Modified Technique for Thoracomyoplasty after Posterolateral Thoracotomy

Abstract

Objective: Thoracomyoplasty after prior posterolateral thoracotomy (PLT) remains a challenge for the thoracic surgeon. Thoracodorsal artery division after PLT impairs the vascularization supply of the latissimus dorsi muscle (LDM) resulting in muscle mass reduction due to distal atrophy. This makes adequate filling of residual empyema space and/or surgical closure of bronchial stump insufficiency more difficult, and they require alternative surgical procedures. We present an alternative approach using a four-muscle flap technique to include the infraspinatus, the subscapularis and the teres major muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing residual empyema space and bronchial stump insufficiency. Methods: Between 2002 and 2008 we performed the technique in 7 patients with residual empyema space. Three patients had post-tuberculosis syndrome, 2 had postpneumectomy empyema, and 2 had chronic parapneumonic empyema. Three cases were combined with a bronchopleural fistula. All patients underwent a two-stage procedure. First, open window thoracostomy was performed followed by definitive surgical treatment after 3–6 months. In all cases with bronchial insufficiency the stump was covered with a subscapularis muscle flap. The infraspinatus and the teres muscle group were used in combination with a local thoracoplasty. Results: Mean age was 68 ± 7.9 years. Time from open window thoracostomy to thoracomyoplasty averaged 4 ± 1.3 months. The number of resected ribs ranged between 4 and 8. Mean postoperative stay in the ICU was 3 ± 2.9 days. The thoracic drains were removed after 5 ± 2.3 days. Total hospital stay was 15 ± 7.6 days. No hospital mortality was noted. Minor postoperative complications occurred in 2 cases. Shoulder function without pain allowed abduction up to 90 degrees. Function was decreased by 16 ± 9 degrees compared to preoperative evaluation. No severe progressive scoliosis was noted. Conclusions: Division of the LDM and its vascular supply after posterolateral thoracotomy results in a reduction of muscle mass. The shoulder girdle muscles offer an adequate alternative to fill residual empyema space with acceptable long-term results and restriction in shoulder motion. In all cases with bronchial fistula, bronchial stump closure with a pedicled subscapular muscle was an effective alternative operative technique.

muscle flap - bronchial fistula - thoracoplasty - posterolateral thoracotomy

References

• 1 Horrigan T P, Snow N J. Thoracoplasty: current application to the infected pleural space.  Ann Thorac Surg. 1990;  50 695-699
• 2 Deslauriers J, Jacques L F, Gregoire J. Role of Eloesser flap and thoracoplasty in the third millennium.  Chest Surg Clin N Am. 2002;  12 (3) 605-623
• 3 Shipkov C, Mojallal A, Uchikov A. The importance of muscle-sparing thoracotomy for the treatment of postresectional complications after thoracotomy.  Eur J Cardiothorac Surg. 2007;  32 550-556
• 4 Nomori H, Horio H, Hasegawa T, Suemasu K. Intrathoracic transposition of a pectoralis major and pectoralis minor muscle flap for empyema in patients previously subjected to posterolateral thoracotomy.  Surg Today. 2001;  31 295-299
• 5 Widmer M K, Krueger T, Lardinois D, Banic A, Ris H B. A comparative evaluation of intrathoracic latissimus dorsi and seratus anterior muscle transposistion.  Eur J Cardiothorac Surg. 2000;  18 435-439
• 6 Arnold P G, Pairolero P C. Intrathoracic muscle flaps. An account of their use in the management of 100 consecutive patients.  Ann Surg. 1990;  211 (6) 656-660 discussion 660-662
• 7 Robinson S. The treatment of chronic nontuberculous empyema.  Surg Gynecol Obstet. 1916;  22 557-571
• 8 Thourani V H, Lancaster R T, Mansour K A, Miller Jr J I. Twenty-six years of experience with the modified Eloesser flap.  Ann Thorac Surg. 2003;  76 (2) 401-405 discussion 405-406
• 9 Clagett O T, Geraci J E. A procedure for the management of postpneumonectomy empyema.  J Thorac Cardiovasc Surg. 1963;  45 141-145
• 10 Vallieres E. Management of empyema after lung resections (pneumonectomy/lobectomy).  Chest Surg Clin N Am. 2002;  12 (3) 571-585
• 11 Pairolero P, Arnold P G, Trastek V F, Meland N B, Kay P P. Postpneumonectomy empyema. The role of intrathoracic muscle transposition.  J Thorac Cardiovasc Surg. 1990;  99 958-68
• 12 Meland N B, Arnold P G. Intrathoracic transposistion of soft tissue. Cohen M Mastery of plastic surgery. Boston, MA; Little Brown 1994: 1268-1275
• 13 Shipkov C, Uchikov A. The latissimus dorsi muscle divided in the course of thoracotomy for empyema cavity obliteration.  Eur J Cardiothorac Surg. 2004;  25 (1) 146-147
• 14 Seify H, Mansour K, Miller J, Douglas T, Burke R, Losken A, Culbertson J, Jones G, Nahai F, Hester T R. Single-stage muscle flap reconstruction of the postpneumonectomy empyema space: the Emory experience.  Plast Reconstr Surg. 2007;  120 1886-1891
• 15 Harris S U, Nahai F. Intrathoracic muscle transposition. Surgical anatomy and techniques of harvest.  Chest Surg Clin N Am. 1996;  6 (3) 5001-5018
• 16 Koch H, Tomaselli F, Pierer G, Schwarzl F, Haas F, Smolle-Jüttner F M, Scharnagl E. Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy.  Eur J Cardiothorac Surg. 2000;  21 874-878
• 17 Arnold P G, Pairolero P C, Waldorf J C. The serratus anterior muscle: intrathoracic and extrathoracic utilization.  Plast Reconstr Surg. 1984;  73 (2) 240-246
• 18 Arnold P G, Pairolero P C. Use of pectoralis major muscle flap to repair defects of anterior chest wall.  Plast Reconstr Surg. 1979;  63 (2) 205-213
• 19 Larson D L, McMurtrey M J. Musculocutaneous flap reconstruction of chest-wall defects: an experience with 50 patients.  Plast Reconstr Surg. 1984;  73 (5) 734-740
• 20 Yokomise H, Fukuse T, Ike O, Inui K, Mizuno H, Wada H et al. Unsuccessful omentopexy in thoracic surgery.  Thorac Cardiovasc Surg. 1997;  45 (3) 145-148