Preserving the intercostal nerves as a goal in thoracotomy

http://dx.doi.org/10.1590/S1806-37132014000600013 The current intercostal nerve preservation strategy requires that care be taken when closing a thoracotomy. There are currently three thoracotomy closure techniques: • transosteal or transcostal suture closure • transperiosteal suture closure(5) • pericostal suture closure, whereby sutures are placed in the virtual space between the periosteum and the neurovascular bundle(6) Three interrupted sutures are generally placed in order to close an extensive thoracotomy. When a rib fracture occurs, one or more sutures are needed in order to stabilize and align the fracture fragments. Synthetic absorbable 1-0 polyglactin 910 suture should be used whenever possible. For increased suture strength, a double-loop, U-shaped suture (i.e., a double 1-0 suture) is generally recommended. Below, I describe the thoracotomy closure technique whereby sutures are placed in the virtual space between the periosteum and the neurovascular bundle at the lower rib. The surgical needle with absorbable 1-0 suture is passed into the thoracic cavity through a point above the upper edge of the rib cranial to the thoracotomy. The needle inside the thoracic cavity is retrieved with the needle holder, and the suture is pulled until it reaches half of its length. The needle goes into the thoracic cavity again and out of the chest wall through a point located very close to the entry point. A U-shaped suture (i.e., a double 1-0 suture) is thus obtained, the strength of which is greater. The needle is removed, and the suture ends are trimmed with straight Kelly forceps. The suture end inside the thoracic cavity is pulled out and looped around the Kelly forceps so that the double suture is halved. The procedure described above is performed for each of the three or four sutures required for thoracotomy closure, thus concluding the first step of the closure technique. Preserving the intercostal nerves as a goal in thoracotomy