Denis Browne's thoracotomy revised

The three main issues involved in thoracotomy technique for the repair of oesophageal atresia (OA) are: (1) prevention of chest wall deformities; (2) adequate surgical exposure; and (3) the cosmetic appearance of the skin scar. Adequate surgical exposure should be the first priority. The technique described is an endeavour to address all the above concerns, a modification of the technique described by Denis Browne that eliminates the risk of injury to the long thoracic nerve (LTN). A retrospective analysis from case notes of 70 children (1974-1997) with OA from a single surgeon's practice was performed. Data collected included the presence of complications such as wound problems, chest-wall deformities, and evidence of nerve palsies including winged scapula. A uniform technique of a vertical skin incision in the mid-axillary line, preservation of the latissimus dorsi, and division of the serratus anterior muscle anterior to its nerve was followed in all cases. No wound infection, breakdown, or seroma formation was seen in any case. On long-term followup (range 1-22 years, mean 10.5 years) no chest wall deformities or nerve palsies were observed. This modification gives excellent exposure, avoids injury to the LTN, does not lead to chest-wall deformity, and gives a pleasing cosmetic result. The scar is hardly noticeable with the arm by the side of the body.