2_Apical Axillary Thoracotomy

Apical Axillary Thoracotomy Eric Vall ie ` res T he apical axillary thoracotomy is a muscle sparing and cosmet ically appeal ing incisio n. 1 It provid es access to the apex of the lung, the upper ribs, and the hemithorax posteriorly. Because of these attributes, it was once, for many, the preferred “minimally invasive” approach for the surgical treatment of recurrent pri- mar y spontaneous pne umothoraces or hig h tho raci c sympathectomies. 2,3 1 Bec ause of the li mit ed exp osure pro vid ed by api cal axil lary thora cotomy, doubl e lume n intub ation is strong ly recommended when working through this incision. The pa- tient is positioned in a lateral decubitus with the ipsilateral axilla exposed. This position can be accomplished by abduct- ing the shoulder at or just above 90 degrees and ﬂexing the elbow at 90 degrees by strapping it on a padded, rigid bar across the head of the table. 2 An alternative approach is to elevate the extended arm at 90 degrees above the head by placing it in a traction-pulley system with a 1-lb weight. The latter option frees up the ﬁeld anteriorly and potentially offers better access to the incision for the operator situated on the anterior side of the table. SURGICAL TECHNIQUE 58 Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 8, No 2 (May), 2003: pp 58-61

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5 Division of the intercostal muscles along the upper border of the third or fourth rib, or a subperiosteal excision of thethird rib allows access to the pleural space that is then entered under direct vision.

6 A small, self-retaining retractor is then placed. Further division of the intercostal muscles from within the chest, bothanterior and posterior to the incision, may facilitate widening the intercostal space opening.

60 ERIC VALLIE ` RES