Allows access to anterior, middle and posterior mediastinal structures
- Preparation
- Double lumen endobronchial tube
- Positioning
- Lateral decubitus
- Roll under dependent axilla to protect shoulder and axillary contents
- Flex dependent arm 90 degres at shoulder
- Drape superior arm over pillow or onto a cephalad sling
- Sandbag/Vacuum bag
- Flex lower leg 90 degrees with pillow between
- Secure strap
- Brake table to increase space between ribs
- Stand patient’s back
- Incision
- Mark
- Mark anterior axillary line at inframammary fold
- Extending laterally to pass 2-3cm below inferior angle of scapula
- Spinous process of T3, inferior to tip of scapula
- Curvilinear incision from
- Expose and divide Lat.dorsi
- Diathermy onto rib
- Work down through fascia
- Count ribs and enter between 5th and 6th ribs (line of oblique fissure)
- Finger thoracostomy
- Divide intercostal muscles
- Finochietto Rib Retractor or Tudor-Edwards retractors
- Diathermy anterior and posteriorly through intercostal muscle
- Mark
- Closure
- 28-32Fr Drains through separate stab incisions
- Close interspace with 1 PDS superior edge to superior edge o Close muscle layer continuous PDS
- Close subcutaneous fat with 2/0 Vicryl
- Close skin with subcuticular stich or staples
- Relative anatomy
- Diaphragm
- Upper limit of diaphragm at 4th intercostal space o Midclavicular line sits at 8th rib
- Mid axillary line at 10th rib
- Intercostal neurovascular bundle located on costal groove on inferior aspect of rib
- Vein, artery, nerve; superior to inferior
- Make incision close to superior margin of lower rib in tube thoracostom
- Diaphragm
