![]() ![]() The superior aspect of the flap is left attached to the under surface of the upper rib in the intercostal space at this time to avoid potential damage to the vascular pedicle of the flap from passage of instruments through the working incision during the operation. An army-navy or Richardson retractor can be used to retract the anterior aspect of the incision to allow for mobilization greater than the length of the working incision. This can be done gently with a periosteal elevator or a peanut dissector. The intercostal muscle is then detached from the superior aspect of the lower rib after entering the pleural cavity using a combination of cautery and blunt dissection. An incision is made in the intercostal muscle where it attaches to the lower rib for the length of the working incision. Low cautery settings are used to decrease the risk of thermal injury to the neurovascular pedicle. The intercostal space is identified when the rib cage is reached and using a finger, blunt dissection is performed posteriorly and anteriorly to separate the other muscles of the chest wall from the intercostal space. Retraction using army-navy retractors in the superior and inferior aspect of the wound help with exposure. The muscles of the chest wall are divided carefully with cautery until the intercostal space is reached. The working incision is placed in line with the major fissure usually in the 5 th intercostal space in the mid axillary line ( Figure 1). The camera port is placed slightly posterior to the anterior superior iliac spine line in the 7 th or 8 th intercostal space. The surgeon stands anteriorly while the assistant can stand on either side of the patient.įigure 1. The arm is positioned on an airplane to ensure that it will not interfere with the use of the instruments. The patient is placed in the standard lateral decubitus position for a posterior thoracotomy. Standard contraindications to VATS would prevent the use of this technique in harvesting the intercostal muscle. ![]() Previous thoracotomy in the same intercostal space of the working incision would make that ICM difficult to harvest for use as a buttress. However, if the vascular pedicle has been injured and its viability is of concern, then another flap should be considered for buttressing. ![]() One of the main advantages of using an ICM flap is that it is a well vascularized structure. No additional preoperative workup is needed for the procedure other than that required for the underlying condition. (6-8) There has been only one report of video assisted thoracoscopic (VATS) mobilization of ICM flap in the literature.(9) The technique described below allows harvest of an intercostal flap in patients undergoing thoracoscopic lobectomy. (1-3) In addition, creating an ICM has been associated with less pain and quicker return to function following lung resection with thoracotomy. These include patients with poorly controlled diabetes, pulmonary infections, immunocompromised patients, those receiving neoadjuvant therapy or adjuvant radiation (N2 disease found at the time of surgery) or chemotherapy. (4, 5) Recent evidence supports the use of an ICM flap after lung resection in high risk patients. (1-3) It has also been used to reinforce suture lines after bronchoplastic resections, esophageal repair and esophagogastric anastomoses. The intercostal muscle (ICM) flap has proven to be a reliable buttress for the bronchial stump following pneumonectomy and lobectomy.
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