Persistent twitching of the latissimus dorsi muscle after a posterolateral thoracotomy

We report a case of persistent twitching of the latissimus dorsi muscle following a posterolateral thoracotomy, which continued despite several attempts at control including denervation, and was ultimately cured by total resection of the muscle.     

Microvascular transfers of latissimus dorsi and serratus anterior muscles in rats

The thoracodorsal artery supplies the latissimus dorsi and serratus anterior in the rat in the same fashion as in the human. In the rat, the thoracodorsal artery and vein average 0.57 mm and 0.71 mm in diameter, respectively, at their origins and can be used as pedicles averaging 19 mm in length to the latissimus dorsi muscle and 27 mm to the serratus anterior muscle. We successfully transferred both of these muscles to groin vessels by means of end-to-end or end-to-side anastomoses. The serratus anterior muscle was technically easier to transfer because its pedicle was longer. We conclude that the serratus anterior transfer in the rat is a feasible animal model for microvascular muscle transfer and may be a useful standard model for pharmacological and biochemical studies in transplanted muscle.     

Feasibility of latissimus dorsi and serratus anterior muscle-sparing vertical thoracotomy in general thoracic surgery

Postero-lateral thoracotomy has many complications such as postoperative pain, limitation in the motion of the shoulder, decreasing pulmonary function from immobilization, increasing lung atelectasis from over-use of analgesia, and increasing pulmonary morbidity, especially in elderly patients. So, muscle-sparing thoracotomy appears to be a good alternative. But it has also many disadvantages such as seroma and the needs for drains, limitation of an accessible operative field, and difficulties with risky procedures. We have modified muscle-sparing vertical thoracotomy. We performed 134 procedures on 131 patients from October 2000 to September 2003, including 15 cases of esophageal cancer, 95 cases of lung cancer, and 24 cases of other disease. Operative procedures were lobectomy in 74 cases, bilobectomy in 12 cases, pneumonectomy in 10 cases, wedge resection in 8 cases, decortication in 2 cases, Ivor Lewis procedure in 13 cases, and others in 15 cases. There was no occurrence of wound infection, arrrhythmia, fibrillation, and subcutaneous seroma except the first two cases. We had seven reoperations (two postoperative bleeding, three postpoperative BPF, one EGstomy leak, one RML torsion) and four operative mortalities (one postpneumonectomy BPF, two pneumonia, one heart failure). Our muscle-sparing vertical thoracotomy can be done safely in most thoracic surgery including lung and esophageal cancer, therefore it is a feasible procedure.     

Differences in intramuscular vascular connections of human and dog latissimus dorsi muscles

BACKGROUND: Distal ischemia and necrosis of the dog latissimus dorsi muscle flap used in experimental cardiomyoplasty have been reported. However, little information on the intramuscular vascular anatomy of the dog latissimus dorsi is available. It is unclear whether there are any anatomic factors relating to the muscle flap ischemia and necrosis, and whether the dog latissimus dorsi is a suitable experimental model. METHODS: To study the intramuscular vascular territories in the dog latissimus dorsi muscle, and to compare the intramuscular vasculature of the dog with that of the human, 5 fresh dog cadavers and 7 fresh human cadavers were injected with a mixture of lead oxide, gelatin, and water (200 mL/kg) through the carotid artery. Both the dog and the human latissimus dorsi muscles and neurovascular pedicles were dissected and radiographed. The intramuscular vascular anatomy of the latissimus dorsi muscles was compared. RESULTS: Radiographs demonstrate clearly that the pattern of latissimus dorsi intramuscular anastomoses between branches of the thoracodorsal artery and the perforators of posterior intercostal arteries in the proximal half of the muscle are different between the dog and the human. In the dog muscle, vascular connections between the thoracodorsal artery and the posterior intercostal arteries are formed by reduced-caliber choke arteries, whereas four to six true anastomoses without a change in caliber between them are found in the human muscle. The portion of the latissimus dorsi muscle supplied by the dominant thoracodorsal vascular territory was 25.9% +/- 0.3% in the dog and 23.9% +/- 0.5% in the human. For further comparison, an extended vascular territory in the latissimus dorsi muscle was demonstrated, including both the thoracodorsal territory and the posterior intercostal territories. The area of the extended vascular territory was 52% +/- 0.5% of the total muscle. CONCLUSIONS: The dog latissimus dorsi model may not be a perfect predictor of the behavior of the human latissimus dorsi muscle flap in cardiomyoplasty.     

Single pedicle microvascular transfers of the serratus anterior and latissimus dorsi muscles in rats

In the rat, the serratus anterior and latissimus dorsi muscles receive axial vascular pedicles from the thoracodorsal artery. This anatomy was confirmed by dissections, and 10 microvascular transfers of the latissimus-serratus flap on a common pedicle were performed with a 90% success rate. The flaps had an average weight of 1.8 g. This flap is a reliable small animal model for microvascular muscle transplants and contains sufficient tissue to be used in multiple biochemical assays.     

Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy.

OBJECTIVE: Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. METHODS: Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. RESULTS: In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. CONCLUSIONS: Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive potential. Advantages are low additional donor site morbidity and anatomical reliability. As it is located near the site of the defect, there is no need for additional surgical sites or intraoperative repositioning. In our service, the split latissimus dorsi muscle flap has proven to be a valuable and reliable option in thoracic wall reconstruction.     

Use of the latissimus dorsi and the serratus anterior muscles as a combined flap

Flaps composed of the latissimus dorsi and the serratus anterior muscles have been used to repair extensive defects in 10 patients with no remarkable disabilities of shoulder function. The latissimus dorsi and serratus anterior muscles are consistently nourished through the subscapular-thoracodorsal vessels. Thus, the 2 flaps can be based on 1 vascular pedicle. If required, the ribs beneath the serratus anterior muscle, which are vascularized by the periosteal circulation, can be transferred with the muscle. The vascular pedicle of this flap is long and anatomically reliable. Care must be taken to avoid tension or torsion of the pedicle when positioning the flap.     

The latissimus dorsi flap for reconstruction of the brachium and shoulder

The latissimus dorsi was transferred on its neurovascular pedicle to reconstruct the shoulder or brachium in nineteen patients. Group I consisted of seven patients in whom transfer of the latissimus dorsi was used only to obtain active flexion of the elbow. Although there was complete necrosis of the transferred muscle in one patient, six patients achieved an average of 111 degrees of active flexion and full extension of the elbow. There was only a modest gain in active supination because of pre-existing pronation contractures. The three patients in Group II had sustained loss of the flexor muscles of the elbow and the overlying soft tissue as a result of trauma. After the latissimus dorsi musculocutaneous flexorplasty, an average of 135 degrees of active flexion of the elbow was restored, but there was an average loss of 12 degrees of extension. The three patients in Group III had a large, noninfected defect of the soft tissue over the shoulder or brachium; the bone, shoulder joint, or neurovascular structures were exposed in each patient. Transfer of the latissimus dorsi with the overlying skin provided satisfactory coverage of the defect. The six patients in Group IV had chronic osteomyelitis or septic arthritis of the glenohumeral joint. Treatment consisted of radical débridement of the infected soft tissue and bone followed by transfer of the latissimus dorsi. This provided satisfactory coverage for subsequent osteosynthesis of the humerus or arthrodesis of the shoulder when one of these procedures was indicated. At the time of writing, an average of 2.3 years after the latissimus dorsi transfer, none of the patients in this group (including one who died nine months post-operatively of unrelated causes) had drainage.     

The latissimus dorsi flap for reconstruction of a paralysed deltoid

A case with complete paralysis of the deltoid muscle with irreperable axillary nerve lesion was treated with a functional muscle transfer. The latissimus dorsi muscle was preparated as an island flap, turned over and sutured to the trapezius at one side and to the original deltoid insertion on the humerus at the other side. Function and cosmesis were excellent.     

The reverse turnover latissimus dorsi flap for closure of midline lumbar defects.

The surgical treatment of wounds located in the median lumbar area is difficult. When occurring after neurosurgical procedures, they may display a high level of complexity because of dural exposure, deep irregular three-dimensional contours, and bacterial contamination of the wound. The difficulty of reconstruction in that region of the body is made greater by the few possible regional flaps available in the vicinity. In order to obtain well-vascularised tissue, with good resistance to bacterial contamination and easy to shape into such defects, the reverse turnover latissimus dorsi flap is a useful surgical option. Between 1998 and 2003, four patients presented with complex lumbar wounds in our department. Three patients were adults (mean age: 63 years) and one patient was 1 year old. In all cases, reconstruction was needed in the lumbar area after surgery on the spine. All wounds presented with bacterial contamination. In three cases, dural exposure was present, while in the fourth case, a small remnant of the posterior vertebral bony lamina was still present after debridement. In all four cases, the reconstruction was successfully achieved by turning over the latissimus dorsi to reach the lumbar midline defect. In one case, the adult paraplegic patient, only the inferior part of the muscle was harvested, to preserve an innervated upper part of the muscle for upper limb function. In the four cases, long term results were excellent (the mean follow up was 3.5 years), with no residual infection.     

Axillary vertical incision thoracotomy sparing pectoralis major muscle and latissimus dorsi muscle: an approach for patent ductus arteriosus

The technique of an axillary vertical incision thoracotomy sparing pectoralis major muscle and latissimus dorsi muscle for a closure of patent ductus arteriosus is presented. After an mid-axillary vertical incision, serratus anterior muscle is incised on the third intercostal space between pectoralis major muscle and latissimus dorsi muscle. The space between serratus anterior muscle and rib cage (Spatium intermusc. thoracale) is dissected with a finger, through this space the 3rd intercostal thoracotomy is performed in the axillary and dorsal portion. The ventral part of intercostal muscle is incised from inside of the thoracic cavity for sparing the pectoralis major muscle. We performed this technique in two patients aged 1 year, and secured equally good operative fields as could be secured by the original axillary vertical incision thoracotomy described by Browne.     

The latissimus dorsi musculocutaneous flap for extremity reconstruction in orthopedic surgery

The latissimus dorsi was transferred as a pedicle flap in ten patients and as a free vascular flap in ten others for extremity reconstruction. Group I comprised ten patients in whom the transfer was used solely to cover a skin or soft-tissue defect. Although there was partial necrosis of the transferred skin in one patient, the remaining nine patients obtained complete coverage without further reconstructive surgery. Group II comprised five patients in whom transfer of the latissimus dorsi was performed for active flexion or extension of the elbow or for abduction of the shoulder. Postoperatively, muscle strength obtained was classified from Grades 0 to 5 according to the muscle testing method. Three patients obtained muscle strength of Grade 3, while two obtained Grade 2. Group III comprised five patients who had brachial plexus palsy after high-dose irradiation. Coverage of the skin and soft tissue was performed after neurolysis of the brachial plexus palsy to free the tissue bed of scarred tissue. Postoperatively, sensory and motor disturbances were alleviated in four of five patients.     

大鼠臂丛上中干损伤后肱三头肌背阔肌功能状态变化的实验研究

目的:研究大鼠臂丛神经下干对上肢三头肌、背阔肌的支配权重,为临床臂丛上干损伤后,同侧C_7移位的可行性提供依据。方法:成年SD大鼠,将一侧臂丛中、上干切除,术后2周、2个月后,分别做同侧三头肌、背阔肌电生理检测,健侧对照。结果:术后2周,三头肌、背阔肌动作电位波幅明显下降,动作电位潜伏期明显延长。术后2个月,该两项指标均可以恢复到正常水平。结论:臂丛下干单独存在时,在短期内肱三头肌、背阔肌功能明显下降,但随着时间延长,该两肌肉可以恢复正常电活动。     

Intrathoracic application of the reverse latissimus dorsi muscle flap.

The use of the reverse latissimus dorsi muscle flap based on its paraspinous perforators for posterior trunk wound coverage has been described previously. However, few studies have reported its intrathoracic application. In this study the authors present their experience in treating 3 patients with various intrathoracic defects using the reverse latissimus dorsi muscle flap. There were 1 male and 2 female patients who ranged in age from 4 to 74 years (mean, 49 years). The etiology included an infected aortic graft, a bronchopleural fistula, and a recurrent congenital diaphragmatic hernia. Follow-up ranged from 2 to 24 months. Successful outcomes were achieved in all 3 patients, and there was no recurrence or wound complication identified. Their results demonstrate the versatility and reliability of the reverse latissimus dorsi muscle flap in treating low posterior intrathoracic defects.     

Microneurovascular transfer of contralateral latissimus dorsi in Poland's syndrome.

A 2-year-old girl with Poland's syndrome presented with syndactyly of the first, second and third webs of the left hand and ipsilateral absence of the sternocostal portion of pectoralis major. Latissimus dorsi on the same side was also absent. A microvascular free contralateral latissimus dorsi muscle transfer was undertaken to reconstruct the chest wall and anterior axillary fold. The transfer was innervated by intercostal nerve transfer and produced a neuromuscular unit of good aesthetic appearance and function.