The importance of muscle-sparing thoracotomy for the treatment of postresectional complications after thoracotomy.

We read with great interest the article of Athanassiadi et al. [1] ‘Muscle-sparing versus posterolateral thoracotomy: a prospective study’ which elegantly compares the two approaches for thoracic surgery. Based on the results of their prospective study Athanassiadi et al. concluded that the rates of occurrence of acute and chronic pain and morbidity are equivalent after lateral muscle-sparing thoracotomy (MST) and standard posterolateral thoracotomy (PLT) provided careful operative technique is used. Their conclusions are supported by the results of Ochroch et al. who found no difference in the rate of postoperative pain and overall recovery between the two methods [2]. Therefore, the choice between MST and PLT remains dependant on the underlying thoracic pathology and the surgeon’s preferences. In this sense, it seems that the most important advantage of the MST is the ‘sparing of the thoracic muscles’, and it is not by chance that the name of this approach to the thorax is called ‘muscle-sparing thoracotomy’. Although there are several techniques to perform a MST, the principle remains the same — preserving the vascular pedicle to the muscle and thus preserving its main source of blood supply. But why should one insist on the preservation of the muscles and their blood supply? Although significantly reduced during the last years, the empyema and postresectional complications remain a difficult-to-treat problem and the vascularised muscle flaps represent a basic tool in the armamentarium for their treatment [3]. In standard PLT, the latissimus dorsi and serratus anterior muscles are divided to gain exposure to the thoracic cavity. Thus, the use of the two muscles as vascularised muscle flaps is rendered difficult and hazardous. In MST, these muscles are preserved along with their blood supply and can be utilized, if needed, as pedicle vascularised transposition flaps. This remark gains increasing importance if we take into consideration the fact that the latissimus dorsi muscle is the most useful flap in thoracic reconstruction because of its reliable blood supply, big arc of rotation and grand surface [4]. Although even divided, the latissimus dorsi can still be used as two separate flaps with two separated blood supplies [5], this remains a difficult and hazardous challenge. In our practice, we have found that the MST offers a certain advantage in the treatment of eventual postthoracotomy empyemas because of the preserved possibilities of construction of safe latissimus dorsi flaps. That is why we strongly support the conclusion of Athanassiadi et al. that probably the most important advantage of the MST is the preservation of the thoracic muscles and their blood supply for the treatment of eventual postresectional complications.