Transaxillary Minithoracotomy: The Optimal Approach for Certain Pulmonary and Mediastinal Lesions

doi:10.1016/S0003-4975(10)64912-0

The Annals of Thoracic Surgery

Volume 22, Issue 3, September 1976, Pages 254-259

https://doi.org/10.1016/S0003-4975(10)64912-0 Get rights and content

Abstract

This report concerns the use of trans-axillary thoracotomy for a variety of pulmonary, pleural, and mediastinal conditions in 50 patients. Primary and metastatic carcinomas, pneumothoraces, and benign lesions such as bronchogenic cysts and neurogenic tumors can be identified, evaluated, and treated with confidence. Reduced postoperative pain and morbidity, rapid return of arm and shoulder movements, reduced hospital stay, and excellent cosmetic result are among the advantages of this approach when compared with the usual posterolateral thoracotomy.

References (3)

HJB Atkins
Sympathectomy by the axillary approach
Lancet
(1954)

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Cited by (33)

Oncologic Equivalence of Minimally Invasive Lobectomy: The Scientific and Practical Arguments
2018, Annals of Thoracic Surgery
Citation Excerpt :
Once cooperative group science infrastructure matured, randomized trials optimized the extent of resection, not the approach, and lobectomy became the preferred operation. Of lobectomy approaches, axillary or other limited thoracotomies bear special mention because they disrupted routine at well-respected centers before the emergence of VATS [11, 12]. Although proponents preferred them for all early-stage tumors, exposure concerns were cited by both investigators and detractors.
Despite the slow adoption of minimally invasive lobectomy (MIL), it is now a preferred approach for early lung cancer. Nevertheless, ongoing concerns about MIL oncologic effectiveness has led to calls for prospective, randomized trials.
Retrospective analysis of on-line databases, collected readings, and other scholarly experiences of the experienced authors were used to construct this review. All available reports that contained long-term survival comparisons for open versus MIL were tabulated.
The preponderance of limited randomized and numerous large propensity-matched database analyses indicate equivalent or improved long-term MIL survival for early-stage disease. MIL lymph node dissection quality has been challenged; however, this was attributed to MIL avoidance of central tumors in early reports. Although technical inadequacies for MIL should be amplified for advanced cancer resections, early reports show no such concern. In fact, for special populations such as older, frail patients, evidence is much stronger that MIL confers a survival advantage.
MIL is an oncologically equivalent operation with substantially less morbidity, especially in frail populations. It is reasonable to suggest that MIL should be the technique of choice, even a quality indicator, for lobectomy.
Thoracic Surgical Anatomy and Procedures
2010, Medical Management of the Thoracic Surgery Patient
Thoracic Surgical Anatomy and Procedures
2009, Medical Management of the Thoracic Surgery Patient
Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients
2005, Annals of Thoracic Surgery
Citation Excerpt :
Reduced acute and late pain, and morbidity, after the muscle-sparing alternative are well reported [26–28]. Likewise, thoracic surgeons have long considered the axillary thoracotomy as an optimal approach for pulmonary and mediastinal lesions [29–31]. We have, furthermore, preferred to use a short horizontal midaxillary incision in the skin, as this does not compromise any axillary glands, and does cross Langer′s lines in perpendicular fashion.
Partial sternotomy, as well as posterolateral or anterolateral right-sided thoracotomy, are used for correction of selected cardiac lesions in children. However, in female patients impaired breast development after an anterolateral thoracotomy is reported, and for both the posterolateral and the anterolateral approach, partial transection of large muscle groups is required. The midaxillary approach may help to avoid these side effects and improve the cosmetic result.
Beginning in April 2003, our institutional policy changed toward a midaxillary approach in prepubescent patients with an atrial septal defect, in whom criteria for catheter closure were not fulfilled. Thoracotomy was performed after a horizontal midaxillary incision and mobilization of the latissimus dorsi and splitting of the serratus anterior. Aorta and caval veins were cannulated directly. The atrial septal defect was closed during electrically induced fibrillation of the heart.
Until August 2004, this technique was applied in 36 patients (30 girls, 6 boys), with no need for conversions to another approach. Mean patient age was 6.9 ± 2.6 years (range, 4 to 14 years), with a mean weight of 23.8 ± 11.2 kg (range, 15 to 69 kg). Skin incision ranged from 4.5 to 6.0 cm. Mean cardiopulmonary bypass time was 31 ± 13 minutes (range, 13 to 73 minutes), with a mean ventricular fibrillation time of 21.2 ± 7.4 minutes (range, 10 to 42 minutes). In 28 of 36 patients a patch was used. No phrenic nerve damage occurred.
The midaxillary approach is a safe alternative to lateral thoracotomies frequently used in cardiac surgery for atrial septal defect closure. It helps to improve the cosmetic result in the prepubescent patient group. We believe that its application should not be expanded to include repair of more complex lesions or to patients below the age of 3 to 4 years. For these, variations of cosmetically favorable partial sternotomy techniques should be applied.
Surgical management of spontaneous pneumothorax
2005, EMC - Chirurgie
Le pneumothorax spontané peut être primaire (survenant sur un poumon sain) ou secondaire (survenant sur un poumon avec une pathologie sous-jacente). Il est caractérisé par le risque de récidive. Le traitement chirurgical est indiqué en cas de pneumothorax persistant après drainage, en cas de pneumothorax récidivant, dès la première récidive, ou en cas de pneumothorax bilatéral. Le geste chirurgical consiste à réséquer éventuellement certaines des zones bulleuses et surtout à provoquer une symphyse pleurale. Cette symphyse peut être obtenue soit par pleurectomie partielle, soit par irritation chimique et/ou mécanique de la plèvre. Ce traitement chirurgical peut être effectué soit par thoracotomie, soit par chirurgie thoracoscopique vidéoassistée qui est maintenant la technique la plus couramment utilisée pour le pneumothorax spontané primaire.
Spontaneous pneumothorax may be primary (occurring in healthy subjects) or secondary (occurring in individuals with pulmonary disease). The risk of recurrence is about 30%. Surgery is indicated in case of persistence despite drainage or incomplete lung reexpansion, first recurrence, or bilateral pneumothorax. Surgical management consists in resection of bullous area and pleurodesis. The techniques used for pleurodesis are the chemical pleurodesis, the mechanical abrasion or the parietal pleurectomy. The surgical treatment may be realized either by thoracotomy or by video-assisted thoracic surgery which is the preferential technique in case of a patient with primary spontaneous pneumothorax.
Inverse T incision provides improved accessibility to the upper mediastinum
2005, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Standard incisions include median sternotomy (Milton 1897), standard and extended (Paulson) posterolateral thoracotomy, and anterior and anterolateral thoracotomy. For specific upper mediastinal pathologies, a transaxillary minithoracotomy2 or a transcervical approach3 can be used, whereas clamshell4 and hemiclamshell incision5 provide more extensive access to the anterior mediastinum. However, in rare cases even this existing large reserve of different approaches does not provide sufficient access.

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: Presented at the Twelfth Annual Meeting of The Society of Thoracic Surgeons, Jan 26–28, 1976, Washington, DC.

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Transaxillary Minithoracotomy: The Optimal Approach for Certain Pulmonary and Mediastinal Lesions

Abstract

Lancet