Sava Durkovic1 and Paolo Scanagatta2*
1University of Milan, School of Medicine, School of General Thoracic Surgery, Milan, Italy 2Division of Thoracic Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
Received: 20 August, 2015; Accepted: 08 September, 2015; Published: 10 September, 2015
Paolo Scanagatta, MD, Fondazione IRCCS Istituto Nazionale dei Tumori, S.C. Chirurgia Toracica Via G.Venezian 1, 20133 Milano, Italy, Tel: +39 (0)2 2390 2384; Fax: +39 (0)2 2390 2907; E-mail:
Durkovic S, Scanagatta P (2015) Muscle-Sparing Thoracotomy: A Systematic Literature Review and the “AVE” Classification. J Surg Surgical Res 1(3): 035-044. 10.17352/2455-2968.000011
© 2015 Durkovic S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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 well-described 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.
The issue of operative “open” accesses to the thorax remains complex, even if we limit ourselves to major pulmonary resections (segmentectomy, lobectomy and pneumonectomy or more than two non-anatomical sublobar resections). The variable of interest within this health care intervention that is in focus of this article is the operative approach. Selecting the best one among many alternatives may be important for the patient, surgeon and health-policy makers. Systematic literature review on the subject of muscle-sparing thoracotomies is lacking.
The term “thorax” has Grecian origin and it refers to ancient Grecian armour  used as a protection that consisted of two bronze sheets, one for the protection of the breast and abdomen, the other for the back .
Gerardus Mercator (1512-1594) was a Flemish cartographer . He is remembered for the first cylindrical world map projection which is named after him. It was presented in 1569. He named it Nova et Aucta Orbis Terrae Descriptio ad Usum Navigatium Emendate: “new and augmented description of Earth corrected for the use of navigation”. His idea was to help navigation by sea . Furthermore Mercator was the first in the world to use the word “Atlas” to describe a collection of maps .
Each projection is an attempt to fit a curved surface onto a flat sheet, so that some distortion of the true layout of the projected surface is inevitable . Thoracic cartography might mean fitting thorax onto a flat surface by way of a cylindrical projection. It shares some common features with that of Mercator: it is meant to help “navigation” through thoracotomies, and it is the first one of its kind.
Mercator-like projection of the human body covered by the “ancient” thorax at the cutaneous level is presented on Figure 1. Base of the neck is added in an orthographical manner for clarity. The “Greenwich” is on the anterior median line. Instead of meridians and parallels, concentric circles that correspond to lines of skin tension or Kraissl’s lines are drawn . Unlike Langer’s lines which are determined on cadavers during rigor mortis, these lines are determined on living persons and are essentially perpendicular to the direction of the underlying muscle fibers which are easy to follow on Figure 2. Secondary endpoint of this research will be to explore the relationship between these lines and skin incisions perpendicular to them.