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Eur J Cardiothorac Surg 2004;25:146
© 2004 Elsevier Science NL
Letter to the Editor |
a Division of Plastic and Craniofacial Surgery, Medical University-Plovdiv, Hirurgicheski kliniki, floor 3, #66 Peshtersko shosse blvd, 4002 Plovdiv, Bulgaria
b Division of Thoracic and Abdominal Surgery, Medical University-Plovdiv, Hirurgicheski kliniki, floor 3, #66 Peshtersko shosse blvd, 4002 Plovdiv, Bulgaria
Received 6 October 2003; accepted 20 October 2003.
* Corresponding author. Tel.: +359-32-602935
e-mail: cshipkov{at}hotmail.com
Key Words: Empyema • Latissimus dorsi muscle flap • Thoracotomy
The article of Koch et al. [1] is extremely interesting and valuable with its description of the pedicle latissimus dorsi (LD) muscle flap for emyema cavity obliteration after thoracotomy, a fact often declared impossible [2].
The treatment of empyema cavities has not changed a lot since originally described by Hippocrates 2000 ago—drainage of the infected empyema and obliteration of the empyema space by allowing the lung to come up to the chest wall, taking the chest wall down to the lung, or by using muscle flaps are the basics in this treatment [3].
The main source for obliteration of the empyema cavities remain the pedicle muscle vascularized flaps. Almost all accessible muscles of the chest wall were used for this purpose—the pectoralis major and minor muscles [2], serratus anterior muscle [4], intercostal muscles, rhomboideus and trapezius muscles, TRAM and omentum flap [3]. In this large variety of flaps the pedicle LD muscle flap, one of the most reliable and safe options for reconstruction of the thorax, remains aside. This is due to the fact the quite often a posterolateral thoracotomy results in division of the muscle, thus rendering its use hazardous because of sectioning of its main pedicle (the thoracodorsal vessels). Our clinical experience shows that this is the case even in thoracotomies named lateral.
However, we should not forget that the LD is a type V muscle according to their blood supply, and can be based either on the thoracodorsal vessels or on the intercostal or lumbar perforators. In this case the latissimus dorsi happens to be divided in two parts—one proximal part, supplied by the thoracodorsal vessels or the serratus branch; and one distal part supplied by the paravertebral or intercostal perforators. Thus, both parts of the muscle can be employed and two flaps can be designed corresponding to the two parts of the muscle and their blood supply, as wonderfully depicted by Koch et al. [1].
We strongly support the results and technique depicted by Koch et al. We have also used successfully the previously sectioned LD muscle on its intercostals perforators for obliteration of an empyema cavity. Our impression is that the lower part of the sectioned muscle (distal to the thoracotomy incision), based on the perforators is sufficient for cavities in the lower part of the thorax, but can hardly reach the proximal parts of the thoracic cavities. In such cases it can be combined with a pectoralis major and/or minor flap to complete the obliteration of the upper parts of the thorax, as depicted by Nomori et al. [2]. We have not used the upper part of the sectioned latissimus dorsi muscle so far.
The article of Koch et al. points out also the significance of the so-called latissimus dorsi-sparing thoracotomy [5]. Though the LD can be used even previously sectioned, we could render safe its use by preserving it from sectioning, that is by performing a latissimus dorsi-sparing thoracotomy when possible.
Footnotes
The authors of the original paper [1] were invited to comment on this Letter to the Editor but declined the offer.
References
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