SURGICAL PERSPECTIVES

DR SETH JOTHAM- MD, MMED, FIOASD

VOL 1: THORACOTOMY

2024
DEPARTMENT OF SURGERY - SFUCHAS
DR SETH JOTHAM @ 2024

TABLE OF CONTENTS

INTRODUCTION ................................................................................................................................. 2

APPLIED ANATOMY.......................................................................................................................... 2

GENERAL INDICATIONS FOR THORACOTOMY ........................................................................ 3

CONTRAINDICATION FOR THORACOTOMY.............................................................................. 3

PRE OP OPTIMIZATION FOR SPECIFIC FACTORS .................................................................... 4

APPROACH CONSIDERATIONS ...................................................................................................... 5

TYPES OF THORACOTOMY SURGERIES ..................................................................................... 6

THE CONCEPT OF EMERGENCY ROOM/DEPARTMENTAL THORACOTOMY (EDT) ....... 14

GENERAL COMPLICATIONS OF THORACOTOMY PROCEDURE ......................................... 17

POST-OPERATIVE CARE AND MONITORING ........................................................................... 19

FOR FURTHER READING ............................................................................................................... 21

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INTRODUCTION
Thoracotomy is the surgical procedure with an incision made to access the pleural space and the
contents of the thoracic cavity. Given the structures to be accessed with in the cavity, different
incisions have been established to easy the procedure and these incisions qualify the types of
thoracotomies to be studied hereunder.

APPLIED ANATOMY
The thoracic cavity also called the chest cavity is the second largest hollow space of the body.

 Borders: It is bordered anteriorly by the sternum, posteriorly by the thoracic vertebral

bodies, thoracic outlet superiorly and inferiorly by the diaphragm.
 Two parts of the thoracic cavity are: Pleural cavity and the mediastinum
 The pleural cavity encloses the parenchyma of the lungs while the mediastinum contains
the rest of the structures with in the cavity such as the heart, great vessels, thymus,
esophagus, and trachea,
 The mediastinum is divided to superior and inferior parts where by the inferior one further
subdivided to the anterior, middle and the posterior mediastinum (Figure 1)

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GENERAL INDICATIONS FOR THORACOTOMY

Since it gives a direct access unto the chest cavity, thoracotomy can be used for two main purposes:

Purpose 1: For diagnostic purposes, especially when a tissue sample is needed for microbiological
and histopathological reviews to ascertain the diagnosis

Purpose 2: As a traditional approach used as part of surgeries to treat several diseases and
conditions, including:

 Cardiac conditions: such as congenital cardiac defects (atrial septal defect), valvular
disease of the aortic, mitral, or tricuspid valve, specific locations of coronary artery disease,
pericardial disease, and certain tumors of the heart and pericardium
 Pulmonary diseases: These may include pulmonary malignancy (primary or metastases),
pleural malignancies, pneumothoraces, or empyema
 Esophageal disease: such as esophageal cancer in adults and tracheoesophageal fistulas in
infants
 An unknown mediastinal masses
 To access the anterior spine
 In trauma and emergencies requiring resuscitation, such as a penetrating chest injuries and
intrathoracic hemorrhages

CONTRAINDICATION FOR THORACOTOMY

 They can either be absolute or relative and depend upon the circumstances surrounding a
thoracotomy.
 May be contraindicated in patients who have had prior thoracotomy in the planned location,
making re-entry unsafe,
 Patients who are too frail to undergo anesthesia
 In patients who will derive no benefit from operative intervention.

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PRE OP OPTIMIZATION FOR SPECIFIC FACTORS

The outcome of surgical procedures is not measured only by clinical end points but also shorter
stays and lower costs. Patients’ discharge is delayed commonly due to inadequate pain relief,
infection, arrhythmias, prolonged air leak and debility. Many complications that occur from
thoracic operations can be anticipated. An aggressive preoperative work up mitigates morbidity
and shortens convalescence.

1. Smoking

Historically, 6 weeks of smoking cessation before surgery is recommended to avoid the copious
bronchorrhea that accompanies regeneration of the cilia that clear mucus between 2 and 4 weeks
after smoking cessation. there are few studies which challenge this notion of timing of smoking
cessation. Even 3-5 days of stopping could improve clearance and decrease of secretions.
However, most centers still recommend a 4-6 weeks’ cessation

2. Pre-operative education and physiotherapy

Preoperative physiotherapy and education is done in many centres as part of work up for
thoracotomy. Physiotherapists and thoracic ward medical and other staff perform a variety of care
for patients undergoing surgery both pre and post operatively. All these are done to prevent
postoperative complications like atelectasis, pneumonia, effusions and empyema

3. Investigations

Apart from other pre-operative workouts, Patients are also investigated for cardiac ailments if
there are symptoms, signs or significant cardiac history prior to performing elective thoracic
surgery.

Investigations may include echocardiography, cardiac viability study or angiogram.

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4. Reviewing of drug and medications history

Patients who are on antiplatelets should have their medications withheld 7 days prior to
surgery if possible.

If patients are on warfarin, then it is stopped 3 days prior to surgery and are covered with
heparin

5. Antibiotics prophylaxis

Patients are given a single dose of antibiotics for elective cases and they are continued for
infected cases or restarted postoperatively if needed.

APPROACH CONSIDERATIONS

There are about three principles that can guides the choice of the thoracotomy incision to be used

I. Adequate exposure must be achieved. The choice of incision is aided by a thorough

understanding of the surface anatomy and a comprehensive review of the radiographic
images that are obtained preoperatively.
II. Chest-wall function and appearance should be preserved to the extent possible. This
principle include non-spreading video-assisted thoracoscopic surgery (VATS) procedures,
muscle-sparing techniques, avoidance of excessive rib retraction, and rib preservation
when possible.
III. The third principle is that closure must be meticulous and appropriate. Strict layered
closure is the rule for thoracic surgical incisions. Every effort should be made to
approximate the individual divided chest-wall muscles in appropriate layers; otherwise, a
significant delay in the recovery of range of motion (ROM) may result.

Care must be taken to avoid over approximating the ribs and to prevent an override; this
will help minimize postoperative pain.

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TYPES OF THORACOTOMY SURGERIES

They are of three types

1. Anterolateral thoracotomy
2. Posterolateral thoracotomy
3. Axillary thoracotomy

1. ANTEROLATERAL THORACOTOMY

The anterolateral thoracotomy provides excellent access to either upper lobe, the right middle
lobe, and the anterior hila. It can be extended across the sternum into the opposite chest
(clamshell incision).

It is a preferred approach for unilateral lung transplantation. Bilateral sequential lung

transplantation can usually be performed through bilateral anterolateral thoracotomy without
sternal division.

Pros

 This incision has the advantage of allowing the patient to remain supine throughout the
procedure.
 Cosmetic results are superior to a median sternotomy or posterolateral thoracotomy.

Cons

 The exposure to the posterior pleural space is more limited than with a posterolateral
thoracotomy.
 For procedures requiring excellent posterior exposure, this incision should be avoided.

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Surgical technique (commonly infra-mammary approach)

Step 1 (Positioning): Patient is placed in the supine position with a small roll under the
ipsilateral shoulder

The patient's arms are tucked and the skin incision begins in the fourth or fifth interspace at the
lateral edge of the sternum and curves along the submammary crease to the anterior axillary line.

Palpating the second rib where it joins the sternomanubrial joint can help in locating the fourth
interspace.

This interspace provides good exposure for most resections and lung transplantation.

Step 2: The incision is carried down through the subcutaneous tissue to the pectoralis fascia. In
heavy patients or women with pendulous breasts, it is necessary to elevate the soft tissue or
breast tissue so that the pectoral muscle can be divided at the level of the fourth interspace.
Intercostal muscles are divided along the length of the incision.

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Step 3: Further exposure can be gained by removing a small portion of the fourth costal
cartilage or by disarticulating the costosternal joint. For this latter technique, the mammary
vessels are dissected and ligated to avoid tearing them. With placement of a retractor and rib
spreading, the intercostal muscles are divided posteriorly to increase exposure.

Step 4: Placement of a rib spreader or Balfour retractor (current recommendation is

Finochietto retractor) at right angle enables satisfactory lateral retraction of the latissimus and
serratus muscles.

Step 5: The incision is closed by approximating the ribs with 4 pericostal sutures. The pectoralis
muscle is then reapproximated, followed by the subcutaneous tissue and the skin.

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2. POSTERO LATERAL THORACOTOMY

The posterolateral thoracotomy is the gold standard for access to the thorax. It provides access
to all the thoracic viscera, and is mainly used for pulmonary resections (pneumonectomy or
lobectomy), chest wall resection, or esophageal surgery

Pros

 Excellent exposure of the thoracic cavity.

Cons

 Division of the major muscles resulting in increased potential for blood loss
 Much time spent for opening and closing the incision
 Prolonged ipsilateral shoulder and arm dysfunctions
 Compromised pulmonary functions with increased incidences for post thoracotomy pain
syndrome

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Surgical technique

step 1 (Positioning): The patient is placed in a full lateral decubitus position with appropriate
pressure-point padding. Soft rolls, bean bags, and straps of 2-in. (5-cm) adhesive tape are used to
secure the patient to the table.

The lower leg is flexed at the hip and knee, while the upper leg is kept straight with pillows in
between the legs.

The dependent arm is flexed, as is the superior arm, to yield the so-called praying position. Safely
preventing the upper arm from hanging over onto the chest is important because such overhang
can limit the space within which the surgeon is maneuvering instruments within the bony thorax.

Widely preparing and draping the patient and marking the incision and significant anatomic
landmarks with a felt-tip pen prior to skin incision are also important

Step 2 (incision) : The incision starts in front of the anterior axillary line at the anterior border of
the latissimus dorsi and passes 3-6 cm below the scapula tip, extending posteriorly and cephalad
midway between the posterior midline over the vertebral bodies and the medial border of the
scapula.

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Step 3 (muscle divisions) : The latissimus dorsi is identified and divided with the electrocautery
in line with the incision; some muscular vessels are likely to require individual ligation,

The serratus anterior is in a deeper plane, and it is divided as low as possible, close to the muscular
attachment, to minimize the amount of distal denervated muscle. In this same plane, posteriorly, a
small portion of the trapezius or (higher up) the rhomboid muscles may have to be divided if
necessary for additional exposure

Step 4 (pleural cavity entry) : More than one way of entering the pleural space exists. The easiest
and most common method is the intercostal approach, which enters along the superior border of
the rib to avoid injury to the underlying intercostal neurovascular bundle.

Step 5 (retraction) : A large Finochietto-type rib retractor is used to open the incision, with the
large blade inserted superiorly to ensure that the scapula is retracted. Sometimes, a smaller Tuffier-
type rib spreader can also be used anteriorly to widen the exposure. Opening the rib spreader
slowly and gradually to avoid rib fractures is important.

Step 6 (closure) : after completion, At least four pericostal sutures of heavy absorbable material
(eg, No. 2 polyglycolic acid) are placed. If a rib is resected, wider sutures are placed around the
remaining ribs.

The muscular layers are approximated with a continuous suture; ideally, the latissimus dorsi is
closed in two layers, with the anterior and posterior fascial layers separately reapproximated and
care taken to minimize muscular bunching.

3. AXILLARY THORACOTOMY

An axillary thoracotomy is a muscle sparing approach to the thoracic cavity, used for
pneumonectomy and pneumothorax operations. Can also be used in: Approaching
Emphysematous Bulla, Apical Pleurectomy, thoracic sympathectomy and in Drainage Procedures

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Pros

 Reduces muscle damage

 Good cosmetic outcome

Cons

 Limited exposure to the thoracic viscera

 potential for injury to the intercostobrachial nerve and the long thoracic nerve

Surgical technique

Step 1 (positioning) : The patient is placed in the lateral decubitus position with the ipsilateral
arm flexed at the elbow and rotated superiorly, where it is suspended vertically and secured to a
strand so as to open up the axilla, with care taken not to overextend the arm

Step 2 (incision) : A 6-cm curvilinear incision is made at the base of the axillary hairline from the
anterior margin of the latissimus dorsi to the posterior margin of the pectoralis major. These
muscles are retracted, and the third intercostal space is identified.

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Step 3 (further dissection) : Care is taken to preserve the long thoracic neurovascular bundle that
courses in the posterior aspect of the incision over the ribs. If the incision is used for first-rib
resection, blunt dissection is carried upwards to develop the plane, with care taken not to injure
the intercostobrachial nerve that exits the second intercostal space

Step 4 : During closure, the retracted muscles are allowed to fall back in place after the pericostal
sutures are placed. In certain situations, when no significant thoracic drainage is expected, no
pleural drain is placed, and the inevitable small postoperative pneumothorax is usually well
tolerated.

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THE CONCEPT OF EMERGENCY ROOM/DEPARTMENTAL THORACOTOMY

(EDT)

Emergent thoracotomy is a procedure that is intended to temporize wounds and stabilize a patient
via direct control of intrathoracic injuries, decompression of pericardial tamponade, and control of
the aorta to prevent exsanguination.

There are particular situations when an emergent thoracotomy is indicated. However, in those
instances, this procedure could very well be life-saving, allowing the patient to survive to definitive
interventions.

The primary goals of emergency room thoracotomy are following:

 Hemorrhage control
 Release of cardiac tamponade
 For open cardiac massage
 Prevention of air embolism
 Exposure of descending thoracic aorta for cross-clamping
 Repair cardiac or pulmonary injury

Indications for Emergency Room Thoracotomy

American college of surgeons’ committee on trauma indications are:

 Precordial wound in a patient with pre hospital cardiac arrest

 Trauma patient with cardiac arrest after arrival to emergency department
 Profound hypotension (<70mmhg) in patient with a truncal wound who is either
unconscious or an operating room is unavailable
 Patients who suffer penetrating cardiac trauma, who have cardiac tamponade identified on
the FAST exam, or individuals who are pulseless and received CPR less than 15 minutes
after traumatic thoracic injury.

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 Blunt thoracic injury without other mortal injuries (such as massive cranial deformity),
who lose vital signs but still preserve signs of life. An example of this blunt trauma
mechanism would include injuries sustained from motor vehicle accidents with steering
wheel trauma to the chest. The emergency room thoracotomy may be able to buy time until
transport to an operating theater can be arranged. In the right patient population, this can
not only save a life but can potentially lead to good recovery and function following
otherwise fatal injuries.

Contraindications to EDT

 Blunt thoracic injury without pre hospital witnessed cardiac activities

 Penetrating abdominal trauma without cardiac activities
 Non traumatic arrest
 Severe head injury
 Severe polytrauma

Technique for EDT

Step 1(position): The patient should be positioned supine with both arms abducted and extended
to 90 degrees. Generally, a left-sided approach is used, since this provides access to the left thorax,
pericardium, heart, and aorta.

Step 2(incision) : A skin incision is made with a #10 blade scalpel, from the sternum through the
4 or 5 intercostal space below the nipple, and continued laterally to the posterior mid-axillary line
following the curve of the ribs. Female patients should have their breasts retracted superiorly.

The initial incision should incise through the skin and subcutaneous fat and can be continued to
the ribs on thin patients. If bleeding from the right thorax is suspected, a right-sided approach can
be utilized.

An incision can be extended from left to right, below the sternum, to make a clamshell incision
which exposes the anterior mediastinum, aortic arch, and great vessels. There is a debate going on
regarding the best approach, and some contend that for the average emergency provider who is

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less accustomed to the procedure and with incomplete information regarding the extent of injuries,
the clamshell incision should be the preferred approach

Step 3 (exposure): After entering the chest, rib spreaders are inserted between the ribs with the
arm directed toward the axilla and the ratchet bar down. Then the rib spreader is expanded
maximally to optimize exposure.

After entering the chest, optional right-sided main-stem bronchus intubation may aid in reducing
left lung ventilation and further maximizing exposure. Any visible bleeding should be controlled
with direct pressure or laparotomy sponges.

Clamps should be used only as a last resort. Bleeding from major pulmonary vasculature can be
controlled by directly clamping the injured lung tissue or vessel, clamping the pulmonary hilum,
or using the “pulmonary hilar twist” maneuver (the last two also reduce the potential for air
embolism).

Step 4 (control hemorrhage) : Hemorrhage repair is typically temporizing, meant to deliver the
patient to definitive repair within the operating room.

Direct bleeding from the heart can be controlled with direct digital pressure, simple suturing, or
staples. If a significant defect is present, balloon occlusion can be used to achieve hemostasis by
inserting a Foley catheter into the defect, inflating the balloon with saline, and withdrawn until
tamponade is achieved.

Remember to open up the pericardium enough to remove all the blood tamponading the heart

Additional bleeding should be controlled with direct pressure or laparotomy sponges

Step 5: Take the patient to theatre for definitive surgery

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Complications OF EDT

Emergency room thoracotomy is a life-saving procedure; however, its benefit should be weighed
against its complications.

 During the primary incision, ribs can be transected, creating sharp edges that can puncture
or lacerate the operator.
 During pericardiotomy, coronary arteries can be accidentally ligated or, more commonly,
the phrenic nerve can be transacted.
 Damage to the phrenic nerve
 Ischemia to distal organs due to cross-clamping of the aorta
 Recurrent bleeding from the chest wall or internal mammary artery
 Infection

GENERAL COMPLICATIONS OF THORACOTOMY PROCEDURE

I. Postoperative hemorrhage

Immediate postoperative bleeding can be caused due to surgical bleeding or coagulopathy, surgical
bleeding being more common. A set of standard coagulation tests are performed and coagulopathy
is corrected accordingly. Depending on the coagulation profile factors like FFP, Platelets,
cryoprecipitate or factor 7 is given if the patient is bleeding due to profound coagulopathy

A chest tube output of 1000 ml in 1 hour necessitates an immediate return to the operating room
with concurrent correction of coagulopathy.

Serial drainage exceeding 200 ml per hour for 2 to 4 hours after correction of a coagulopathy
also indicates surgical bleeding and dictates re-exploration

II. Infection

Infection is a possible complication and can be a soft tissue infection of the incisional site, the
development of pneumonia, or the development of empyema

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III. Pneumothorax

If the pleura and lung parenchyma are damaged

IV. Pleural effusion

Pleural effusion is another complication that would not be unusual to see in a thoracotomy patient.
Often drainage tubes are left in place after thoracotomy procedures to help prevent this
complication.

V. Incisional pain

Incisional pain is an expected postoperative finding but can be classified as a postoperative

complication if there is damage to the costal neurovascular bundle while accessing or closing the
thoracic cavity.

Incisional pain can lead to splinting and decreased inspiratory and coughing efforts. Each of these
puts a patient at greater risk of developing infectious complications.

Post-thoracotomy pain syndrome is defined as pain along the thoracotomy incision site that
persists for greater than two months after the operation

VI. Shoulder dysfunction

Shoulder dysfunction is caused by the division of neurovascular bundles and musculature in

traditional non-muscle sparing thoracotomy incisions

VII. Cardiac herniation

Cardiac herniation is a rare complication and happens in the early postoperative period.
Cardiovascular collapse is the presenting feature Jugular pulse is elevated and there can be
cyanosis in the drainage area of superior venacava. Ventricular fibrillation may occur.

Treatment is emergency thoracotomy with reposition of the herniated heart into the pericardial sac
and repairing the defect of the pericardium

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POST-OPERATIVE CARE AND MONITORING

I. Pain management

There are various ways by which pain is managed. They include epidural catheters preoperatively,
paravertebral methods pre or intraoperatively or intravenous patient controlled analgesia. On
withdrawing these agents’ patients will need oral analgesics for duration of time till they are pain
free. These include paracetamol, NSAID and narcotic agents. It is essential to maintain multimodal
pain management post operation

II. Management of fluid and electrolytes

Post thoracic surgery especially in resections intravenous fluids are given in reduced amounts to
prevent pulmonary insufficiency. Care is taken not to overhydrate the patient and oral feeding in
encouraged as soon as possible.

Intravenous fluids should be used judiciously and a conservative strategy of administration of

maintenance fluids is recommended at 1–2 ml/kg/h in the intra- and post-operative periods and
that a positive fluid balance of 1.5 l should not be exceeded, to mitigate the risk of multifactorial
post-operative acute lung injury/ARDS

Essential electrolytes shall be managed and given as per their deficit and maintenance levels

III. Intercostal catheter

Intercostal catheter is watched for drainage and air leak. If the postoperative chest X-ray shows
expanded lung fields the no suction is applied even if there is bubbling.

In pneumonectomy patients, no suction is applied after surgery and the balanced drainage system
is filled with 1cm of liquid unlike routine thoracic cases where it is filled with 2 cm of fluid.

In pneumonectomy patients the drains are removed the next day and in lobectomy patients as soon
as possible

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IV. Infection prevention and control

Antibiotic prophylaxis should be given as per WHO recommendations extending to 24/48 hrs
after surgery.

Proper surgical site care

Early recovery after surgery (ERAS) strategies should be implemented to reduce the rate of
infection

V. Physiotherapy and early mobilization

Postoperative insufficiency occurs because of infection, inability to clear secretions or oedema

around day 2 or 3, to prevent these from happening attention should be given to physiotherapy,
bronchodilators, restriction of intravenous fluids and tracheal toilet.

Chest physiotherapy includes deep breathing and coughing exercises and incentive spirometry.
Pulmonary insufficiency is more common in patients have low FEV1. If there is inability to do so
then endotracheal suctioning or mini tracheostomy should be used for clearing secretions.

Diuretics are used if necessary and antibiotics are started if clinically indicated without waiting for
radiological deterioration.

Early postoperative ambulation and physiotherapy reduces complications like atelectasis,

pneumonia, empyema and DVT.

VI. Prevention of thrombo embolic events (VTE)

The prophylaxis should start when the patients are admitted in the hospital. Everyone should be
given a prophylactic dose of heparin subcutaneously if not contraindicated at a dose 5000 IU twice
daily and this is continued in the postoperative period till discharge.

All patients should have stockings and the high-risk patients should be on compression stockings.

If there are signs of DVT then a Doppler in arranged and patients put in treatment dose of heparin
infusion and an IVC filter put in if necessary.

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FOR FURTHER READING

1. Chang B, Tucker WD, Burns B. Thoracotomy. [Updated 2022 Jul 25]. In: StatPearls [Internet].

Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

2. Weare S, Gnugnoli DM. Emergency Room Thoracotomy. [Updated 2022 Jul 25]. In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan

3. Anand Iyer and Sumit Yadav. Postoperative Care and Complications After Thoracic Surgery.

May 23rd, 2012 Published: June 12th, 2013

4. Rohit Shahani, MD. horacic Incisions Technique. Updated: Feb 01, 2022

5. Seth Force, MD G.Alexander Patterson, MD. Anterolateral thoracotomy. THORACIC

INCISIONS| VOLUME 8, ISSUE 2, P104-109, MAY 01, 2003

6. Teach me surgery, cardiothoracic incision, sept 2021, rev 12

7. Lynne MD, Douglas Thoracotomy Medical Review, Oct 26 2022

8. Francis c, Aman C, thoracic surgical techniques, august 2018

jothamambele@gmail.com

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