A postero-lateral thoracotomy scar indicates a surgical approach that provides access to the thoracic cavity, primarily for operations on the lungs, esophagus, spine, or other structures within the chest. The differential considerations for such a scar are related to the underlying reasons for the surgery. Here's a structured list of potential differentials:
Pulmonary Resections
Pulmonary Resections
- Lobectomy or Segmentectomy: Removal of a lobe or segment of the lung, often for lung cancer or severe infections.
- Pneumonectomy: Complete removal of a lung, typically for extensive disease like widespread lung cancer.
- Decortication: Removal of a thick layer of fibrous tissue, often due to chronic infection leading to empyema (pus in the pleural space) or pleuritis.
- Drainage of Lung Abscesses: Surgical intervention might be necessary for large or refractory lung abscesses.
- Bullae Resection: For conditions like severe bullous emphysema, where large air-filled spaces impair lung function.
- Bronchiectasis: Surgical management might be considered in localized disease not responsive to medical treatment.
- Repair of Chest Wall Deformities: Like pectus excavatum or pectus carinatum.
- Spinal Access for Anterior Spine Surgery: Such as for correction of spinal deformities or removal of tumors.
- Aortic Surgery: Access for repair of thoracic aortic aneurysms or dissections.
- Cardiac Surgery: Rarely, a thoracotomy approach might be used for certain cardiac procedures if sternotomy is not viable.
- Esophagectomy: Removal of part or all of the esophagus, typically for cancer.
- Esophageal Diverticulum Resection: Surgical removal of diverticula in the esophagus.
- Thoracic Outlet Syndrome (TOS): Decompression surgery for severe cases.
- Tumor Resection: Removal of benign or malignant tumors within the thoracic cavity, not limited to but including the lungs, mediastinum, pleura, and chest wall.
- Rib Fracture Fixation: Surgical intervention for severe, unstable rib fractures.
- Hemothorax or Pneumothorax Management: In cases where drainage is insufficient or there are complications.
Fig 1 – Common cardiothoracic incisions. ① Midline sternotomy, ② Pacemaker scar, ③ Posterolateral thoracotomy, ④ Anterolateral thoracotomy, ⑤ Axillary thoracotomy
A surgical incision is an aperture into the body to permit the work of the planned operation to proceed.
In cardiothoracic surgery, the routinely used incisions are the midline sternotomy, thoracotomy, and pacemaker incisions.
In this article, we shall look at the anatomy and clinical use of these common cardiothoracic incisions.
Median SternotomyThe median sternotomy ① is the most common thoracic incision.
It is predominately used for open heart surgery, such as valve replacements, CABG, or cardiac transplant.
Typically, a 4-5cm incision is made in the left infraclavicular region. There are three main types of incision used – horizontal, oblique and deltopectoral.
Once the incision is made, a subcutaneous ‘pocket‘ is created – in which the pacemaker is implanted.
ThoracotomyA thoracotomy is an incision used to access the pleural space of the thorax. The three main subtypes are the posterolateral incision, anterolateral incision, and axillary incision.
Posterolateral IncisionThe posterolateral thoracotomy ③ is the gold standard for access to the thorax. It provides access all the thoracic viscera, and is mainly used for pulmonary resections (pneumonectomy or lobectomy), chest wall resection, or oesophageal surgery.
The incision is made with the patient in the lateral decubitus position. It starts from between the scapula and mid-spinal line, and extends laterally to the anterior axillary line.
Before reaching the thoracic cavity, the incision passes through the latissimus dorsi and serratus anterior muscles, then transects the rhomboids and trapezius.
Anterolateral IncisionThe anterolateral thoracotomy ④ incision can be used in a variety of operations for cardiac, pulmonary, and oesophageal pathology.
The incision runs from the lateral border of the sternum to the mid-axillary line at the 4th or 5th intercostal space, dividing through the pectoralis major and serratus anterior in its approach.
Axillary IncisionAn axillary thoracotomy ⑤ is a muscle sparing approach to the thoracic cavity, used for pneumonectomy and pneumothorax operations.
The incision is made between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space.
Whilst the incision reduces muscle damage and has good cosmetic outcomes, it has limited exposure to the thoracic viscera.
In cardiothoracic surgery, the routinely used incisions are the midline sternotomy, thoracotomy, and pacemaker incisions.
In this article, we shall look at the anatomy and clinical use of these common cardiothoracic incisions.
Median SternotomyThe median sternotomy ① is the most common thoracic incision.
It is predominately used for open heart surgery, such as valve replacements, CABG, or cardiac transplant.
- Anatomy – The incision is made from the substernal notch to around the xiphoid process, before cutting directly through the sternum to enter the thoracic cavity.
- Discussion – A widely used incision, which provides good access to the thoracic cavity and the mediastinum. It can predispose to significant scar formation and chronic chest pain.
Typically, a 4-5cm incision is made in the left infraclavicular region. There are three main types of incision used – horizontal, oblique and deltopectoral.
Once the incision is made, a subcutaneous ‘pocket‘ is created – in which the pacemaker is implanted.
ThoracotomyA thoracotomy is an incision used to access the pleural space of the thorax. The three main subtypes are the posterolateral incision, anterolateral incision, and axillary incision.
Posterolateral IncisionThe posterolateral thoracotomy ③ is the gold standard for access to the thorax. It provides access all the thoracic viscera, and is mainly used for pulmonary resections (pneumonectomy or lobectomy), chest wall resection, or oesophageal surgery.
The incision is made with the patient in the lateral decubitus position. It starts from between the scapula and mid-spinal line, and extends laterally to the anterior axillary line.
Before reaching the thoracic cavity, the incision passes through the latissimus dorsi and serratus anterior muscles, then transects the rhomboids and trapezius.
Anterolateral IncisionThe anterolateral thoracotomy ④ incision can be used in a variety of operations for cardiac, pulmonary, and oesophageal pathology.
The incision runs from the lateral border of the sternum to the mid-axillary line at the 4th or 5th intercostal space, dividing through the pectoralis major and serratus anterior in its approach.
Axillary IncisionAn axillary thoracotomy ⑤ is a muscle sparing approach to the thoracic cavity, used for pneumonectomy and pneumothorax operations.
The incision is made between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space.
Whilst the incision reduces muscle damage and has good cosmetic outcomes, it has limited exposure to the thoracic viscera.