1. Dr.mehdi hadadzadeh Assistant professore of cardiovascular surgery IN THE NAME OF GOD

2. A surgical incision opens an aperture into the thorax to permit the work of the planned operation to proceed

3. If an operation is difficult, you are not doing it properly," applies directly to the incision used

4. The choice of incision: underlying pathology the site (e.g. lung, chest wall, oesophagus) experience of the surgeon

5. Types of incisions Median Sternotomy Posterolateral thoracotomy Anterolateral thoracotomy Lateral thoracotomy Bilateral thoracosternotomy Subxiphoid(pericardial window)

6. Posterolateral thoracotomy gold standard of thoracic incisions excellent exposure for most general thoracic procedures including the lung, heart, aorta, the lower esophagus, and diaphragm This approach is also used for spinal operations

7. Preoperative preparation Assessment of pulmonary function given a dose of antibiotics preoperatively preoperative education and incentive spirometry training as to the importance of adequate inspiration postoperatively to prevent atelectasis (lung collapse

9. Position complete lateral decubitus position use of sandbags, rolled sheets front and back or bean bags supporting the back and the abdomen

10. The lower leg is flexed at the knee and hip while the upper leg lies straight on the top of the pillow

11. to avoid post operative complications ; cutaneous necrosis, venous thrombosis or nerve compression.

12. arm placed on an angle pad free from any fixation.

13. Incision The position of the vertebral spines and the nipple is notified. The standard incision follows between scapula and mid-spinal line to the anterior axillary line passing 3cm below the tip of the scapula.

16. The skin incision :No. 10 scalpel latissimus dorsi and serratus anterior muscles : No. 10 scalpel or cautery Posteriorly, the muscle layers of the rhomboid and trapezius are incised The pleural space :incising the musculature between the ribs or via an osteotomy transect the muscles on the superior border of the ribs to avoid injuring the neurovascular bundle. ribs may be transected or resected

17. at the level of the 5th rib for exposure of the upper thoracic area :COA level of the 6th or 7th rib for lower thoracic area (e.g., lower esophageal or diaphragmatic surgery)

18. After operation drainage tubes must be placed The rib approximator is closed and No.1 chromic or No. 1 vicryl sutures are placed to encircle the bone along the length of the incision. Silk sutures are to be avoided as it increases postoperative pain The cut ends of the trapezius and latissimus dorsi muscles are then approximated and sutured subcutaneous tissue is closed using an interrupted 3-0 absorbable sutures. The skin is closed using surgical clips or a running 4-0 subcuticular stitch such as Monocryl.

20. disadvantages of this incision increased potential for blood loss and moderate time requirement for opening and closing the incision prolonged ipsilateral shoulder and arm dysfunctions compromised pulmonary function and chronic post thoracotomy pain syndromes scolioses have been described in children

21. Median sternotomy Most common thoracic incision Indications:cardiac operations-anterior mediastinal lesions-bilateral lung procedures Speed in opening and closing Supine position and arms in patient,s side

22. Incision Incision from below the suprasternal notch toa point between the xyphoid and umblicus An electric saw with a vertical blade is used An oscillating saw is used for repeated sternotpmy

23. Bone wax is a useful tool to control bleeding from sternum sterile mixture of beeswax and isopropyl palmitate

24. Sternal retractor is used in lower thired of the sternum and gradually opened

25. Stainless steel wire is at present the standard suture in median sternotomy

26. Disadvantage of this incision Scar formation Brachial plexus injury Chronic chest pain

27. Axillary(lateral)thoracotomy Advantages:muscle sparing-ease and speed-good cosmetic Disadvantages:limited exposure Choice in majority of pulmonary resections,PDA ligation,PA banding and…. Lateral decubitus position homolateral arm is abducted at 90° at the shoulder level, flexed at the elbow Incision Between posterior border of pectoralis major and anterior border of latisimus dorsi through the 4th or 5th intercostal space;

30. Bilateral thoracosternotomy(clamshell) Previously choice for bilateral lung transplant Incision along the inframammary creases and across the sternum 4 or 5 th intercostal space Poor healing of wound

32. Anterolateral thoracotomy Useful in variety of operation on heart,pulmonary resection and esophagus Supine and operation site elevated30 degree

33. Incision from lateral border of sternum to midaxillary at 4or5interspace Pectoralis major and seratus anterior is divided

34. Indications:pericardial effusion,pericardial biopsy,epicardial pacemaker Supine posision,midline incision over the xiphoid Subxiphoid incision(pericardial window)

35. Intrapleural(chest) tubes Whenever thoracotomy has been done exit of fluids and air and monitors of bloodloss Separate incision