Eur J Cardiothorac Surg 2008;33:928-930. doi:10.1016/j.ejcts.2008.01.040
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Harvest technique for pedicled transposition of latissimus dorsi muscle: an old trade revisited
Amir Abolhodaa,*,
Garrett A. Wirthb,
Trung D. Buib,
Jeffrey C. Millikena
a University of California, Irvine, Medical Center, Department of Surgery, Division of Cardiothoracic Surgery, Orange, CA, United States
b University of California, Irvine, Medical Center, Department of Surgery, Orange, CA, United States
Received 13 July 2007;
received in revised form 21 December 2007;
accepted 16 January 2008.
* Corresponding author. Address: Division of Cardiothoracic Surgery, Department of Surgery, University of California, Irvine Medical Center, 101 The City Drive, Building 53, Room 117, Orange, CA 92868-3298, United States. Tel.: +1 714 456 3634; fax: +1 714 456 8870. (Email: aabolhod{at}uci.edu; gwirth{at}uci.edu; buitd{at}uci.edu; jmillik{at}uci.edu).
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Abstract
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Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.
Key Words: Latissimus dorsi muscle flap • Harvest technique • Thoracic surgery
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1. Introduction
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Intrathoracic transposition of an extrathoracic muscle to buttress repair of a bronchopleural fistula (BPF) was first described in 1911 by Abrashanoff [1]. For many decades to follow, thoracic surgeons have utilized extrathoracic muscle flap transposition as an effective technique to obliterate potential pleural space problems, especially in the presence of chronic infectious disease, and to reinforce closure of postoperative BPF [2–4]. The chest-wall skeletal muscles most frequently utilized have been latissimus dorsi, serratus anterior, and pectoralis major, in that order. Although the technique for harvesting a pedicled latissimus dorsi (PLD) muscle flap has been extensively described in the Plastic and Reconstructive Surgery literature [5,6], a simplified step-wise description of the method adoptable by practicing thoracic surgeons has been scantly reported [7,8]. In this report, we describe our technique for mobilization of a PLD muscle during a primary or redo posterolateral thoracotomy for its use as a prophylactic flap to prevent BPF or recurrent empyema.
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2. Technique
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A skin diagram outlining the surface projections of latissimus dorsi, its thoracodorsal pedicle and the proposed thoracotomy incision is depicted in Fig. 1
. Through a standard posterolateral thoracotomy incision, the anterior border of the latissimus dorsi muscle is identified. Superior and inferior subcutaneous flaps are raised superficial to the muscle fascia extending to its anterior and posterior borders. Next, the plane deep to the muscle is developed at its superior anterior aspect near the posterior axillary line, separating it from the slips of the serratus anterior muscle; the dissection is then carried down inferiorly toward the iliac crest. Using electrocautery, the muscle is then detached from its points of origin (iliac crest, posterior superior iliac spine, sacrum, thoracolumbar fascia, T10-L5 spinous processes, and inferior four ribs). Next, the posterior deep plane is elevated in a caudal to cephalic direction. The minor segmental vessels from the intercostal and lumbar arteries are clipped or suture ligated and divided. The dissection is then carried toward the muscle insertion in order to identify the vascular pedicle taking care not to elevate the trapezius muscle. The thoracodorsal neurovascular pedicle becomes visible on the deep surface of the latissimus dorsi muscle once it is separated from the serratus anterior muscle near the axillary fold (Fig. 2a). The pedicle is found approximately 2–3 cm medial to the anterior muscle border and approximately 9 cm below the apex of the axilla. The muscle flap's arc of rotation and effective length may be increased by dividing the thoracodorsal nerve, serratus and circumflex scapular artery branches, as well as partially, or completely detaching its point of insertion onto the intertubercular groove of the humerus (Fig. 2b). We routinely divide the thoracodorsal nerve in order to prevent any muscle stimulation that may disrupt the inset of the muscle. The muscle is then wrapped in a moist laparotomy pad to be used for transposition later. The average time for harvesting the entire muscle is approximately 20–30 min.
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Fig. 1. Preoperative skin diagram: the purple lines depict surface projections of latissimus dorsi muscle; the red and green lines outline the thoracodorsal neurovascular bundle. The solid black line shows the anterior aspect of the proposed thoracotomy incision.
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Fig. 2. (a) Intraoperative photograph showing the thoracodorsal vascular pedicle of the PLD muscle flap. (b) Intraoperative photograph showing the bulk of the harvested PLD muscle flap.
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At the completion of the intrathoracic procedure, a counter incision is made in the second intercostal space to transpose PLD muscle into the thoracic cavity taking care not to twist or apply undue tension on the vascular pedicle. The muscle is loosely tacked to the mediastinal pleura with several interrupted 3-0 Vicryl sutures. The muscle donor site is closed in two layers over two large bore (19 Fr) closed suction drains. Drains are frequently required for 1–3 weeks due to a moderate risk of seroma formation. We recommend taking the full-length of the muscle due to the excessive amount of shortening the surgeon will encounter once it is released from its origin and insertion. This will ensure adequate length for proper tension free inset within the thoracic cavity.
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3. Comment
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The latissimus dorsi muscle is the largest intrathoracic muscle flap that can be harvested on a single vascular pedicle. It may measure up to 20 cm x 40 cm. This flat, triangular muscle has a type V pattern of blood supply. It relies on one dominant pedicle that is the thoracodorsal artery and its associated venae comitantes with at least one secondary segmental pedicle (i.e. posterior intercostal or lumbar perforating vessels). This muscle is routinely partially or completely divided in most primary posterolateral thoracotomy incisions; its preservation and subsequent pedicled transposition can obviate need for an additional elaborate dissection or incision for harvesting an extrathoracic muscle for coverage of a bronchial stump at risk for dehiscence. Furthermore, due to its large bulk and reliable long vascular pedicle, the PLD muscle flap can reach and obliterate an infected apical or mid-thoracic dead space with ease and minimal tension. The only potential limitation of a thoracodorsal artery-based PLD is its ability to reach the lower, supra-diaphragmatic recess of the pleural space for which an alternative flap should be considered.
Over the past two and half years, we have exclusively utilized transposition of ipsilateral PLD muscle flap as a prophylactic measure against development of BPF or recurrent empyemas in 10 consecutive patients with a myriad of intrathoracic inflammatory, infectious or malignant pathologies with great results. There were no operative deaths, no clinically overt BPFs, and no recurrent postoperative empyemas. Two patients developed minor wound seromas that were managed observantly.
The primary function of the latissimus dorsi muscle is to adduct, extend and rotate the humerus internally. Because of presence of a number of synergistic shoulder girdle muscles, latissimus dorsi can be sacrificed with impunity without affecting shoulder or arm function. On late clinic follow-up, none of our patients have developed any functional disability or chest wall contour deformity related to PLD harvest.
Our technique for harvesting a PLD muscle flap is quick, reproducible and easily adoptable by most thoracic surgeons. This valuable technique should be part of the armamentarium of any thoracic surgeon dealing with challenging intrathoracic diseases.
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References
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- Abrashanoff: Plastiche methode der Schlessung von Fistelgangen, welche von inneren organen kommen. Zentralbl Chir 1911;38:186.
- Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account of their use in the management of 100 consecutive patients. Ann Surg 1990;211(6):656-660.[Medline]
- Cerfolio RJ. The incidence, etiology and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001;13:3-7.[Medline]
- Meyer AJ, Krueger T, Lepori D, Dusmet M, Aubert JD, Pasche P, Ris HB. Closure of large intrathoracic airway defects using extrathoracic muscle flaps. Ann Thorac Surg 2004;77(2):397-404.[Abstract/Free Full Text]
- Hochberg J, Ardenghy M, Yuen J, Graeber GM, Warden HE, Gonzalez-Cruz R, Conrado RM, Francel TJ. Utilization of muscle flaps in the treatment of bronchopleural fistulas. Ann Plast Surg 1999;43(5):484-492.[CrossRef][Medline]
- Dosios T, Papadopoulus O, Mantas D, Georgiou P, Asimacopoulos P. Pedicled myocutaneous and muscle flaps in the management of complicated cardiothoracic problems. Scand J Plast Reconstr Surg Hand Surg 2003;37(4):220-224.[CrossRef][Medline]
- Harris SU, Nahai F. Intrathoracic muscle transposition: surgical anatomy and techniques of harvest. Chest Surg Clin North Am 1996;3(6):501-518.
- Marshall MB, Kaiser LR, Kucharczuk JC. Simple technique for maximal thoracic muscle harvest. Ann Thorac Surg 2004;77:1465-1466.[Abstract/Free Full Text]
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Abstract
1. Introduction
