Thoracotomy
Encyclopedia
Thoracotomy is an incision into the pleural space of 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 lung
s, 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
.
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 an incision through an intercostal space
on the back, and is often widened with rib spreaders
. It is a very common approach for operations on the lung
or posterior mediastinum
, including the esophagus
. When performed over the fifth 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 tube
s—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 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 nearly all cases a chest tube
, or more than one chest tube is placed. These tubes are used to drain air and fluid until the patient heals enough to take them out (usually a few days). Complications such as pneumothorax
, tension pneumothorax, or subcutaneous emphysema
can occur if these chest tubes become clogged. Furthermore, complications such as pleural effusion or hemothorax
can occur if the chest tubes fail to drain the fluid around the lung in the pleural space after a thoracotomy. Clinicians should be on the look out for chest tube
clogging as these tubes have a tendency to become occluded with fibrinous material or clot in the post operative period, and when this happens, complications ensue.
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 epidural
s although results vary from person to person and are dependent on many numerous factors.
. Like laparoscopic surgery, its applications are rapidly expanding. Robotic surgery
is a new but rarely used innovation with questionable advantages.
Chest
The chest is a part of the anatomy of humans and various other animals. It is sometimes referred to as the thorax or the bosom.-Chest anatomy - Humans and other hominids:...
. It is performed by a surgeon, and, rarely, by emergency physicians, to gain access to the thoracic organs, most commonly the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
, the lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
s, the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
or thoracic aorta
Aorta
The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...
, or for access to the anterior spine
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
such as is necessary for access to tumors in the spine.
Thoracotomy is a major surgical maneuver—the first step in many thoracic surgeries
Thoracic surgery
Thoracic surgery is the field of medicine involved in the surgical treatment of diseases affecting organs inside the thorax . Generally treatment of conditions of the lungs, chest wall, and diaphragm....
including lobectomy
Lobectomy
Lobectomy means surgical excision of a lobe. This may refer to a lobe of the lung, a lobe of the thyroid , or a lobe of the brain ....
or pneumonectomy
Pneumonectomy
A pneumonectomy is a surgical procedure to remove a lung. Removal of just one lobe of the lung is specifically referred to as a lobectomy, and that of a segment of the lung as a wedge resection .-Indications:...
for lung cancer
Lung cancer
Lung cancer is a disease characterized by uncontrolled cell growth in tissues of the lung. If left untreated, this growth can spread beyond the lung in a process called metastasis into nearby tissue and, eventually, into other parts of the body. Most cancers that start in lung, known as primary...
—and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation
Mechanical ventilation
In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...
.
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
Atelectasis
Atelectasis is defined as the collapse or closure of alveoli resulting in reduced or absent gas exchange. It may affect part or all of one lung. It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation.It is a very common finding in chest x-rays and other...
or pneumonia
Pneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
.
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
Anterior mediastinum
The anterior mediastinum exists only on the left side where the left pleura diverges from the mid-sternal line.It is narrow, above, but widens out a little below.-Boundaries:It is bounded:* in front by the sternum* laterally by the pleurae...
.
Posterolateral thoracotomy is an incision through an intercostal space
Intercostal space
The intercostal space is the space between two ribs . Since there are 12 ribs on each side, there are 11 intercostal spaces, each numbered for the rib superior to it.-Structures in intercostal space:* several kinds of intercostal muscle...
on the back, and is often widened with rib spreaders
Retractor (medical)
A retractor is a surgical instrument by which a surgeon can either actively separate the edges of a surgical incision or wound, or can hold back underlying organs and tissues, so that body parts under the incision may be accessed. The two are each available in many shapes, sizes, and styles...
. It is a very common approach for operations on the lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
or posterior mediastinum
Posterior mediastinum
The posterior mediastinum is an irregular triangular space running parallel with the vertebral column.-Boundaries:It is bounded:* anteriorly by the pericardium * inferiorly by the thoracic surface of the diaphragm ....
, including the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
. When performed over the fifth intercostal space, it allows optimal access to the pulmonary hilum
Hilum of lung
Above and behind the cardiac impression is a triangular depression named the hilum, where the structures which form the root of the lung enter and leave the viscus. These include the pulmonary artery, superiormost on the left lung, the superior and inferior pulmonary veins, lymphatic vessels and...
(pulmonary artery
Pulmonary artery
The pulmonary arteries carry deoxygenated blood from the heart to the lungs. They are the only arteries that carry deoxygenated blood....
and pulmonary vein
Pulmonary vein
The pulmonary veins are large blood vessels that carry blood from the lungs to the left atrium of the heart. In humans there are four pulmonary veins, two from each lung...
) and therefore is considered the approach of choice for pulmonary resection (pneumonectomy
Pneumonectomy
A pneumonectomy is a surgical procedure to remove a lung. Removal of just one lobe of the lung is specifically referred to as a lobectomy, and that of a segment of the lung as a wedge resection .-Indications:...
and lobectomy
Lobectomy
Lobectomy means surgical excision of a lobe. This may refer to a lobe of the lung, a lobe of the thyroid , or a lobe of the brain ....
).
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
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
. Anterolateral thoracotomy, like most surgical incisions, requires the use of tissue retractors
Retractor (medical)
A retractor is a surgical instrument by which a surgeon can either actively separate the edges of a surgical incision or wound, or can hold back underlying organs and tissues, so that body parts under the incision may be accessed. The two are each available in many shapes, sizes, and styles...
—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
Thoracic surgery
Thoracic surgery is the field of medicine involved in the surgical treatment of diseases affecting organs inside the thorax . Generally treatment of conditions of the lungs, chest wall, and diaphragm....
.
Upon completion of the surgical procedure, the chest
Chest
The chest is a part of the anatomy of humans and various other animals. It is sometimes referred to as the thorax or the bosom.-Chest anatomy - Humans and other hominids:...
is closed. One or more chest tube
Chest tube
A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air or fluid , or pus from the intrathoracic space...
s—with one end inside the opened pleural cavity
Pleural cavity
In human anatomy, the pleural cavity is the potential space between the two pleura of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally...
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
Pleural cavity
In human anatomy, the pleural cavity is the potential space between the two pleura of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally...
, preventing the development of pneumothorax
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
or hemothorax
Hemothorax
A hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...
.
Complications
In addition to pneumothoraxPneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
, complications from thoracotomy include air leaks, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, bleeding
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
and respiratory failure
Respiratory failure
The term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial...
. Postoperative pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
is universal and intense, generally requiring opioids, and does interfere with the recovery of respiratory function.
In nearly all cases a chest tube
Chest tube
A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air or fluid , or pus from the intrathoracic space...
, or more than one chest tube is placed. These tubes are used to drain air and fluid until the patient heals enough to take them out (usually a few days). Complications such as pneumothorax
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
, tension pneumothorax, or subcutaneous emphysema
Subcutaneous emphysema
Subcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air, occurs when gas or air is present in the subcutaneous layer of the skin. Subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to trapped air...
can occur if these chest tubes become clogged. Furthermore, complications such as pleural effusion or hemothorax
Hemothorax
A hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...
can occur if the chest tubes fail to drain the fluid around the lung in the pleural space after a thoracotomy. Clinicians should be on the look out for chest tube
Chest tube
A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air or fluid , or pus from the intrathoracic space...
clogging as these tubes have a tendency to become occluded with fibrinous material or clot in the post operative period, and when this happens, complications ensue.
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 epidural
Epidural
The term epidural is often short for epidural analgesia, a form of regional analgesia involving injection of drugs through a catheter placed into the epidural space...
s although results vary from person to person and are dependent on many numerous factors.
VATS
Video-assisted thoracic surgery (VATS) is a less invasive alternative to thoracotomy in selected cases, much like laparoscopic surgeryLaparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...
. Like laparoscopic surgery, its applications are rapidly expanding. Robotic surgery
Robotic surgery
Robotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms for technological developments that use robotic systems to aid in surgical procedures....
is a new but rarely used innovation with questionable advantages.