Reply to Terzi et al. Whole or split latissimus dorsi muscle for intrathoracic transposition

Thank you for your insightful comments regarding a modified technique of latissimus dorsi muscle harvest for this complex patient population [1]. We are in agreement that the split muscle can be utilized and may offer benefits in certain circumstances. Rib resection is not required in either circumstance (whole or split muscle technique), but offers the protection of nearly eliminating any risk of pedicle compression. In general, the split muscle is a slightly advanced technique, and the majority of surgeons may benefit from total muscle harvest until the comfort level with the vascular divisions is sufficient to apply the modification. Also, the split muscle may be enough to cover a bronchial stump, but may be insufficient to obliterate a potential space (e.g. empyema, decortication, etc.) that may accompany a bronchopleural fistula. Furthermore, if the nerve requires transection for increased arc of rotation, there is very little benefit to preservation of the remaining muscle segment compared to the benefit of the increased volume to treat the main surgical concern. Finally, if the nerve is not transected, muscle activity poses a potential risk of tissue avulsion with latissimus contraction off of the repair site. The benefits described within our article [2], and the minimal risks involved, allow us to continue to support the use of the latissimus dorsi muscle in this fashion with most, if not all, cardiothoracic surgeons.

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