Posterolateral thoracotomy incision Posterolateral thoracotomy incision is one of the conventional surgical incisions, especially suitable for a variety of lung, esophagus, mediastinum, aorta and diaphragm surgeries, which reveals a stable and adequate field. The patient lies on the operating table on his or her side, and the incision is curved, starting from the anterior axillary line, skirting the scapular angle, and traveling posteriorly and superiorly to reach the midpoint between the conus spinosus and the medial border of the scapula. The length of the incision varies with the plane chosen. In pleurotomy for total lung resection for malignant mesothelioma, the incision at the level of the sixth rib is most often chosen Local anatomy from superficial to deep: skin, subcutaneous tissue, superficial fascia, muscles (latissimus dorsi, serratus anterior, trapezius), and ribs or intercostals, usually the latissimus dorsi muscle is required to be separated, and the trapezius muscle is separated if the incision is required to be made more posteriorly upward. The anterior serratus is usually free to be retracted anteriorly, but if fuller visualization of the operative field is required, the anterior serratus is severed as close as possible to the beginning of its rib cage. After entering the pleural cavity through an intercostal or bed-of-costs incision, the incision is opened with a rib retractor to visualize the field. The advantages of this incision are: adequate visualization of the field and repeatability of the incision. Disadvantages include: high surgical trauma and common incisional complications related to postoperative pain. Open chest incisions are prone to postoperative pain, mainly due to direct compression of the intercostal nerve by the incision retractor or rib fractures. Separation of the latissimus dorsi and serratus anterior can also cause postoperative pain and muscle dysfunction. Another potential problem with this incision is the reduced shoulder motion postoperatively, which can cause bursitis and frozen shoulder. This incision is used to visualize the upper and middle portions of the lungs and mediastinum, and is useful for open biopsy of the lungs or pericardial drainage, whereas it is more difficult to visualize the lower lobes. The advantage is that there is less disruption of muscle tissue and the procedure is relatively less invasive. The patient is placed in the supine position, with the operated side elevated 30-45 degrees and the operated side’s upper limb slightly internally rotated, or the forearm is fixed to a brace. To relax the latissimus dorsi and serratus anterior. The anterolateral incision is chosen in the fourth or fifth intercostal space, along the skin folds of the lower edge of the mammary glands, turning outward and upward, anteriorly to the sternum, and posteriorly along the ribcage to the mid-axillary line or posterior axillary line. The anterior open thoracotomy incision is usually confined between the midclavicular line and the anterior axillary line at the inframammary margin. The corresponding intercostal space is accessed after blunt separation of the fascia and muscle of the pectoralis major and serratus anterior. An anterolateral incision extends the exposure after separating the lateral serratus anterior muscle. In women, it may be necessary to free the mammary gland outside the pectoralis major fascia to expose the corresponding intercostal space. Careful control and ligation of the mammary vessels is required before entering the pleural cavity. Dissection of the sternocostal joints, or even transection of the sternum, may further expand the extent of visualization in the anterior mediastinal direction. This incision has always been the main surgical approach in cardiac surgery, with excellent exposure of the anterior mediastinum and trachea, and simultaneous exposure of both lungs. Bilateral pneumonectomy and combined cardiopulmonary surgery can be performed through this incision. With advances in minimally invasive surgery, many physicians prefer to use multiple small incisions instead of the median incision. The median split sternal approach has the following two common skin incisions: 1. Median straight skin incision: the traditional standard surgical incision, but postoperative scarring affects aesthetics. 2. 2. Bilateral inframammary skin incision: instead of the standard median skin incision, it can also split the sternum into the chest. The advantage is that the incision is more hidden, but more traumatic. Bilateral inframammary skin incision is suitable for children and women. The patient is placed in the supine position with both upper limbs on either side of the body. A straight incision is made from the upper fossa of the sternum to the subxiphoid process, incising the skin, subcutaneous tissues, fascia, and anterior periosteum of the sternum layer by layer, and the pectoral muscles are usually uncrossed in the midline without freeing. The sternum is opened below the white line, and the internal clavicular ligament is separated by electrocautery in the suprasternal fossa. The suprasternal fossa contains the jugular venous arch, which connects the two anterior jugular veins; therefore, the suprasternal fossa should be carefully separated, and injury to this vein before splitting the sternum can cause hemorrhage. Split the sternum along the midline of the sternum with a sternal saw, and use electrocautery and bone wax to control the bleeding of the sternal wound. Clam-type thoracotomy Before the use of the less invasive median sternotomy, this incision has been used as a standard cardiac surgical incision, and is now used in double lung transplantation, pericardiectomy or double lung metastases resection, due to the covert nature of this incision, some physicians are still used in cardiac surgery for young women, and tracheal intubation of patients are not suitable for the median incision, so it is also often used in this incision. The patient is placed in the supine position with the arms abducted, and an arcuate incision is made bilaterally under the mammary glands at the level of the fourth intercostal space to the midaxillary line on both sides. Electrocautery separates the fascial layer, pectoralis major muscle, intercostal muscle and wall pleura, separates and ligates the intramammary blood vessels, transversely splits the sternum, and the rib retractors are used to retract the incision bilaterally. Anterior flap incision The anterior flap incision is also known as the half clam incision, which is the combined incision of the anterolateral incision and the upper median split sternotomy. It allows full visualization of the upper mediastinum, trachea, aortic arch and its branches. The patient is placed in the supine position with the neck extended and the head turned to the nonoperative side. The incision starts 5-6 cm above the suprasternal fossa, at the anterior edge of the sternocleidomastoid muscle on the operative side, down through the midline of the sternum, reaches the level of the second and third intercostal space, then arcs along the intercostal space to reach the anterior axillary line, separates the deep cervical fascia and the fascia over the sternum to control the bleeding of the anterior cervical vascular branches, electrocauterizes and opens the pectoralis major muscle on the surface of the corresponding intercostal space, and with the same anterior-lateral incision, enters the pleural cavity and controls the bleeding of the intramammary vessels on the edge of the sternum. The sternum was partially split in a straight line from the suprasternal fossa with a sternal saw, and the extent of the sternal split was the same as the extent of the skin incision. After completing the incision, a large skin flap including part of the chest wall, pectoral muscles and neck muscles was formed, and the anterior mediastinum was fully revealed after tractioning the skin flap. Sixth, to protect the muscle of the open chest incision At present, the vast majority of thoracic surgery do not need the traditional large open chest incision, with the improvement of surgical techniques, cutting suture device and other advances, the application of unilateral ventilation anesthesia, so that more and more surgeries can be carried out under a small open chest incision. There are many muscle-protecting open chest incisions that protect muscle tone in the early postoperative period, reduce pain, minimize the amount of analgesic medication, and protect lung function. However, these advantages have not been demonstrated in cases with long-term follow-up. Such incisions have the following common features: freeing of the latissimus dorsi and serratus anterior muscles and retraction of these muscles instead of severance. The longer intercostal muscles need to be separated to avoid rib fracture because of the restriction on retraction of the ribs. It has now been found that when such incisions are chosen, extensive muscle and skin freeing in order to adequately visualize the operative field results in the complication of mucous edema of the wound. Modified muscle-protecting incisions using a straight skin incision can be performed for some mediastinal, pulmonary, and esophageal surgeries, with the advantages of reduced freeing and chest wall trauma, increased shoulder motion in the postoperative patient, and reduced postoperative pain. Seventh, axillary open thoracotomy incision The most unaffected appearance of the open thoracotomy incision is the axillary open thoracotomy incision, which can reveal the pulmonary alveoli in the apical part of the lungs, chest wall tumors, the upper sympathetic chain severance or the first rib resection, but also applies to some of the lobar resection or segmental resection of the lungs. The patient is placed in the lateral position with a 45o posterior tilt, and the upper extremity on the operative side is abducted 90o at the shoulder and secured to a head frame, taking care that the skin does not come into contact with electrically conductive objects (metal braces) to avoid intraoperative burns. The incision is located at the level of the second intercostal space or flat 3rd rib, between the posterior aspect of the pectoralis major muscle and the anterior border of the latissimus dorsi muscle, and the muscle is protected by a straight, transverse, or curved axillary incision. In the case of a straight incision in the midaxillary line, the length of the incision may be from the axillary hairline to the ninth intercostal space. The chest wall is incised layer by layer up to the serratus anterior muscle, and as soon as the muscle of the chest wall is reached, the latissimus dorsi muscle is freed posteriorly, and by freeing the serratus anterior muscle at the beginning of the ribs, the serratus anterior muscle is then lifted up to the desired entry intercostal space. Generally at the level of the third intercostal space, the anterior serratus and intercostal muscles are separated to allow access to the thoracic cavity, and the incision is retracted with a small retractor to reveal the operative field.The Balfour retractor is placed at the right corner of the rib retractor to retract the muscle. During electrocautery, care should be taken to avoid injury to the intercostal branch and the long thoracic nerve; the former is a branch of the intercostal nerve emanating from the second intercostal space, and the latter is located on the posterior side of the incision, on the surface of the anterior serratus muscle; injury to this nerve can result in a pterygoid shoulder deformity. Flaps should be avoided to minimize postoperative wound edema. This incision is minimally invasive, but care should be taken not to overstretch the affected upper arm to avoid injury to the brachial plexus nerve. This incision is suitable for most intrathoracic surgery, but it is more difficult to free the pulmonary hilum or resect the chest wall. VIII. Other thoracic surgical incisions (I) Neck incision 1. Transverse neck incision Adopt supine position, with the shoulder pads between the shoulders, so that the neck is tilted back, the chest is elevated, and the head is turned to the non-surgical side. A collar-like incision is made at about one transverse finger above the clavicle, starting from the lateral edge of the sternocleidomastoid muscle on one side and ending at the medial edge of the sternocleidomastoid muscle on the opposite side. The skin, subcutaneous tissue and the vastus cervicis muscle were incised, and under the vastus cervicis muscle, the skin flap was separated from the sternocleidomastoid muscle and the strap muscle fascia, and stopped upward at the level of the cricoid cartilage, and stopped downward at the upper edge of the sternum and the clavicle, and the skin flap was retracted with sutures or retractors. After cutting the fascia in the sulcus between the sternocleidomastoid and sternocleidomastoid muscles, the dissection reaches the anterior intervertebral space in a deep direction, between which the middle thyroid vein can be ligated. The deep medial part of the incision (near the esophagotracheal groove) should not be violently pulled to avoid injury to the recurrent laryngeal nerve. The transverse cervical incision is completed after carefully freeing the esophagus. 2.Cervical longitudinal incision, also known as anterior sternocleidomastoid incision, is used in the lateral position because it is often used in conjunction with open thoracotomy incision, otherwise it is mostly used in the flat position. When lying on the side, the head is elevated and tilted back, and the skin of the neck, shoulder and upper arm on the operation side is sterilized, and the sterile sheet is wrapped around the upper limb, when making chest incision, the upper limb on the operation side is put in front of the chest in the shape of hugging the shoulder, and when making neck incision, the neck is put in the back of the chest side in the downward position. The incision was made at the anterior border of the sternocleidomastoid muscle, down to the suprasternal notch, and up to the upper middle third of the sternocleidomastoid muscle, beyond the level of the thyroid cartilage. The skin, broad cervical muscle and deep cervical fascia are incised, and the sternocleidomastoid muscle is retracted backward. After separating the neck muscles, the esophagus is freed behind the thyroid gland and trachea and bluntly freed under the thoracic inlet to avoid injury to the recurrent laryngeal nerve, and the esophagus is cut off or retracted to complete the neck incision. (ii) Mid-abdominal incision or paramedian incision is the most commonly used abdominal incision in China, which is suitable for people with narrow rib arches. Mid-abdominal incision: in the midline of the abdomen, from the xiphoid process to the umbilicus, incise the skin, subcutaneous tissues and the white line of the abdomen, enter the abdomen, and complete the mid-abdominal incision. 1, abdominal “T” shaped incision median incision to the midpoint of the raphe and the umbilicus, and to both sides of the rib arch as a transverse incision, for those with narrower rib arches, slightly better than the median incision exposure, but more traumatic. 2, abdominal transverse incision The incision under the right rib margin extended to the left rib margin is suitable for those with wider rib arches, its advantages: good healing of the incision after multi-layer suture, and less incidence of incisional splitting or incisional hernia. Operation method: through the lower edge of the right rib arch, one transverse finger next to the rectus abdominis muscle sheath, incise the skin and subcutaneous tissues, cross the midline under the raphe, and extend to the left under the left rib arch. The electric knife cuts the external and internal oblique abdominal muscles and their fascia, cuts the anterior rectus abdominis sheath and rectus abdominis muscle (the anterior and posterior sheaths of the left rectus abdominis muscle are cut, the left rectus abdominis muscle can be preserved and retracted), and cuts the transversus abdominis fascia and the posterior sheath of rectus abdominis muscle in a deeper direction, then opens the peritoneum, and cuts the sickle ligament to complete the transversus abdominis incision. (C) Cervicothoracic joint incision (cervical median split sternotomy) position with the cervical transverse incision, cervical transverse incision plus segmental sternum partially split to the level of the 3rd or 4th thoracic rib joint, because esophageal surgery on the incision of pollution is heavier, so we should avoid completely split the sternum, in order to maintain the stability of the sternum, is conducive to the control of the incision infection. Operation method: make a transverse cervical incision on the upper sternal incision, the same method as above, make a longitudinal median incision on the upper sternum, and extend it up to the transverse cervical incision, so that the incision is in the form of a “T” shape or an inverted “L” shape. The posterior sternal space is bluntly separated, and the sternum is partially split longitudinally to avoid shifting the incision and to protect the deep tissues. If the exposure is unsatisfactory, the sternum can also be completely or partially transected at the 3rd or 4th intercostal space, avoiding injury to the innominate vein and bilateral internal thoracic arteries. Between the left and right jugular veins, the beginning of the innominate artery is brought down to the right, and the esophagus is exposed to complete the combined cervicothoracic incision. Wire fixation of the sternum was performed while suturing the incision. (iv) Combined thoraco-abdominal incision In 1896, Mikulicz completed the first combined thoraco-abdominal incision, and the first time it was done in a living human was by Marwedel (1903), which was the third case in a human. In 1909, Tiegel completed a combined thoraco-abdominal incision in stage II. In 1920, Kirschner completed a combined thoraco-abdominal incision in stage I. In 1941, Garlock reported a combined thoraco-abdominal incision for the treatment of pancreatic cancer. The incision is made through the sixth, seventh, or eighth intercostal space or rib bed, posteriorly to the posterior axillary line, naturally forward over the rib arch, and forward to a straight abdominal incision or an oblique incision reaching the epigastric midline. Along the incision, the anterior serratus muscle, external oblique abdominal tendon membrane, rectus abdominis sheath are incised to reveal the deep intercostal muscles, rib arch and transversus abdominis muscle, the chest is opened through the intercostal space, the rib arch is cut off, the deep abdominal muscles and the peritoneum are incised to enter the abdomen, and the diaphragm is incised along the transversus abdominis muscle, completing the thoracic and abdominal joint incision. When closing the combined thoracoabdominal incision, the diaphragm is often closed first with interrupted sutures, and the stitch spacing should not be more than 1 cm.The cartilage of the rib arch can be closed with a thick triangular needle, a No. 7 silk thread, or two 0 non-invasive sutures in a figure-of-eight fashion. The chest is routinely closed after placement of a drain in the chest cavity. The peritoneum and abdominal wall were closed with continuous and interrupted reinforcement sutures. (E) Cervical mediastinoscopy and anterior mediastinal incision Mediastinoscopy and mediastinal incision are not only used for the staging of lung cancer, but also can be used for the diagnosis of other mediastinal diseases, which can be used when there is clear mediastinal lymph node enlargement shown by CT or MRI. The patient is placed in supine position with shoulders down to stretch the neck, a transverse incision is made in one finger on the upper sternal fossa, the muscle layer is separated and retracted to both sides at the midline, the thyroid isthmus is retracted upward, and the paratracheal fascia is incised sharply, and then the fingers are separated and pushed away from the anterior tracheal fascia, and a mediastinoscope is inserted along the gap, and the biopsy can be taken to reach enlarged lymph nodes, and the surgery is completed. A mediastinal incision is used to biopsy periaortic and subaortic lymph nodes that are inaccessible to the mediastinoscope; usually, this incision is completed in the left second intercostal space, but it can be done on the right side to biopsy right mediastinal lymph nodes. Using a transverse incision in the second intercostal space adjacent to the sternum, the pectoralis major muscle is separated by electrocautery up to the superior border of the third rib, the intercostal muscles are separated, avoiding damage to the intramammary vessels and the mural pleura, and then bluntly separated into the mediastinum, where the lymph nodes are biopsied under direct visualization or mediastinoscopy.