Thoracotomy

PROCEDURE OF THE DAY

Thoracotomy

Thoracotomy is an incision into the chest. It is performed by a surgeon, and, rarely, by emergency physicians, to gain access to the thoracic organs, most commonly the heart, the lungs, the esophagus or thoracic aorta, or for access to the anterior spine such as is necessary for access to tumors in the spine.

Thoracotomy is a major surgical maneuver—the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer—and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation.

Thoracotomies are thought to be one of the hardest surgical incisions to deal with post-op, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia.

Approaches

There are many different approaches to thoracotomy. The most common modalities of thoracotomy follow.

Median sternotomy provides wide access to the mediastinum and is the incision of choice for most open-heart surgery and access to the anterior mediastinum.

Posterolateral thoracotomy is a very common approach for operations on the lung or posterior mediastinum, including the esophagus. When performed over the 5th intercostal space, it allows optimal access to the pulmonary hilum (pulmonary artery and pulmonary vein) and therefore is considered the approach of choice for pulmonary resection (pneumonectomy and lobectomy).

Anterolateral thoracotomy is performed upon the anterior chest wall; left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic cardiac arrest. Anterolateral thoracotomy, like most surgical incisions, requires the use of tissue retractors—in this case, a "rib spreader" such as the Tuffier retractor.

Bilateral anterolateral thoracotomy combined with transverse sternotomy results in the "clamshell" incision, the largest incision commonly used in thoracic surgery.

Upon completion of the surgical procedure, the chest is closed. One or more chest tubes—with one end inside the opened pleural cavity and the other submerged under saline solution inside a sealed container, forming an airtight drainage system—are necessary to remove air and fluid from the pleural cavity, preventing the development of pneumothorax or hemothorax.

Complications

In addition to pneumothorax, complications from thoracotomy include air leaks, infection, bleeding and respiratory failure. Postoperative pain is universal and intense, generally requiring opioids, and does interfere with the recovery of respiratory function. In the long term post operatively chronic pain can develop known as thoracotomy pain syndrome, this can last from a few years to a lifetime of continued pain and discomfort. Treatment to aid pain relief for this condition includes intra thoracic nerve blocks/opiates and epidurals although results vary from person to person and are dependent on many numerous factors.

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