Improper positioning of a patient undergoing lateral thoracotomy can result in intraoperative nerve damage. Therefore each area susceptible to nerve pressure should be adequately padded. The torso ideally should rest on a large gel pad or foam egg crate placed on the bed or on the “beanbag” if one is used. This is particularly important to prevent peroneal nerve injury to the dependent leg. If tape or a strap is used across the table, it should be placed between the iliac crest and the femoral head to avoid pressure injury on sensory nerves that circle around the skeleton at both points. Both the up and down arms are susceptible to nerve injury. This can occur to the ulnar nerve along the ulnar groove at the elbow, resulting in loss of sensation in the ring and small fingers or to the radial nerve along the inner aspect of the biceps, resulting in loss of dorsiflexion of the wrist. An inflated but unpadded bean bag or the post used to support the upper arm can cause these pressure complications. Most often the injuries are transient, but they can be quite troublesome for the patient. For patients undergoing median sternotomy or clamshell incisions, it is also important to properly pad the ulnar grooves bilaterally when the arms are tucked by the side. In addition, all intravenous and arterial line connectors should be tightened, the stopcocks secured, and the entire connection padded. Finally, the head must be supported and kept neutral to prevent brachial plexus stretching and injury.

All operations must begin with a surgical time out to confirm patient identity, planned procedure, and that the proper side is being operated upon. The World Health Organization has promulgated the so-called Expanded Time Out, which can include procedures to ensure the administration of prophylactic antibiotics, venous thromboembolic prophylaxis, beta blockers, and so on (Fig. 39-1). Copies may be obtained at http://www.who.int.easyaccess1.lib.cuhk.edu.hk/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf. Backster² and colleagues used a similar checklist prior to cardiac surgery. They stated “By politely challenging our surgical team as to the inclusion of these five risk-avoidance strategies in 167 consecutive patients, we increased our compliance to more than 90% for each preventive measure.”

The standard posterolateral incision is usually made 2 cm below the tip of the scapula. In some instances, particularly in obese patients, the spine of the scapula, which obliquely crosses the medial four-fifths of the dorsal surface of the scapula at its upper part and separates the supraspinatus fossa from the
infraspinatus fossa, can be mistaken for the tip. This results in an incision that is too high and across the body of the scapula. Correction must be accomplished by enlarging the incision to allow its use or by closing it and making the proper incision. Either course results in postoperative pain and impairment of shoulder mobility.

Entrance into the chest should be preceded by confirmation that the lung is moving independently of the parietal pleura. This should be noted even with a lack of ventilation as long as there is no visceral and parietal pleural symphysis. Once it is confirmed, the pleura may be opened by piercing it with a firm object such as a Kelly clamp, the cold cautery tip, or the blunt end of a scalpel. Freedom along the incision should be confirmed as the pleura is further opened and the lung should be actively retracted away from the incision to prevent a parenchymal injury.

Rib spreading should be kept to the least amount compatible with a safe operation. To obtain further rib spreading, the costotransverse ligament may be divided. This ligament attaches to the nonarticular portion of the rib tubercle. Care must be taken to avoid injuring the posterior ramus branch of the segmental thoracic artery, which runs backward through a space bounded above and below by the necks of the ribs, medially by the body of a vertebra, and laterally by an anterior costotransverse ligament. It is a very important vessel because it gives off a spinal branch that enters the vertebral canal through the intervertebral foramen. Once this vessel is transected, it retracts behind the articular portion of the tubercle, which presents a
small oval surface for articulation with the end of the transverse process of the lower of the two vertebrae to which the head is connected. To expose the ramus branch, the articular tubercle may be opened. Careful cautery can be used. However, because the nerve root damage and segmental ganglion are in close proximity, neurologic injury may result. A sponge can be temporarily placed at the angle, but the surgeon must avoid packing this space, because its base is the vertebral foramen and injury to the spine is possible. Another method of control is to apply liquid hemostatic agents.