Refinements to Open Procedure Reduce Pain to Minimally Invasive Levels
 |
Decreasing damage to intercostal nerves during posterior lateral thoracotomy and harvesting and leaving the intercostal muscle flap intact instead of cutting it before rib spreading significantly reduce postoperative pain.
|
Chronic pain affects up to 67% of patients who have had a thoracotomy, and experts believe this pain is related to intercostal nerve trauma. UAB thoracic surgeon Robert J. Cerfolio, MD, has refined a pain-reduction technique he originally outlined in 2005 (J Thorac Cardiovasc Surg. 130[4]:987-993) that further reduces the pain of posterior lateral thoracotomy by harvesting and leaving the intercostal muscle (ICM) flap intact instead of cutting it before rib spreading.
The prospective randomized trial found that,
when coupled with rib drilling for placement of intercostal sutures, the enhanced technique reduces pain during postoperative weeks 3 to 12, results in a quicker return to baseline activity, and lessens the need for analgesics compared with the 2005 procedure (Ann Thorac Surg. 2008;85:1901-1907).
Cerfolio constantly searches for ways to reduce pain by avoiding intercostal nerve injury. In 2003 he reported that rib drilling and placement of intracostal sutures resulted in less pain during thora-cotomy closure than perioperative sutures. The 2005 UAB study showed further pain reduction when surgeons harvested the ICM flap before rib spreading. This technique let surgeons avoid crushing the ICM and the intercostal nerve with the retractor. In that study the ICM was harvested, cut distally, and reflected posteriorly to avoid obstructing the surgeon's view during the operation.
In the most recent study surgeons performed ICM harvest before rib spreading in 160 patients who were randomized to one of two groups, either group C or D. In group C, the muscle was cut distally and reflected posteriorly, as had been done previously. In group D, the ICM and intercostal nerves were left intact distally and allowed to dangle under the retractor after it was placed. The intercostal nerve later was placed in a small soft drain during the operation so it would not obstruct the surgeon's view.
Patients in group D had significantly lower numeric pain scores at postoperative weeks 3, 4, 8, and 12 compared with group C. Fewer patients in group D used prescription pain medications at postoperative weeks 4, 8, and 12, and at 12 weeks they were more likely to have returned to their baseline activity levels (89%) compared with those in group C (74%).
"With this new rib-, nerve-, and muscle-sparing technique, we are able to get all the safety and oncologic benefit of open lobectomy—removal of all lymph nodes and sealing and palpating the lung—with as little pain and the same recovery time as video-assisted thoracoscopic surgery [VATS]," Cerfolio says. "Patients resume full activity only 2 to 3 weeks after the operation."
He says the new technique allows surgeons to enter the chest, control the vessels, and resect all nodes, as do VATS techniques, with the additional advantage in oncologic cases of allowing lung palpation. Cerfolio recently coauthored a prospective study on the benefit of palpation in cancer cases (J Thorac Cardiovasc Surg. 2008;135:261-268). "Radiographic scans may suggest the other lobes are normal, but we find nodules in them 15% of the time—and half of those are malignant," he says.
"Although VATS techniques will be increasingly used, a certain percentage of cases, particularly oncologic cases, cannot be performed in this manner," he says. "Thoracotomy will remain a common procedure for general thoracic surgeons."
For more information contact Dr. Robert Cerfolio at 1-800-UAB-MIST or at mist@uabmc.edu