Muscle-sparing thoracotomy: Anatomy and technique.

The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes.  However, subsequent study results  have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors.

PURPOSE: To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade. STUDY DESIGN: We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative. RESULTS: We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005). CONCLUSIONS: Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.