French-window thoracotomy: postoperative pain avoidance for short-stay lung cancer surgery

Although long years have passed since video-assisted thoracic surgery (VATS) lobectomy (VL) appeared as a new approach for resection of lung cancer, its practicality is not clear even today. As the significance of VL has still been under discussion, it has not gained consensus of its superiority to standard lateral thoracotomy. However, we think that returning to the classical posterolateral thoracotomy (PLT) is only a setback, so we developed a new thoracotomy approach that spares the thoracic bony cage by protecting costovertebral and costosternal junctions without spreading the ribs, the same mechanism for avoiding pain as in VL. It was named French-window thoracotomy (FWT). Postoperative pain and length of hospital stay after pulmonary lobectomy were compared between PLT (n = 18) and FWT (n = 13).

An anterolateral skin incision was made along the fifth intercostal space. The operative field was made through double intercostal spaces by cutting two ribs temporally at anterior and posterior points. The bone-muscle flaps were rolled back outside with protection of intercostal neurovascular bundles. The four cut points of the ribs were firmly repaired by the staking technique with stainless steel mesh wire and a stainless steel sleeve after intrathoracic manipulation.

There was a significant difference between PLT and FWT lobectomy (55.6% vs 7.7%, respectively, P = 0.0059) with regard to severe postoperative pain. Patients undergoing a FWT lobectomy had a shorter postoperative stay (6.4 +/- 2.1 vs. 12.3 +/- 3.3 days, P = 0.000003).

The lobectomy patients by FWT complained less of postoperative pain and required a shorter postoperative stay than with patients with the classical rib-spreading thoracotomy. We believe that FWT is an anatomically correct approach for preserving the whole structure of the chest cage.