- Anterior to thoracic spine
Incision is carried from postero superiorly around the angle of the scapula, obliquely sloping to anterior inferiorly. The length of the incision will depend on the length of the planned instrumentation.
The posterior superior end of the incision should be sufficiently high to access the most cranial vertebra to be instrumented. This is best checked by image intensifier. Similarly the most inferior part of the incision should allow access to the most caudal vertebra to be instrumented.
The skin and subcutaneous tissues and overlaying muscles are incised in line with the incision down to the rib to be exposed.
Depending on the length of instrumentation, a single or double thoracotomy will need to be performed. The rib is dissected subperiosteally and then cut from the posterior angle to as far anterior as possible avoiding injury to the neurovascular bundle. The rib is saved for subsequent bone grafting.
The pleura is then cut thereby entering the chest without injuring the lung. A rib spreader is used to open the space created.
The lung is then retracted anteriorly to expose the spine. It is optimal to have single lung ventilation with selective collapse of the ipsilateral lung tissue to provide exposure of the thoracic vertebral column.
If a double thoracotomy is required, then the second rib to be excised should be at least one level, ideally two levels, below the first thoracotomy site.
Closure is carried out in layers. Care is taken to avoid including the intercostal nerve in the suture.
Chest drains are usually inserted via a separate stab incision.