thoracotomy

[Latin thōrāx, thōrāc-, thorax + -TOMY.]

Definition

Thoracotomy is the process of making of an incision (cut) into the chest wall.

Purpose

A physician gains access to the chest cavity (called the thorax) by cutting through the chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the condition of the lungs; removal of a lung or part of a lung; removal of a rib; and examination, treatment, or removal of any organs in the chest cavity. Thoracotomy also provides access to the heart, esophagus, diaphragm, and the portion of the aorta that passes through the chest cavity.

Lung cancer is the most common cancer requiring a thoracotomy. Tumors and metastatic growths can be removed through the incision (a procedure called resection). A biopsy, or tissue sample, can also be taken through the incision, and examined under a microscope for evidence of abnormal cells.

A resuscitative or emergency thoracotomy may be performed to resuscitate a patient who is near death as a result of a chest injury. An emergency thoracotomy provides access to the chest cavity to control injury-related bleeding from the heart, cardiac compressions to restore a normal heart rhythm, or to relieve pressure on the heart caused by cardiac tamponade (accumulation of fluid in the space between the heart's muscle and outer lining).

Demographics

Thoracotomy may be performed to diagnose or treat a variety of conditions; therefore, no data exist as to the overall incidence of the procedure. Lung cancer, a common reason for thoracotomy, is diagnosed in approximately 172,000 people each year and affects more men than women (91,800 diagnoses in men compared to 80,100 in women).

Description

The thoracotomy incision may be made on the side, under the arm (axillary thoracotomy); on the front, through the breastbone (median sternotomy); slanting from the back to the side (posterolateral thoracotomy); or under the breast (anterolateral thoracotomy). The exact location of the cut depends on the reason for the surgery. In some cases, the physician is able to make the incision between ribs (called an intercostal approach) to minimize cuts through bone, nerves, and muscle. The incision may range from just under 5 in (12.7 cm) to 10 in (25 cm).

During the surgery, a tube is passed through the trachea. It usually has a branch to each lung. One lung is deflated for examination and surgery, while the other one is inflated with the assistance of a mechanical device (a ventilator).

A number of different procedures may be commenced at this point. A lobectomy removes an entire lobe or section of a lung (the right lung has three lobes and the left lung has two). It may be done to remove cancer that is contained by a lobe. A segmentectomy, or wedge resection, removes a wedge-shaped piece of lung smaller than a lobe. Alternatively, the entire lung may be removed during a pneumonectomy.

In the case of an emergency thoracotomy, the procedure performed depends on the type and extent of injury. The heart may be exposed so that direct cardiac compressions can be performed; the physician may use one hand or both hands to manually pump blood through the heart. Internal paddles of a defibrillating machine may be applied directly to the heart to restore normal cardiac rhythms. Injuries to the heart causing excessive bleeding (hemorrhaging) may be closed with staples or stitches.

Once the procedure that required the incision is completed, the chest wall is closed. The layers of skin, muscle, and other tissues are closed with stitches or staples. If the breastbone was cut (as in the case of a median sternotomy), it is stitched back together with wire.

Diagnosis/Preparation

Patients are told not to eat after midnight the night before surgery. The advice is important because vomiting during surgery can cause serious complications or death. For surgery in which a general anesthetic is used, the gag reflex is often lost for several hours or longer, making it much more likely that food will enter the lungs if vomiting occurs.

For a thoracotomy, the patient lies on his or her side with one arm raised (A). An incision is cut into the skin of the ribcage (B). Muscle layers are cut, and a rib may be removed to gain access to the cavity. (C). Retractors hold the ribs apart, exposing the lung (D). After any repairs are made, the cut rib is replaced and held in place with special materials (E). Layers of muscle and skin are stitched. (Illustration by GGS Inc.)

Patients must tell their physicians about all known allergies so that the safest anesthetics can be selected. Older patients must be evaluated for heart ailments before surgery because of the additional strain on that organ.

Aftercare

Opening the chest cavity means cutting through skin, muscle, nerves, and sometimes bone. It is a major procedure that often involves a hospital stay of five to seven days. The skin around the drainage tube to the thoracic cavity must be kept clean, and the tube must be kept unblocked.

The pressure differences that are set up in the thoracic cavity by the movement of the diaphragm (the large muscle at the base of the thorax) make it possible for the lungs to expand and contract. If the pressure in the chest cavity changes abruptly, the lungs can collapse. Any fluid that collects in the cavity puts a patient at risk for infection and reduced lung function, or even collapse (called a pneumothorax). Thus, any entry to the chest usually requires that a chest tube remain in place for several days after the incision is closed.

The first two days after surgery may be spent in the intensive care unit (ICU) of the hospital. A variety of tubes, catheters, and monitors may be required after surgery.

Risks

The rich supply of blood vessels to the lungs makes hemorrhage a risk; a blood transfusion may become necessary during surgery. General anesthesia carries such risks as nausea, vomiting, headache, blood pressure issues, or allergic reaction. After a thoracotomy, there may be drainage from the incision. There is also the risk of infection; the patient must learn how to keep the incision clean and dry as it heals.

After the chest tube is removed, the patient is vulnerable to pneumothorax. Physicians strive to reduce the risk of collapse by timing the removal of the tube. Doing so at the end of inspiration (breathing in) or the end of expiration (breathing out) poses less risk. Deep breathing exercises and coughing should be emphasized as an important way that patients can improve healing and prevent pneumonia.

Normal Results

The results following thoracotomy depend on the reasons why it was performed. If a biopsy was taken during the surgery, a normal result would indicate that no cancerous cells are present in the tissue sample. The procedure may indicate that further treatment is necessary; for example, if cancer was detected, chemotherapy, radiation therapy, or more surgery may be recommended.

Morbidity and Mortality

One study following lung cancer patients undergoing thoracotomy found that 10–15% of patients experienced heartbeat irregularities, readmittance to the ICU, or partial or full lung collapse; 5–10% experienced pneumonia or extended use of the ventilator (greater than 48 hours); and up to 5% experienced wound infection, accumulation of pus in the chest cavity, or blood clots in the lung. The mortality rate in the study was 5.8%, with patients dying as a result of the cancer itself or of postoperative complications.

Alternatives

Video-assisted thoracic surgery (VATS) is a less invasive alternative to thoracotomy. Also called thoracoscopy, VATS involves the insertion of a thoracoscope (a thin, lighted tube) into a small incision through the chest wall. The surgeon can visualize the structures inside the chest cavity on a video screen. Such instruments as a stapler or grasper may inserted through other small incisions. Although initially used as a diagnostic tool (to visualize the lungs or to remove a sample of lung tissue for further examination), VATS may be used to remove some lung tumors.

An alternative to emergency thoracotomy is a tube thoracostomy, a tube placed through chest wall to drain excess fluid. Over 80% of patients with a penetrating chest wound can be successfully managed with a thoracostomy.

See also Thoracoscopy.

Resources

Books

Bartlett, Robert L. "Resuscitative Thoracotomy." (Chapter 17). In Clinical Procedures in Emergency Medicine. Philadelphia: W. B. Saunders Company, 1998.

Townsend, Courtney M., et al. "Thoracic Incisions." (Chapter 55). In Sabiston Textbook of Surgery. Philadelphia: W. B. Saunders Company, 2001.

Periodicals

Blewett, C.J. et al. "Open Lung Biopsy as an Outpatient Procedure." Annals of Thoracic Surgery (April 2001): 1113-5.

Handy, John R., et al. "What Happens to Patients Undergoing Lung Cancer Surgery? Outcomes and Quality of Life Before and After Surgery." Chest 122, no.1 (August 14, 2002): 21-30.

Swanson, Scott J. and Hasan F. Batirel. "Video-Assisted Thoracic Surgery (VATS) Resection for Lung Cancer." Surgical Clinics of North America 82, no.3 (June 1, 2002): 541-9.

Organizations

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org.

Society of Thoracic Surgeons. 663 N. Saint Clair St., Suite 2320, Chicago, IL 60611-3658. (312) 202-5800. http://www.sts.org.

Other

"Detailed Guide: Lung Cancer." American Cancer Society. [cited April 28, 2003]. http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=26.

— Diane M. Calabrese Stephanie Dionne Sherk

Key Terms: Aorta, Catheter, Diaphragm, Esophagus, Trachea.

Definition

Thoracotomy is the process of making of an incision (cut) into the chest wall.

Purpose

A physician gains access to the chest cavity by cutting through the chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the condition of the lungs, or removal of a lung or part of a lung, removal of a rib, and examination, treatment or removal of any organs in the chest cavity. Thoracotomy also gives access to the heart, esophagus, diaphragm and the portion of the aorta that passes through the chest cavity (thorax).

Lung cancer is the most common cancer for which a thoracotomy is necessary. Tumors and metastatic growths can be removed through the incision. A biopsy, or tissue sample for study, can also be taken through the incision.

Precautions

Patients must tell their physicians about all known allergies so that the safest anesthetics can be selected for the surgery. Older patients must be evaluated for heart ailments (usually with an electrocardiogram) before surgery because the anesthesia, as well as the thoracotomy, put an additional strain on the heart.

Description

The chest cavity can be entered from the side (later-ally) or the front (also known as anterior or sternal aspect) or the back (also known as posterior aspect). The exact place in which the cut is made depends on why the surgery is being done. In some cases, the physician is able to make the incision between ribs (called an inter-costal approach) to minimize the cuts through bone, nerves and muscle.

The incision is quite long, about seven inches. During the surgery, a tube is passed through the trachea. It usually has a branch to each lung. One lung is deflated so that it can be examined or surgery performed on it. The other lung remains expanded, and the patient breathes with the assistance of a mechanical device (a ventilator).

The pressure differences that are set up in the thoracic cavity by the movement of the diaphragm (the large muscle at the base of the thorax) make it possible for the lungs to expand and contract. The phases of expansion and contraction move air in and out of the lungs. If the pressure in the chest cavity changes abruptly, the lungs can collapse. Any fluid that collects in the cavity puts a patient at risk for infection and for reduced lung function, even collapse (pneumothorax). Thus, any entry to the chest usually requires that a chest tube remain for several days after the incision is closed.

Preparation

Patients are told not to eat after midnight the night before, or at least 12 hours before surgery. The advice is important because vomiting during surgery can cause serious complications and death. For surgery in which a general anesthetic is used, the gag reflex is often lost for several hours or longer, making it much more likely that food will enter the lungs if vomiting occurs.

Aftercare

Opening the chest cavity means cutting through muscle, nerves and often, ribs. It is a major procedure. Consequently, it most often involves a hospital stay as long as five to seven days. The skin around the drainage tube to the thoracic cavity must be kept clean and the tube must be kept unblocked.

The first two days after surgery may be spent in the intensive care unit of the hospital. A variety of tubes, catheters and monitors may be required after surgery.

Questions to Ask the Doctor

• If a biopsy is the only reason for the procedure, are thoracoscopy or a guided needle biopsy options (instead of thoracotomy)?

Risks

The rich supply of blood vessels to the lungs makes hemorrhage, or uncontrolled bleeding, a risk. General anesthesia is required in most cases, and carries a risk, particularly unanticipated allergic reaction. After a thor-acotomy, there may be drainage from the incision. There is also the risk of infection. The patient must learn how to keep the incision clean and dry as it heals.

After a chest tube is removed, a patient is vulnerable to lung collapse (pneumothorax). Physicians aim to reduce the risk of collapse by timing the removal the tube. Doing so at the end of inspiration (breathing in) or the end of expiration (breathing out) poses less risk. Deep breathing and coughing should be emphasized as an important way patients can help themselves and prevent pneumonia.

Resources

Periodicals

Blewett, C.J., et al. "Open lung biopsy as an outpatient procedure." Annals of Thoracic Surgery April 2001: 1113-1115.

—Diane M. Calabrese

Incision of the chest wall; may be intercostal, by rib resection or trans-sternal.

• transsternal t. — the usual intercostal incision is extended across the sternum to the opposite intercostal space. Used when very wide exposure to the thorax is required.

This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (June 2009)

Thoracotomy is an incision into the pleural space of the chest.^[1] 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.

Contents 1 Approaches 2 Complications 3 VATS 4 External links 5 References

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 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 epidurals 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 surgery. Like laparoscopic surgery, its applications are rapidly expanding. Robotic surgery is a new but rarely used innovation with questionable advantages.

External links

• Thoracotomy and Heart Surgery

References

1. ^ thoracotomy at Dorland's Medical Dictionary

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