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J Thorac Cardiovasc Surg 2005;129:221-223
© 2005 The American Association for Thoracic Surgery

Brief Communications

Inverse T incision provides improved accessibility to the upper mediastinum

Gabriel Mihai Marta, MDa, Clemens Aigner, MDa, Walter Klepetko, MDa,*

a Department of Cardio-Thoracic Surgery, University Hospital of Vienna, Vienna, Austria

Received for publication January 27, 2004; revisions received March 26, 2004; accepted for publication April 6, 2004.

* Address for reprints: Walter Klepetko, MD, University Hospital of Vienna, Department of Cardio-Thoracic Surgery, Waehringer Guertel 18-20, 1090 Vienna, Austria (E-mail: walter.klepetko{at}meduniwien.ac.at).

The choice of the appropriate incision for a thoracic surgical procedure is crucial for a successful operation and a satisfying postoperative functional result. Especially in oncologic surgery of advanced mediastinal tumors, the close contact to vital structures demands an optimal surgical field. This report presents an innovative new access as an alternative to the variety of already existing thoracic incisions.


   Clinical summary
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 Clinical summary
Discussion
 References
 
A 59-year-old woman presented with exertional dyspnea and orthopnea and pronounced congestion of the jugular veins. Chest x-ray film showed a mediastinal widening. Computed tomography of the thorax revealed an anterior mediastinal mass with a diameter of 15.8 x 7.6 cm, with close contact to all major vessels and structures of the upper mediastinum and extension on both sides to the area of the phrenic nerves. However, radiologically, no signs of proved infiltration of vital structures were detected (Figure 1). The pulmonary function test revealed a moderate obstructive disease with a forced vital capacity of 2.19 L (68.1%) and a forced expiratory volume in 1 second of 1.53 L (59.4%). The histologic examination of tumor samples obtained by means of computed tomography–guided biopsy revealed the presence of a malignant mesenchymal fibrous tumor. Further staging examinations excluded any metastatic disease.



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  		Figure 1. Preoperative computed tomographic image of the thorax: anterior mediastinal mass with a diameter of 15.8 x 7.6 cm and close contact to the structures of the upper mediastinum. Radiologically, no signs of infiltration of vital structures were proved.

 
The patient underwent 2 cycles of induction chemotherapy with ifosfamide and epirubicin, which did not result in reduction of the tumor size.

The decision was therefore made to offer the patient a surgical resection of the mass.

During planning of the operative procedure, it became obvious that because of the extension of the tumor and its close relationship to the vital mediastinal structures, standard approaches, such as median sternotomy or transverse thoracosternotomy (clamshell or crossbow incision),1 would not allow equally good exposure of all anterior and supra-aortic mediastinal structures or sufficient access to the lateral portions of the mediastinal mass. Therefore a combination of these 2 standard surgical incisions, transverse thoracosternotomy (clamshell or crossbow incision) at the level of the third intercostal space combined with a partial proximal median sternotomy, was performed (Figure 2).



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  		Figure 2. Inverse T incision: transverse thoracosternotomy (clamshell or crossbow incision) at the level of the third intercostal space combined with a partial proximal median sternotomy.

 
The intraoperative view revealed the tumor mass, with a well-defined surface, sharply bounded margins, and multiple pronounced humps, filling the upper mediastinum and expanding laterally toward the 2 hemithoraces and evidently compressing the mediastinal structures and the lungs, respectively (Figure 3, A).



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  		Figure 3. Macroscopic view inside the surgical field: A, the site primary to resection; B, the site after resection.

 
Through the large and excellent access, the resectability of the tumoral mass was confirmed, and the dissection of the tumor, beginning at the anterior pericardium, was started. The pericardium was partially resected in its cranial part, followed by bilateral preparation of the pulmonary hilar structures. Both phrenic nerves, as well as the recurrent nerve on the left side, were successfully separated from the tumor capsule and preserved. The tumor was then completely separated from the aortic arch, vagus nerve, vena cava superior, and the vessels of the superior mediastinum. Finally, after ligature of several small arterial and venous vessels, the specimen was removed en bloc (Figure 3, B). For oncologic reasons, an extended mediastinal lymphadenectomy was added.

Wire cerclage was used for closure of the median sternotomy, and polyglactin 910 (Vicryl; Ethicon, Inc, Somerville, NJ), as well as enforced polydioxanone (Ethicon) sutures, were used for the bilateral thoracotomy, respectively.

The patient was extubated in the recovery room 2 hours after the operation. The drainage tubes were removed 48 hours after the operation, and the patient was discharged from the hospital on the 13th postoperative day, without any postoperative complications.

During a further 4-month follow-up period, the patient remained free of any symptoms and recovered completely. Clinically, no evidence of wound-healing disturbances or thoracic wall instability was detected.

Lung function test results improved significantly toward a postoperative maximum forced vital capacity of 2.58 L (80.1%) versus 2.19 L (68.1%) preoperatively and a maximum forced expiratory volume in 1 second of 1.81 L (70.6%) versus 1.53 L (59.4%) before the operation.

The final histologic study revealed an atypical fibrous tumor with an unusually high mitotic activity, which was not considered to be malignant and was proved to be fully resected within normal tissue (R0). All dissected lymph node stations were free of tumor.


   Discussion
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 Clinical summary
 Discussion
References
 
A variety of surgical approaches for treatment of complex intrathoracic diseases have been described. 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. The case described herein made it necessary to create a new surgical approach to successfully remove the tumor mass.

The proposed inverse T incision has not been described in the literature yet and therefore represents a completely new approach. It provides excellent access to the upper mediastinum, as well as to both pulmonary hili, and thus allows an effective dissection virtually in the entire upper third of the thoracic cavity. Additional advantages of the incision are the preservation of the stability and functionality of the sternocostal arch, which facilitates a rapid postoperative respiratory rehabilitation.

Potential disadvantages of the technique could be wound-healing disturbances, which were not observed in this particular case.

Although the use of this new technique should remain limited to selected cases, it represents a valuable alternative to the already existing spectrum of thoracic incisions.


   References
Top
 Clinical summary
 Discussion
 References
 

  1. Shields TM, LoCicero J, Ponn RB. General thoracic surgery. 5th ed.. Philadelphia: Lippincott Williams & Wilkins; 2000.
  2. Becker RM, Munro DD. Transaxillary minithoracotomy: the optimal approach for certain pulmonary and mediastinal lesions. Ann Thorac Surg. 1976;22:254-259.[Abstract]
  3. Cooper JD, Al-Jilaihawa AN, Pearson FG, Humphrey JG, Humphrey HE. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg. 1988;45(3):242-247.
  4. Kaiser LR, Pasque MK, Trulock EP, Low DE, Dresler CM, Cooper JD. Bilateral sequential lung transplantation: the procedure of choice for double-lung replacement. Ann Thorac Surg. 1991;52(3):438-446.
  5. Korst RJ, Burt ME. Cervicothoracic tumors: results of resection by the "hemi-clamshell" approach. J Thorac Cardiovasc Surg. 1998;115(2):286-294.



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