Thoracotomy - Surgery Through the Chest Wall

Introduction

Thoracotomy is a surgical technique to open the chest cavity. It is performed to treat lung diseases like lung cancer, cardiac problems, or diseases of the other structures in the thoracic cavity. It is also performed to remove tissues from the lungs for examination (biopsy). It is the first procedure in thoracic surgeries, after which procedures like lobectomy or pneumonectomy for lung cancers are performed.

What Is Thoracotomy?

Major organs like the lungs, heart, and associated blood vessels, esophagus, and trachea are situated in the thoracic cavity, protected by the rib cage. Thoracotomy is performed to gain access to these structures. It is a surgical procedure in which an incision is made between the ribs on either side of the chest, and the structures in the thoracic cavity are accessed. The procedure can be anterolateral thoracotomy or posterolateral thoracotomy.

What Is the Difference Between Thoracotomy and Thoracostomy?

• Thoracotomy - It is a procedure in which an incision is made to gain access to the chest cavity. It is usually performed to treat lung diseases of the other structures in the chest cavity.

• Thoracostomy - It is a procedure in which a tube is placed in the pleural space to drain fluid, blood, or air from the space around the lungs.

What Are the Indications of Thoracotomy?

The indications for the thoracotomy procedure include the following:

• Surgical treatment for cardiac, distal aortic, esophageal, and pulmonary diseases.

• Pulmonary malignancy, pleural malignancy, pleural effusion, pneumothoraces, lung collapse, or empyema.

• Congenital cardiac defects, aortic, mitral, or tricuspid valve diseases, coronary artery disease, pericardial disease, and specific tumors of the heart and pericardium.

• Esophageal cancer and tracheoesophageal fistula.

• To perform lung biopsy.

• Removal of lung cancer tissues.

• Disorders of the diaphragm.

What Are the Contraindications of Thoracotomy?

The contraindications can be relative or absolute. It is contraindicated in patients with prior thoracotomy in the same region because re-entry through the same region is unsafe in frail patients. It is contraindicated in severe head injury, multisystem injury, and penetrating abdominal injury without cardiac activity. It is also contraindicated for patients who will not benefit from this procedure.

What Are the Uses of Thoracotomy Procedure?

The uses of the thoracotomy proemergencies

• It is useful in the treatment of lung cancer to operate on the lungs.

• It is done to remove the fractured ribs to prevent injury to the vital organs.

• It is useful in emergency situations to control bleeding from the heart, perform cardiac compressions to pump blood, release cardiac tamponade, prevent air embolism, expose descending thoracic aorta for cross-clamping, and relieve pressure on the heart.

• It is performed to remove part of the chest wall.

• It helps reinflate the collapsed lungs.

• It is useful in removing a blood clot, tumor, or lymph node.

• It is also performed to remove a cyst from the chest, part of a lung or entire lung, or abnormal tissues from the lungs.

How Is Thoracotomy Performed?

Thoracotomy is performed through different techniques, which include:

• Median Sternotomy - Median sternotomy is performed to gain wide access to the mediastinum. It is done during open-heart surgeries to access the anterior mediastinum.

• Posterolateral Thoracotomy - This procedure involves the surgical approach to the lungs, posterior mediastinum, and esophagus. An incision is made on the intercostal space on the back, and the space is widened with rib spreaders. It is performed over the fifth intercostal space to access the pulmonary artery and pulmonary vein (pulmonary hilum). This technique is usually performed for pulmonary resection procedures, including pneumonectomy and lobectomy.

• Anterolateral Thoracotomy - This procedure is performed over the anterior chest wall. Left anterolateral thoracotomy is indicated for open cardiac massage to treat cardiac arrest. It requires the use of rib spreaders like a Tuffier retractor.

A clamshell incision is also performed by combining the bilateral anterolateral thoracotomy approach and transverse sternotomy. The Ashrafian or Aztec thoracotomy was performed to gain access to the heart and pericardium through an anterior thoracic incision in a vertical direction along the costochondral junction. Thoracotomy is the first step in treating lung disorders, after which procedures like lobectomy, segmentectomy, resection, pneumonectomy, and biopsy are performed. After completing the surgery, the chest is closed, and chest tubes are placed. One end of the tube is placed inside the pleural cavity, and the other end is submerged in saline in a sealed container. This forms an airtight drainage system that removes air and fluid from the pleural cavity and prevents the development of pneumothorax or hemothorax. Video-assisted thoracoscopic surgery is a less invasive procedure and an alternative to thoracotomy in selected patients.

What Are the Complications of Thoracotomy?

Complications associated with thoracotomy include:

• Pneumothorax.

• Air leak.

• Infections like pneumonia or empyema.

• Respiratory failure.

• Tension pneumothorax or subcutaneous emphysema.

• Hemothorax.

• Pleural effusion.

• Shoulder dysfunction is due to the presence of neurovascular bundles and musculature in traditional non-muscle-sparing incisions.

• It can cause airway complications like vocal cord injury, bronchopleural fistula, and pulmonary emboli.

• Non-cardiogenic pulmonary edema.

• Post-thoracotomy pain syndrome is the incision site pain that persists for over two months after surgery.

How Is Post-Thoracotomy Pain Managed?

Post-thoracotomy pain is managed with thoracic epidural anesthesia or paravertebral block. But, neuraxial anesthesia is contraindicated in patients with hypovolemia, shock, coagulopathy, thrombocytopenia, sepsis, or infection at the puncture site. The paravertebral block is as effective as epidural anesthesia and prevents the risk of complications. Transcutaneous electrical nerve stimulation is also useful in the management of post-thoracotomy pain. It is effective in the management of moderate to severe post-thoracotomy pain.

What to Expect With Thoracotomy?

Thoracotomy performed for pulmonary or cardiac abnormalities has multiple comorbidities. The procedures performed via thoracotomy incision reduce the cardiopulmonary reserve and increase the risk of postoperative complications. It also increases the rate of mortality and morbidity. The prognosis depends on the reason for thoracotomy and the stage of the disease. It takes two months for the wound to heal, and the pain decreases gradually over time.

Conclusion

Thoracotomy is a major surgical procedure performed to diagnose or treat an illness. Thoracotomy is followed by other surgical procedures. It is performed to diagnose and treat pulmonary abnormalities if noninvasive procedures are ineffective. It is a common surgical procedure. However, video-assisted thoracoscopic surgery is also performed as an alternative.