Los Angeles, California
Milan Stevanovic, M.D.
Associate Professor of Clinical Orthopaedics
Hand and Microsurgery
Keck School of Medicine
University of Southern California
Los Angeles, California
Michael L. Reyes, M.D.
Resident Physician
Department of Orthopaedic Surgery
Los Angeles County/University of Southern California Medical Center
Los Angeles, California
Larry Khoo, M.D.
Resident Physician
Department of Neurosurgery
Los Angeles County/University of Southern California Medical Center
Los Angeles, California
ACKNOWLEDGMENTS
We would like to thank all the individuals who have helped us throughout this project, in particular:
Jane Pennington, Ph.D., of Thieme for her trust in our abilities to accomplish this project, and her endless support, help, guidance, compassion, and phone calls throughout the entire process.
Todd Warnock, David Stewart, and the entire staff of Thieme for countless hours of work and support.
Alan Wolf, M.D. and James Jackman, D.O. for their early support of this project.
Aline Mirzabeigi for her support.
Ernest Nelson for delivering the specimens on short notice, late evenings and weekends.
Dana Pfeffer for typing, re-typing, and re-typing, the text.
Simon Petrossian of Simon Photography for his expert advice and teachings of the art of photography.
Mark Gottula and Denis Nervig of Samy's Camera for their technical advice and support.
Larissa Mousheghian of Five One Visual Communications for her professional help.
PREFACE
This book grew out of my frustration as a resident and also my love of surgical anatomy. As a resident, I would frequently go to the library to review the anatomy of a surgical approach prior to a case. I would refresh my memory about the location of all the critical structures and the landmarks I should be looking for during the approach. Then in the operating room, I would find that the anatomy I was actually looking at was not the same as that pictured in the books. Most of the books were simply drawings. The few photographic atlases that were available used embalmed specimens, which had different colors and all were predissected. In reality, once you are deep to the subcutaneous tissue, you generally have a sheet of fascia covering everything so that all those landmarks so clearly depicted in anatomy books are, in fact, not visible until you dissect them out. The whole point of doing a surgical approach, however, is not to dissect them out but to simply go directly to where you want to go. This book is also a photographic atlas but it uses fresh cadaver specimens so that the colors are not distorted. Additionally, there is no attempt to separate out structures. For some of the approaches, therefore, the pictures do not look as pretty as they do in other books, but they are much more realistic and accurately depict what you see. The text describes the landmarks and how to avoid trouble for each approach.
This book then will give you, the reader, an accurate depiction of what you can expect to find as you go through an approach. It should, therefore, better prepare you for your surgery. One of my favorite surgical mottoes is that a good surgeon can get out of trouble but a better surgeon stays out of trouble. A large part of staying out of trouble is knowing where to go and where not to go. Ideally, you would expose the layers of an approach like turning pages of a book with sure and efficient dissection. This book will be an important tool in teaching you how to do that. The difference between a good fast surgeon and a good slow surgeon is knowledge of anatomy. Your interest in surgical anatomy is to be commended. Your feedback on how to improve this book would be appreciated.
Christopher Jordan, M.D.
SECTION
I
SHOULDER
1
DELTOPECTORAL APPROACH
USES
This approach can be used for any anterior shoulder surgery, including capsular shift and dislocation procedures, proximal humeral fracture work, shoulder prosthetic replacement, and long head of the biceps tendon repair.
ADVANTAGES
The approach is through an internervous plane between the deltoid and pectoralis major. The incision can be expanded proximally or distally as needed.
DISADVANTAGES
For anterior shoulder surgery, this approach is clearly the best, and it has no significant disadvantages.
STRUCTURES AT RISK
Superiorly, the major structure at risk is the acromial branch of the thoracoacromial artery, which is in the medial aspect of the coracoacromial ligament. Inferiorly, the musculocutaneous nerve comes out and enters the biceps approximately 5 cm distal to the coracoid. This structure is usually not cut, but it can be retracted and damaged with the retraction. The axillary nerve is also at risk. This crosses the inferior aspect of the capsule of the shoulder. A retractor placed below the subscapularis and the capsule puts this nerve in grave danger. The cephalic vein can also be damaged if it is not identified and protected as the deltopectoral groove is being developed.
TECHNIQUE
The incision is in the deltopectoral groove and is usually placed directly over one of the axillary skin folds to provide a more cosmetic incision. If the procedure is a capsular shift procedure, then typically most of the incision will be toward the axilla and hardly noticeable. If a more extensive exposure is needed, the incision can be carried all the way from the clavicle to the deltoid insertion.
When working deep to the subcutaneous tissue, it is important to identify the cephalic vein and the deltopectoral groove. The fascia of these two muscles is conjoined, and so frequently there is a small amount of exploration necessary to find that interval. The clue to finding it is usually an indentation, which is occasionally present, or some fat between the muscles. Another clue is the difference in fiber orientation, with the deltoid being more vertical and the pectoralis major being more horizontal. That difference is usually more apparent distally than proximally.
Once the groove is identified and the cephalic vein is identified, usually it is retracted laterally along with the deltoid. However, it can be retracted medially if it looks like that retraction would require the ligation of fewer tributaries or put less stretch on the vein.
Once the vein is identified and protected, you can use your finger to develop a plane between the two muscles and develop the plane underneath the deltoid for a short distance. When these two muscles are separated, you will see the fascia overlying the biceps and the coracobrachialis. This fascia is split in between the two heads of the biceps, retracting the short head medially and the long head laterally. At that point, the subscapularis will be in view and is identified by its muscular layer and the transverse direction of the fibers. You must also be aware that the musculocutaneous nerve enters the coracobrachialis muscle from its medial side and will exit through it and the short head of the biceps on its way down the arm. Aggressive retraction