Muscle-Sparing Thoracotomy: A Systematic Literature Review and the “AVE” Classification

Abstract

Background: To synthesize the concept of muscle-sparing thoracotomies for major pulmonary resections and to explore the relationship between Kraissl's lines and skin incisions perpendicular to them. Methods: Systematic literature review was performed of MEDLINE database. Articles were selected if they described adult patients undergoing major pulmonary resection by way of a welldescribed thoracotomy that neither partially nor completely transects outer thoracic muscles, and that is independent of endoscopic instruments, and video technology. Median sternotomy was excluded. Results and Discussion: On the basis of analysis of 45 articles we propose an anatomical classification of muscle-sparing thoracotomies considering the way in which the muscles are spared. Classification distinguishes five types of muscle-sparing thoracotomies which are represented originally using cylindrical projection of thorax. Type I is realized by enlarging auscultatory triangle, Type II by splitting of latissimus dorsi muscle fibers beneath the bifurcation of thoracodorsal nerve and artery, Type III by retracting latissimus muscle posteriorly and serratus anterior muscle anteriorly, Type IV by separating digitations of serratus anterior muscle in front of the long thoracic nerve, and Type V by disinserting serratus anterior muscle in its medial part. The significance of Kraissl's lines remains unknown. Conclusions: Proposed classification is original and might have a didactic role. It facilitates evidence-based approach to comparative studies. Thoracic maps are a useful way to express this concept. Thoracic maps and human body throughout this text should be placed in the same context as planet earth and world map. They are intended to act as carriers of the results of systematic literature review. Regarding Figure 1 it is essential to notice that the thoracic wall is divided conventionally by anterior and posterior axillary folds in anterior, lateral, and posterior walls. Furthermore, the lower margin Each projection is an attempt to fit a curved surface onto a flat