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J Thorac Cardiovasc Surg 2006;131:762
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Right axillary incision: Is it really superior to anterolateral thoracotomy?

Clinical Fellow in Cardiac Surgery, Nottingham City Hospital NHS Trust, Nottingham NG5 1PB, United Kingdom

To the Editor:

I read the article by Prêtre and associates ¹ on right axillary incision performed for a wide range of congenital cardiac defects. The authors have described the cosmetic and functional advantage of this approach in various surgical procedures. Although I commend them for using this in a wide array of congenital heart diseases, I was surprised to find that the advantage it allegedly scores over anterolateral thoracotomy has been that there is no interference with breast development. While avoiding the necessity of groin cannulation for establishing CPB, there has not been a single incidence of intraoperative technical complications in a series of 140 patients in whom an anterolateral approach was used for atrial septal defect closure in my previous institution's experience (at G.K.N.M Hospital, Coimbatore, India). ² There also has not been any problem with breast development. The institution of CPB was conventional in the main incision itself with no significant increase in operative time or subsequent bleeding or hospital stay. Posterolateral thoracotomy may be technically demanding too, and the necessity for groin exposure in small children makes it less attractive than anterolateral thoracotomy. Once the dissection plane is established well in the submammary tissue, an approach via the fourth intercostal space gives good exposure to both the aorta (once thymic tissues are removed) and the venae cavae for cannulation. Both the atria are easily approachable for most congenital defects. When a correct tissue approximation is achieved with no puckering of breast tissue, there is no anticosmesis involved in breast asymmetry nor any cage deformity if well aligned. To stress again, asymmetric breast development is more feared than proven in these patients who undergo anterolateral thoracotomy.

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1. Prêtre R, Kadner A, Dave H, Dodge-Khatami A, Bettex D, Berger F. Right axillary incision. a cosmetically superior approach to repair a wide range of congenital cardiac defects. J Thorac Cardiovasc Surg 2005;130:277-281.[Abstract/Free Full Text]
   
2. Muralidharan S, Krishnan V Anup, Varma SK, Nagarajan M. Atrial septal defect closure in young females by anterolateral thoracotomy. Ind J Thorac Cardiovasc Surg 2004;20:129-131.
   

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