upper quadrants.

Operative Technique

A lower midline abdominal incision is employed starting atthe pubic symphysis and extending proximally to the umbi-

licus and often above the umbilicus for a few centimeters, the

proximal extension of the incision depending on the proxi-mal extension of the tumor (Fig 1). The incision veers aroundthe left or right side of the umbilicus depending on the loca-

tion of the tumor. The linea alba is identified and incisedmost easily next to the umbilicus. The peritoneum is then

incised. Although the linea alba is incised to the pubic sym-physis, the peritoneal incision as one approaches the lowerend 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 ex-plores the entire abdominal cavity and then assesses the tu-mor that is to be resected. Mere fixation is not a sign ofunresectability as the involved soft tissues can be resected

through this incision. Bone involvement, other than that ofthe pubic bone, can be dealt with through the incisions em-ployed in internal hemipelvectomy.

The abdominal incision is then extended at its lower endtransversely to the mid-inguinal point on the side of involve-

ment, and then vertically over the presumed course of thefemoral artery for a few centimeters or to the apex of thefemoral triangle (Fig 2). If the aim is to simply provide expo-

sure in continuity of the vessels but there is no tumor actually

below the inguinal ligament a short vertical incision over thefemoral vessels suffices to allow for their exposure. On theother hand, if one is to perform an ilioinguinal dissection forbulky lymph nodes, which cannot be safely removed through

the usual incision for radical groin dissection, the verticalportion of the incision is extended to the apex of the femoraltriangle followed by development of flaps. Similarly if one isto remove in continuity the pubic bone or the entire ischio-

pubic ramus en bloc with the adductor muscles, the verticalincision is again long to the apex of the femoral triangle butthen there is no need to develop flaps, 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 throughthe subcutaneous fat exposing laterally the spermatic cord inthe male. The anterior rectus sheath and rectus abdominis aredivided close to the pubic crest and the inguinal ligament

divided at the pubic tubercle (Fig 3). The spermatic cord, ifnot involved by the tumor, can be extricated from the ingui-nal canal by dividing the floor of the canal from its deep

aspect (Fig4). Dividing the internal spermaticvessels deep tothe internal inguinal ring, if necessary, allows the testicle toremain viable if the latter has not been mobilized off its scro-tal sac that provides some blood supply to the testicle. Alter-

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

Fi llmore Hospital , 3 Gates Circle, Buffalo, NY 14209. E-mai l:

[email protected]

94 1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved.

mailto:[email protected]:[email protected]


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natively, the external oblique aponeurosis may be openedfrom the external inguinal ring and the spermatic cord extri-cated by incising the inguinal floor to the internal inguinalring (Figs 5 and 6). Because thecord lies lateral to the inferiorepigastric vessels at the level of the internal ring, completefreedom of the former cannot occur before ligation and divi-sion of the latter.

After the inguinal ligament is divided at the pubic tubercle,the inguinal ligament and the adjacent abdominal wall areretractedanteriorly and laterally so that the inferior epigastricvein andthen thearteryare ligated anddivided at their origin(Fig 7). The lateral third of the inguinal ligament is then

detached off the iliac fascia completing the process of opera-tive exposure.

The operation then continues according to the locationand extent of the tumor. For a tumor of the iliac fossa oneexposes lateral to theexternal iliac arteryanddeep to the iliacfascia the femoral nerve that surrounded by a vessel loop is

dissected from the tumor,unless it is found to be surroundedby the tumor in which case it can be divided. In the lattercase, the patient is unable to actively extend the knee but hecanstill ambulate,after a while without anyexternal support.

When the iliofemoral vessels are involved they are exposedproximally and distally, the tumor is mobilized all the wayaround tethered only by the vessels, the patient is heparin-ized, vascular clamps are applied proximally and distally andthe specimen is removed followed by vascular reconstruc-tion.

When the tumor is attached to the wall of the lesser pelvis,immediately behind the external iliac vein the fascia is in-cised, the bone exposed and the dissection continues onthe bone, on the lateral side of the obturator internus,

taking care of the internal iliac vessels, the overlying ureterand more posterolaterally of the sacral nerves forming thesciatic nerve under the piriformis. The sacral nerves consti-tute the limit of the resection.

The obturator nerve issuing from a position lateral (be-hind) the internal iliac vessels and coursing on the surface ofthe obturator internus fascia toward the obturator foramen isexpendable, since its removal does not cause anydeficienciesin the ordinary use of the lower extremity (Fig 8). The obtu-rator vessels behindthe nerve canalso be ligated anddivided.

The pubic bone, when involved, is removed by dividingthe pubic symphysis with a Gigli saw, the anterior pubisramus close to the acetabulum and the posterior pubic orischial ramus en bloc with the soft tissues involved.

Theclosure of theincisionis simple: Thelateral third of theinguinal ligament is sutured to theiliac fascia (when the latteris removed, to the iliofemoral ligament of the hip joint), andthemedialhalf of the inguinal ligament to Coopers ligament.The anterior sheath and rectus abdominis are sutured to thepubic crest and the midline abdominal incision is closed inroutine fashion (Fig 9).

Figure 1 A right abdominoinguinal incision for a tumor fixed to theright side of the p

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

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