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Sternal Splitting Midline Incision
Vol. 112, September Printed in U.S.,A
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
STERNAL SPLITTING MIDLINE INCISION RICHARD G. KIBBEY
AND
TERRY D. ALLEN
From the Division of Urology, The University of Texas Southwestern 1\lledical School, Dallas, Texas
a patient presents with a carcinoma of the kidney that has already metastasized to the lung. If this metastasis appears amenable to surgical resection the may be motivated to remove the primary lesion and the metastasis at a single procedure. However, such an undertaking may pose some serious particularly if the metastasis is contralateral to the primary tumor. At the suggestion of a consultant in thoracic surgery, a long midline incision incorporating a sternal splitting component was used in 1 such case and to be so that it seemed worthy of reporting. CASE REPORT
V. DV AH 463380713, a 44-year-old white man, was hospitalized with a 4-week history of total, gross, painless hematuria and a 12-pound weight loss. An excretory urogram revealed nonfunction of the right kidney. The left kidney appeared normal. On retrograde pyelography filling defects were noted in the right renal pelvis and ureter consistent with blood while the collecting system itself was distorted a large mass involving the middle and lower portions of the kidney. Selective renal showed neovascularity within the mass of renal cell carcinoma. An inferior venacavogram was normal. Chest x-ray demonstrated a 1 cm. nodule in the right middle lung field but no additional lesions were seen on ful.l chest laminograms and other studies, including a bone survey and barium enema, failed to disclose any evidence of further metastases. The abdomen was explored through a midline abdominal incision. Since nothing was found to contraindicate proceeding further the incision was extended as a median sternotomy (fig. 1). An uneventful radical nephrectomy was done aner which the pleural space was entered through a paramediastinal incision and the entire right lung was rolled into the incision (fig. 2). In addition to the 1 cm. nodule identified, a second 0.5 cm. lesion was encountered. Both lesions were removed wedge resection. The wound was closed in the conventional manner, an anterior chest tube in for 2 days. The postoperative course was uneventful and the was released from the hospital 9 postoperatively. He is currently doing well but the followup is too short to be meaningful. Accepted for publication March 22, 1974.. :313
DISCUSSION
It has long been recognized that in renal noma a solitary metastasis does not indicate an incurable state. and Churchill rP1">nrtc,r1 the first elective resection of a metastasis nephrectomy for carcinoma. 1 Their had been followed months for a pulmonary nodule before the diagnosis was made and was uer formed. Another :3 months elapsed before resection of the pulmonary metastasis, yet the patient for 23 years and died of coronary artery dise'l.se. This is no means an isolated case since others also have reported long-term survival excision of solitary pulmonary metastases. 2 9 Thi;; knowledge is reassuring since about :30 per ce•,t of patients with adenocarcinoma of the wilI have identifiable metastases at the time they are first seen 4 , 5 • 7 and many of these will be pulmonary lesions.<, 6 • 10 It is believed that the longer the time between extirpation of the primary lesion and the appearance of metastaseE., the better the prognosis, 6 ' 11 , 12 although this ion is not shared by all. 3 the situation was 1 Barney, J. D. and Churchill, E. J.: Adenocarcinomo of the kidney with metastasis to the Cured by nephrectomy and lobectomy. J. Urol., 42: 1939 2 Samel!as, W.: Adenocarcinoma of the 10-year apparent cure fol!owing the resection of pulmonary metastasis. J. Urol., 90: 250, 196:3. 'Strieder, ,J. W.: Surgical management of neoplastic pulmonary metastases. New Engl. ,J. Med., 254: 1059.
1956. 4 Chute, R., Ireland, E. F., Jr. and D. · Solitary distant metastases from nomas. J. Urol., 80: 420, 1958. 5 Grabstald, H.: Recent advances in medicine and surgery. Renal cell cancer. 3. Types of treatment. N. State J. Med., 64: 2771, 1964. 'Skinner, D. G., Colvin, R. Pfister, R. C. and Lead better, management of renal cell carcinoma. A and pathologic study of 309 cases. Cancer, 28: 1165, 1971. 7 Middleton, R. G.: Surgery for metastatic renal cell carcinoma. J. Urol., 97: 973, 1967. 8 Potampa, P. B.: A discussion of renal tumor: report of a five year cure following removal of bilateral pulmonary metastases. J. Urol., 85: 488, 1961. 9 Nalle, B. C., Jr.: Distant metastases of 58 renal neoplasms: a case report of secondary metastatic pui.sations from a renal tumor. J. Uro!., 57: 1947 10 Grabstald, H.: Renal-cell cancer. 2. findings. N. Y. State J. Med., 64: 2658, 1964. 11 Wilkins. E. W., Burke, J. F. and Head, ,J. M .. The surgical management of metastatic neoplasms in the lung. J. Thorac. Cardiovasc. 42: 298, 1961. 12 Alexander, J. and Haight, · Pulmonary resection for solitary metastatic sarcomas and carcinomas. Surg., Gynec. & Obst., 85: 129, 1947.
314
KIBBEY AND ALLEN
---,,---TRANSVERSE COLON SMALL INTESTINE FIG. 1
FIG. 2
summarized best by Alexander and Haight who said: "An operation performed to remove a metastatic malignant neoplasm that is assumed to be a solitary one (because no other can be found at the time) is obviously a gamble. As there is some
chance of success, and as failure to remove the lesion surgically will result in death of the patient, the operation needs no other justification." 12 Clearly sympathetic to such a philosophy Skinner and Wilkins and their associates 6 • 11 obtained a 25
STERNAL SPLITTING MIDLINE INCISION
and 31 per cent 5-year survival, respectively, folpulmonary melowing surgical excision of tastases of renal origin. When faced with the simultaneous occurrence of renal adenocarcinoma and a solitary pulmonary metastasis, the urologist has several available options. He may perform the radical nephrectomy immediately and defer resection of the pulmonary lesion until a second procedure. He may attempt to resect both lesions simultaneously through a thoracoabdominal incision but this is only practical if the pulmonary nodule is ipsilaterally placed and even then only when it is located in the lower most portion of the lung. Finally, he may use the sternal splitting midline incision which offers several advantages. 1) The incision is easily and quickly made with minimal blood loss. 2) It allows exposure of either or both lungs in their entirety, thus permitting any necessary pulmonary procedure from wedge resection to total lobectomy. In addition it gives enviable exposure of the heart and intrapericardial vena cava as well as the upper abdominal vena cava. Marshall and associates used such an exposure in removing a tumor thrombus that had extended into the vena cava. 13 3) The median sternotomy is well tolerated and produces far less pain and impairment of respiratory movement in the immediate postoperative period than a 13 Marshall, V. F., Middleton, R. G., Holswade, G. R. and Goldsmith, E. I.: Surgery for renal cell carcinoma in the vena cava. J. Ural., HJ3; 414, 1970.
31b
thoracoabdominal incision. 14 In fact, keloid forma tion, although rare, is the most commonly encoun. tered problem. 15 4) Finally, the patient is spared a second major operation. However, with all of its advantages this incisioL does not provide as good an exposure to the upper pole of the kidney as does a thoracoabdomi.nai approach. Some additional exposure may be obtained by midline incision of the Although Ulm used this incision for several radica.l nephrectomies, 16 we believe it is best reserved for those cases complicated by pulmonary metastases or extensive tumor thrombus involvement of the vena cava when exposure of these specific areas is indicated. SUMMARY
The simultaneous occurrence of renal adenocarcinoma and a solitary pulmonary metastasis provides a special challenge in management. In 1 su.ch case resection of the primary lesion and 2 nary metastases was accomplished in a procedure, using a long midline incision incorporating a sternal splitting component. The adv a•,. tages of this approach are discussed. 14 Mill er, D. R.: Median sternotomy extension of abdominal incision for hepatic lobectomy. Ann. Surg., 175: 193, 1972. "Gibbon, J. H., Jr., Sabiston, D. C., Jr. and F. C.: Surgery of the Chest, 2nd ed. Philadelphia: Saunders Co., p. 143, 1969. 16 Ulm, A. H.: Sternum-splitting incision for radical nephrectomy. J. Urol., 98: 579, 1967.
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
STERNAL SPLITTING MIDLINE INCISION RICHARD G. KIBBEY
AND
TERRY D. ALLEN
From the Division of Urology, The University of Texas Southwestern 1\lledical School, Dallas, Texas
a patient presents with a carcinoma of the kidney that has already metastasized to the lung. If this metastasis appears amenable to surgical resection the may be motivated to remove the primary lesion and the metastasis at a single procedure. However, such an undertaking may pose some serious particularly if the metastasis is contralateral to the primary tumor. At the suggestion of a consultant in thoracic surgery, a long midline incision incorporating a sternal splitting component was used in 1 such case and to be so that it seemed worthy of reporting. CASE REPORT
V. DV AH 463380713, a 44-year-old white man, was hospitalized with a 4-week history of total, gross, painless hematuria and a 12-pound weight loss. An excretory urogram revealed nonfunction of the right kidney. The left kidney appeared normal. On retrograde pyelography filling defects were noted in the right renal pelvis and ureter consistent with blood while the collecting system itself was distorted a large mass involving the middle and lower portions of the kidney. Selective renal showed neovascularity within the mass of renal cell carcinoma. An inferior venacavogram was normal. Chest x-ray demonstrated a 1 cm. nodule in the right middle lung field but no additional lesions were seen on ful.l chest laminograms and other studies, including a bone survey and barium enema, failed to disclose any evidence of further metastases. The abdomen was explored through a midline abdominal incision. Since nothing was found to contraindicate proceeding further the incision was extended as a median sternotomy (fig. 1). An uneventful radical nephrectomy was done aner which the pleural space was entered through a paramediastinal incision and the entire right lung was rolled into the incision (fig. 2). In addition to the 1 cm. nodule identified, a second 0.5 cm. lesion was encountered. Both lesions were removed wedge resection. The wound was closed in the conventional manner, an anterior chest tube in for 2 days. The postoperative course was uneventful and the was released from the hospital 9 postoperatively. He is currently doing well but the followup is too short to be meaningful. Accepted for publication March 22, 1974.. :313
DISCUSSION
It has long been recognized that in renal noma a solitary metastasis does not indicate an incurable state. and Churchill rP1">nrtc,r1 the first elective resection of a metastasis nephrectomy for carcinoma. 1 Their had been followed months for a pulmonary nodule before the diagnosis was made and was uer formed. Another :3 months elapsed before resection of the pulmonary metastasis, yet the patient for 23 years and died of coronary artery dise'l.se. This is no means an isolated case since others also have reported long-term survival excision of solitary pulmonary metastases. 2 9 Thi;; knowledge is reassuring since about :30 per ce•,t of patients with adenocarcinoma of the wilI have identifiable metastases at the time they are first seen 4 , 5 • 7 and many of these will be pulmonary lesions.<, 6 • 10 It is believed that the longer the time between extirpation of the primary lesion and the appearance of metastaseE., the better the prognosis, 6 ' 11 , 12 although this ion is not shared by all. 3 the situation was 1 Barney, J. D. and Churchill, E. J.: Adenocarcinomo of the kidney with metastasis to the Cured by nephrectomy and lobectomy. J. Urol., 42: 1939 2 Samel!as, W.: Adenocarcinoma of the 10-year apparent cure fol!owing the resection of pulmonary metastasis. J. Urol., 90: 250, 196:3. 'Strieder, ,J. W.: Surgical management of neoplastic pulmonary metastases. New Engl. ,J. Med., 254: 1059.
1956. 4 Chute, R., Ireland, E. F., Jr. and D. · Solitary distant metastases from nomas. J. Urol., 80: 420, 1958. 5 Grabstald, H.: Recent advances in medicine and surgery. Renal cell cancer. 3. Types of treatment. N. State J. Med., 64: 2771, 1964. 'Skinner, D. G., Colvin, R. Pfister, R. C. and Lead better, management of renal cell carcinoma. A and pathologic study of 309 cases. Cancer, 28: 1165, 1971. 7 Middleton, R. G.: Surgery for metastatic renal cell carcinoma. J. Urol., 97: 973, 1967. 8 Potampa, P. B.: A discussion of renal tumor: report of a five year cure following removal of bilateral pulmonary metastases. J. Urol., 85: 488, 1961. 9 Nalle, B. C., Jr.: Distant metastases of 58 renal neoplasms: a case report of secondary metastatic pui.sations from a renal tumor. J. Uro!., 57: 1947 10 Grabstald, H.: Renal-cell cancer. 2. findings. N. Y. State J. Med., 64: 2658, 1964. 11 Wilkins. E. W., Burke, J. F. and Head, ,J. M .. The surgical management of metastatic neoplasms in the lung. J. Thorac. Cardiovasc. 42: 298, 1961. 12 Alexander, J. and Haight, · Pulmonary resection for solitary metastatic sarcomas and carcinomas. Surg., Gynec. & Obst., 85: 129, 1947.
314
KIBBEY AND ALLEN
---,,---TRANSVERSE COLON SMALL INTESTINE FIG. 1
FIG. 2
summarized best by Alexander and Haight who said: "An operation performed to remove a metastatic malignant neoplasm that is assumed to be a solitary one (because no other can be found at the time) is obviously a gamble. As there is some
chance of success, and as failure to remove the lesion surgically will result in death of the patient, the operation needs no other justification." 12 Clearly sympathetic to such a philosophy Skinner and Wilkins and their associates 6 • 11 obtained a 25
STERNAL SPLITTING MIDLINE INCISION
and 31 per cent 5-year survival, respectively, folpulmonary melowing surgical excision of tastases of renal origin. When faced with the simultaneous occurrence of renal adenocarcinoma and a solitary pulmonary metastasis, the urologist has several available options. He may perform the radical nephrectomy immediately and defer resection of the pulmonary lesion until a second procedure. He may attempt to resect both lesions simultaneously through a thoracoabdominal incision but this is only practical if the pulmonary nodule is ipsilaterally placed and even then only when it is located in the lower most portion of the lung. Finally, he may use the sternal splitting midline incision which offers several advantages. 1) The incision is easily and quickly made with minimal blood loss. 2) It allows exposure of either or both lungs in their entirety, thus permitting any necessary pulmonary procedure from wedge resection to total lobectomy. In addition it gives enviable exposure of the heart and intrapericardial vena cava as well as the upper abdominal vena cava. Marshall and associates used such an exposure in removing a tumor thrombus that had extended into the vena cava. 13 3) The median sternotomy is well tolerated and produces far less pain and impairment of respiratory movement in the immediate postoperative period than a 13 Marshall, V. F., Middleton, R. G., Holswade, G. R. and Goldsmith, E. I.: Surgery for renal cell carcinoma in the vena cava. J. Ural., HJ3; 414, 1970.
31b
thoracoabdominal incision. 14 In fact, keloid forma tion, although rare, is the most commonly encoun. tered problem. 15 4) Finally, the patient is spared a second major operation. However, with all of its advantages this incisioL does not provide as good an exposure to the upper pole of the kidney as does a thoracoabdomi.nai approach. Some additional exposure may be obtained by midline incision of the Although Ulm used this incision for several radica.l nephrectomies, 16 we believe it is best reserved for those cases complicated by pulmonary metastases or extensive tumor thrombus involvement of the vena cava when exposure of these specific areas is indicated. SUMMARY
The simultaneous occurrence of renal adenocarcinoma and a solitary pulmonary metastasis provides a special challenge in management. In 1 su.ch case resection of the primary lesion and 2 nary metastases was accomplished in a procedure, using a long midline incision incorporating a sternal splitting component. The adv a•,. tages of this approach are discussed. 14 Mill er, D. R.: Median sternotomy extension of abdominal incision for hepatic lobectomy. Ann. Surg., 175: 193, 1972. "Gibbon, J. H., Jr., Sabiston, D. C., Jr. and F. C.: Surgery of the Chest, 2nd ed. Philadelphia: Saunders Co., p. 143, 1969. 16 Ulm, A. H.: Sternum-splitting incision for radical nephrectomy. J. Urol., 98: 579, 1967.