A thoracotomy is a

surgical procedure Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

that involves

cutting Cutting is the separation or opening of a physical object, into two or more portions, through the application of an acutely directed force. Implements commonly used for wikt:cut, cutting are the knife and saw, or in medicine and science the sca ...

open the

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bony skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 layers, namely (from ...

to gain access into the

pleural cavity The pleural cavity, or pleural space (or sometimes intrapleural space), is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enabl ...

, It is mostly performed by specialist cardiothoracic

surgeon In medicine, a surgeon is a medical doctor who performs surgery. Even though there are different traditions in different times and places, a modern surgeon is a licensed physician and received the same medical training as physicians before spec ...

s, although

emergency physician An emergency physician (often called an "ER doctor" in the United States) is a physician who works in an emergency department to care for ill patients. The emergency physician specializes in advanced cardiac life support (advanced life support ...

s or

paramedic A paramedic is a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital. Paramedics work as part of the emergency medical services (EMS), ...

s occasionally also perform the procedure under life-threatening circumstances. The procedure is performed under

general anesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analgesi ...

with double-lumen

intubation Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Most commonly, intubation refers to tracheal intubation, a procedure during which an endotracheal tube is inserted into the trachea to supp ...

, and commonly with

epidural analgesia Epidural administration (from Ancient Greek ἐπί, "upon" + '' dura mater'') is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians a ...

set up pre-

sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...

for postoperative

pain management Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute (medicine), acute and simple to chronic condition, chronic and challenging. Most physici ...

. The procedure starts with controlled cutting through the

skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...

intercostal muscle The intercostal muscles comprise many different groups of muscle Muscle is a soft tissue, one of the four basic types of animal tissue. There are three types of muscle tissue in vertebrates: skeletal muscle, cardiac muscle, and smooth muscle ...

s and then

parietal pleura The pleurae (: pleura) are the two flattened closed sacs filled with pleural fluid, each ensheathing each lung and lining their surrounding tissues, locally appearing as two opposing layers of serous membrane separating the lungs from the medi ...

, and typically involves transecting at least one

rib In vertebrate anatomy, ribs () are the long curved bones which form the rib cage, part of the axial skeleton. In most tetrapods, ribs surround the thoracic cavity, enabling the lungs to expand and thus facilitate breathing by expanding the ...

with a

costotome A bone cutter is a surgical instrument used to cut or remove bones. In addition to surgery, they are also used in forensics and dismemberment. Types of medical bone cutters include: * Unpowered – Unpowered bone cutting implements include ...

due to the limited

range Range may refer to: Geography * Range (geographic), a chain of hills or mountains; a somewhat linear, complex mountainous or hilly area (cordillera, sierra) ** Mountain range, a group of mountains bordered by lowlands * Range, a term used to i ...

bucket handle movement Bucket-handle is a movement of ribs that results in change in transverse diameter of the thorax. Definition One of the most important functions of ribs and Thoracic diaphragm, diaphragm is the change in volume of thorax that helps inhalation, insp ...

each rib has without

fracturing Fracture is the appearance of a crack or complete separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity sur ...

. The incised wound is then spread and held apart with a retractor (

rib spreader A rib spreader, also known as Finochietto retractor, is a type of retractor specifically designed to separate ribs in thoracic surgery (see picture in external lin. Rack-and-pinion-type stainless steel rib spreaders (with a thumb-screw to lock i ...

) to allow passage of

surgical instrument A surgical instrument is a medical device for performing specific actions or carrying out desired effects during a surgery or operation, such as modifying biological tissue, or to provide access for viewing it. Over time, many different kinds of ...

s and the surgeon's hand. Traditional thoracotomy is thus a highly invasive procedure, with

bacterial pneumonia Bacterial pneumonia is a type of pneumonia caused by bacterial infection. Types Gram-positive '' Streptococcus pneumoniae'' () is the most common bacterial cause of pneumonia in all age groups except newborn infants. ''Streptococcus pneumoniae ...

hemothorax A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may inc ...

pleural effusion A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilog ...

/ air leak and intercostal

neuralgia Neuralgia (Greek ''neuron'', "nerve" + ''algos'', "pain") is pain in the distribution of a nerve or nerves, as in intercostal nerve, intercostal neuralgia, trigeminal neuralgia, and glossopharyngeal nerve, glossopharyngeal neuralgia. Classifica ...

being common postoperative complications. However, some recent techniques can perform achieve thoracic access with a smaller incision (usually less than ) and no rib cutting, and are often called a mini-thoracotomy (not to be confused with the

minimally invasive Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definitio ...

thoracoscopy Thoracoscopy is a medical procedure involving internal examination, biopsy and/or resection/drainage of disease or masses within the pleural cavity, usually with video assistance. Thoracoscopy may be performed either under general anaesthesia o ...

). The purpose of thoracotomy is to gain direct-vision access to intrathoracic organs, most commonly the

lung The lungs are the primary Organ (biology), organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the Vertebral column, backbone on either side of the heart. Their ...

s, the

heart The heart is a muscular Organ (biology), organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrie ...

and/or the

esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...

, as well as access to the thoracic

aorta The aorta ( ; : aortas or aortae) is the main and largest artery in the human body, originating from the Ventricle (heart), left ventricle of the heart, branching upwards immediately after, and extending down to the abdomen, where it splits at ...

, the anterior

spine Spine or spinal may refer to: Science Biology * Spinal column, also known as the backbone * Dendritic spine, a small membranous protrusion from a neuron's dendrite * Thorns, spines, and prickles, needle-like structures in plants * Spine (zoology), ...

or even merely to resect portions of the chest wall for

neoplasm A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

s (e.g.

mesothelioma Mesothelioma is a type of cancer that develops from the thin layer of tissue that covers many of the internal organs (known as the mesothelium). The area most commonly affected is the lining of the lungs and chest wall. Less commonly the lini ...

sarcoma A sarcoma is a rare type of cancer that arises from cells of mesenchymal origin. Originating from mesenchymal cells means that sarcomas are cancers of connective tissues such as bone, cartilage, muscle, fat, or vascular tissues. Sarcom ...

fibroma Fibromas are benign tumors that are composed of fibrous or connective tissue. They can grow in all organs, arising from mesenchyme tissue. The term "fibroblastic" or "fibromatous" is used to describe tumors of the fibrous connective tissue. Wh ...

) and

deformities A deformity, dysmorphism, or dysmorphic feature is a major abnormality of an organism that makes a part of the body appear or function differently than how it is supposed to. Causes Deformity can be caused by a variety of factors: *Arthritis a ...

(e.g.

flail chest Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath. ...

pectus carinatum Pectus carinatum, also called pigeon chest or pidgon breast, is a malformation of the chest characterized by a protrusion of the Human sternum, sternum and ribs. It is distinct from the related malformation pectus excavatum. Pectus carinatum has ...

or excavatum). It is the first step in common thoracic surgeries including

lobectomy Lobectomy means ''surgical excision of a lobe''. This may refer to a lobe of the lung (also simply called a lobectomy), a lobe of the thyroid ( hemithyroidectomy), a lobe of the brain (as in anterior temporal lobectomy), or a lobe of the liver ...

pneumonectomy A pneumonectomy (or pneumectomy) is a surgical procedure to remove a lung. It was first successfully performed in 1933 by Dr. Evarts Graham. This is not to be confused with a lobectomy or segmentectomy, which only removes one part of the lung. T ...

for

lung cancer Lung cancer, also known as lung carcinoma, is a malignant tumor that begins in the lung. Lung cancer is caused by genetic damage to the DNA of cells in the airways, often caused by cigarette smoking or inhaling damaging chemicals. Damaged ...

drainage Drainage is the natural or artificial removal of a surface's water and sub-surface water from an area with excess water. The internal drainage of most agricultural soils can prevent severe waterlogging (anaerobic conditions that harm root gro ...

and

decortication Decortication is a medical procedure involving the surgical removal of the surface layer, membrane, or fibrous cover of an organ. The procedure is usually performed when the lung is covered by a thick, inelastic pleural peel restricting lung ex ...

for

empyema An empyema (; ) is a collection or gathering of pus within a naturally existing anatomical cavity. The term is most commonly used to refer to pleural empyema, which is empyema of the pleural cavity. It is similar or the same in meaning as an a ...

diaphragm Diaphragm may refer to: Anatomy * Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen * Pelvic diaphragm or pelvic floor, a pelvic structure * Urogenital diaphragm or triangular ligament, a pelvic structure Other * Diap ...

repairs, or to gain thoracic access in

major trauma Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Dependi ...

Postoperative care Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

of thoracotomy typically involves

intensive care Intensive care medicine, usually called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes p ...

monitoring,

chest tube A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a drain (surgery), surgical drain that is inserted through the chest wall and into the pleural space or the Mediastinum. The insertion of the tube is som ...

and

chest physiotherapy Chest physiotherapy (CPT) are treatments generally performed by physical therapists and respiratory therapists, whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. Other terms include respirat ...

Approaches

There are many different surgical approaches to performing a thoracotomy. Some common forms of thoracotomies include: * Posterolateral thoracotomy is the most common and traditional approach for gaining access to the chest. It is an incision through an

intercostal space The intercostal space (ICS) is the anatomic space between two ribs (Lat. costa). 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 kind ...

on the back, and is often widened with rib spreaders. Patient has to be placed in a lateral decubitus position for this approach. All pressure points should be padded. A pillow should be placed between the two legs. Both arms should be flexed and maintained in "prayer position". A roll can be placed under the 5th intercostal space or the table can be broken at the same level so as to open the intercostal space widely for easy access. It is a very common approach for operations on the

posterior mediastinum Posterior may refer to: * Posterior (anatomy), the end of an organism opposite to anterior ** Buttocks, as a euphemism * Posterior horn (disambiguation) * Posterior probability The posterior probability is a type of conditional probability that ...

, including the

. When performed over the fifth intercostal space, it allows optimal access to the pulmonary hilum (

pulmonary artery A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and ...

and

pulmonary vein The pulmonary veins are the veins that transfer Blood#Oxygen transport, oxygenated blood from the lungs to the heart. The largest pulmonary veins are the four ''main pulmonary veins'', two from each lung that drain into the left atrium of the h ...

) and therefore is considered the approach of choice for pulmonary resection (

and

). Another variant is the "muscle sparing posterolateral thoracotomy" which preserves the Lattisimus Dorsi and Serratus muscles. This leads to less shoulder dysfunction and also allows for these muscles for any future use in case of a complication. * Anterolateral thoracotomy is performed upon the anterior chest wall. The skin incision is performed starting from the posterior axillary line in front of the tip of the scapula towards the submammary crease. The anterior intercostal spaces are wider as compared to the posterior spaces hence provide better exposure while minimising the need for excess rib spreading. It gives a very adequate exposure of lungs, pericardium and diaphragm. Left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic

cardiac arrest Cardiac arrest (also known as sudden cardiac arrest CA is when the heart suddenly and unexpectedly stops beating. When the heart stops beating, blood cannot properly Circulatory system, circulate around the body and the blood flow to the ...

. * Bilateral anterior thoracotomy with transverse sternotomy, or clamshell incision, is the incision of choice for bilateral lung transplantation. It is also a valuable tool in trauma settings. Large mediastinal tumours extending into both hemi-thorax and bilateral pulmonary tumours are also easily accessible via a clamshell incision. * The Ashrafian thoracotomy was devised to give rapid access to the heart and pericardium through an incision that consists of an anterior thoracic incision followed in a vertical direction along the costo-chondral (rib-cartilage) junction. Upon completion of the surgical procedure, the

chest The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main di ...

is closed. One or more

s—with one end inside the opened

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

, preventing the development of

pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...

Complications

In addition to

, complications from thoracotomy include air leaks,

infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...

, bleeding and

respiratory failure Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a r ...

. Postoperative pain is universal and intense, generally requiring the use of

opioid Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...

analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...

s for moderation, as well as interfering with the recovery of respiratory function. Paraplegia complicating thoracotomy is rare but catastrophic. In nearly all cases, one or more

s are 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

tension pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve is formed b ...

, or

subcutaneous emphysema Subcutaneous emphysema (SCE, SE) occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. ''Subcutaneous'' refers to the subcutaneous tissue, and ''emphysema'' refers to trapped air pockets. Since the ...

can occur if these chest tubes become clogged. Furthermore, complications such as pleural effusion or

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

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. Pain following a thoracotomy may be treated by the use of a

nerve block Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. #Local anesthetic nerve block, Local anesthetic nerve block (sometimes referred to as simply "nerve b ...

known as a

rhomboid intercostal block The triangle of auscultation is a relative thinning of the musculature of the back, situated along the medial border of the scapula which allows for improved listening to the lungs. Boundaries It has the following boundaries: * medially, by the ...

. In the long term, post-operative chronic pain can develop, known as thoracotomy pain syndrome, and may last from a few years to a lifetime. Treatment to aid pain relief for this condition includes intra-thoracic nerve blocks/opiates and

epidural Epidural administration (from Ancient Greek ἐπί, "upon" + '' dura mater'') is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians ...

s, although results vary from person to person and are dependent on numerous factors. A recent

Cochrane review Cochrane is a British international charitable organisation formed to synthesize medical research findings to facilitate evidence-based choices about health interventions involving health professionals, patients and policy makers. It includes ...

concluded that there is moderate-quality evidence that

regional anaesthesia Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, i.e. local insensitivity to pain, although other local senses may be affected as well. It all ...

may reduce the risk of developing persistent postoperative pain three to 18 months after thoracotomy.

VATS

Video-assisted thoracoscopic surgery Video-assisted thoracoscopic surgery (VATS) is a type of minimally invasive thoracic surgery performed using a small video camera mounted to a fiberoptic thoracoscope (either 5 mm or 10 mm caliber), with or without angulated visualiz ...

(VATS) is a less invasive alternative to thoracotomy in selected cases, much like

laparoscopic surgery Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medli ...

. There are lesser postoperative complications and better long-term survival following VATS lobectomy compared to open thoracotomy lobectomy for NSCLC. VATS lobectomy does not compromise patient safety or the oncological efficacy.

Post-thoracotomy pain

Thoracic epidural analgesia or paravertebral blockade have shown to be the most effective methods for post-thoracotomy pain control. However, contraindications to neuraxial anesthesia include hypovolemia, shock, increase in ICP, coagulopathy or thrombocytopenia, sepsis, or infection at puncture site. Comparing thoracic epidural analgesia and paravertebral blockade, paravertebral blockade reduced the risks of developing minor complications, however paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain.

Transcutaneous electrical nerve stimulation A transcutaneous electrical nerve stimulation (TENS or TNS) is a device that produces mild electric current to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range of transcutaneously applied currents u ...

has also shown to be useful in the management of post-thoracotomy pain. Specifically, it has been found to be a good adjunct in the management of moderate to severe post-thoracotomy pain and effective as a lone modality in mild post-thoracotomy pain (e.g. after video-assisted thoracoscopy).Ferreira, FC, et al. Assessing the effects of transcutaneous electrical nerve stimulation (TENS) in post-thoracotomy analgesia. Rev Bras Anestesiol. 2011 Sep-Oct;61(5):561-7, 308-10. .

References

External links