Thoracotomy

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Thoracotomy
Emergency Thoracotomy.png
A thoracotomy incision performed through the fourth or fifth intercostal space with rib spreaders to increase visibility of the pleural cavity
ICD-9-CM 34.02
MeSH D013908

A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. [1] It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine (the latter may be necessary to access tumors in the spine). The purpose of a thoracotomy is the first step used to facilitate thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.

Contents

Approaches

There are many different surgical approaches to performing a thoracotomy. Some common forms of thoracotomies include:

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 the use of opioid analgesics for moderation, as well as interfering with the recovery of respiratory function. Paraplegia complicating thoracotomy is rare but catastrophic. [3] [4]

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-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 epidurals, although results vary from person to person and are dependent on numerous factors. A recent Cochrane review concluded that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing persistent postoperative pain after three to 18 months after thoracotomy. [5]

VATS

Video-assisted thoracoscopic surgery (VATS) is a less invasive alternative to thoracotomy in selected cases, much like laparoscopic surgery.

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, hovewer paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. [6] Transcutaneous electrical nerve stimulation 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). [7]

See also

Related Research Articles

Pneumothorax Abnormal collection of air in the pleural space that causes an uncoupling of the lung from the chest wall

A pneumothorax is an abnormal 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 by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax. This can cause a steadily worsening oxygen shortage and low blood pressure and unless reversed can be fatal. Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to atelectasis.

Pleurisy Disease of the lungs

Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever or weight loss, depending on the underlying cause.

Spinal anaesthesia Form of neuraxial regional anaesthesia

Spinal anaesthesia, also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic or opioid into the subarachnoid space, generally through a fine needle, usually 9 cm (3.5 in) long. It is a safe and effective form of anesthesia performed by anesthesiologists, certified anesthesiologist assistants and nurse anesthetists which can be used as an alternative to general anesthesia commonly in surgeries involving the lower extremities and surgeries below the umbilicus. The local anesthetic with or without an opioid injected into the cerebrospinal fluid provides locoregional anaesthesia: true analgesia, motor, sensory and autonomic (sympathic) blockade. Administering analgesics in the cerebrospinal fluid without a local anaesthetic produces locoregional analgesia: markedly reduced pain sensation, some autonomic blockade, but no sensory or motor block. Locoregional analgesia, due to mainly the absence of motor and sympathic block may be preferred over locoregional anaesthesia in some postoperative care settings. The tip of the spinal needle has a point or small bevel. Recently, pencil point needles have been made available.

Epidural administration Medication injected into the epidural space of the spine

Epidural administration 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 and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration involves the placement of a catheter into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by Spanish military surgeon Fidel Pagés. In the United States, over 50% of childbirths involve the use of epidural anesthesia.

Chest tube

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air (pneumothorax), fluid, or pus (empyema) from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter.

Atelectasis Collapse or closure of a lung resulting in reduced or absent gas exchange

Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often called a collapsed lung, although that term may also refer to pneumothorax.

Hemothorax Blood accumulation in the pleural cavity

A hemothorax 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 include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to a collapsed lung, or rarely in association with other conditions.

Nuss procedure Procedure for treating pectus excavatum

The Nuss procedure is a minimally-invasive procedure, invented in 1987 by Dr. Donald Nuss for treating pectus excavatum. He developed it at Children's Hospital of The King's Daughters, in Norfolk, Virginia. The operation typically takes approximately two hours.

Rib fracture Break in a rib bone

A rib fracture is a break in a rib bone. This typically results in chest pain that is worse with inspiration. Bruising may occur at the site of the break. When several ribs are broken in several places a flail chest results. Potential complications include a pneumothorax, pulmonary contusion, and pneumonia.

Arterial switch operation

Arterial switch operation (ASO) or arterial switch, is an open heart surgical procedure used to correct dextro-transposition of the great arteries (d-TGA); its development was pioneered by Canadian cardiac surgeon William Mustard and it was named for Brazilian cardiac surgeon Adib Jatene, who was the first to use it successfully. It was the first method of d-TGA repair to be attempted, but the last to be put into regular use because of technological limitations at the time of its conception.

Lobectomy of the lung is a surgical operation where a lobe of the lung is removed. It is done to remove a portion of diseased lung, such as early stage lung cancer.

Subcutaneous emphysema Medical condition

Subcutaneous emphysema occurs when gas or air travels under the skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching Rice Krispies; This sensation of air under the skin is known as subcutaneous crepitation, a form of Crepitus.

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, with or without angulated visualization, which allows the surgeon to see inside the chest by viewing the video images relayed onto a television screen, and perform procedures using elongated surgical instruments. The camera and instruments are inserted into the patient's chest cavity through small incisions in the chest wall, usually via specially designed guiding tubes known as "ports".

Video-assisted thoracoscopic surgery (VATS) lobectomy is an approach to lung cancer surgery.

Continuous wound infiltration (CWI) refers to the continuous infiltration of a local anesthetic into a surgical wound to aid in pain management during post-operative recovery.

Brachial plexus block

Brachial plexus block is a regional anesthesia technique that is sometimes employed as an alternative or as an adjunct to general anesthesia for surgery of the upper extremity. This technique involves the injection of local anesthetic agents in close proximity to the brachial plexus, temporarily blocking the sensation and ability to move the upper extremity. The subject can remain awake during the ensuing surgical procedure, or they can be sedated or even fully anesthetized if necessary.

Raja Michael Flores, M.D., is an American thoracic surgeon and candidate for mayor of New York City, currently Chief of the Division of Thoracic Surgery at Mount Sinai Hospital and Ames Professor of Cardiothoracic Surgery at the Icahn School of Medicine at Mount Sinai, both in New York City. On March 20, 2021, Dr. Flores announced his campaign for mayor of NYC.

A transmediastinal gunshot wound (TMGSW) is a penetrating injury to a person's thorax in which a bullet enters the mediastinum, possibly damaging some of the major structures in this area. Hemodynamic instability has been reported in approximately fifty percent of cases with a mortality rate ranging from twenty to forty percent. Some studies have shown marked improvement in the mortality rate of patients who survived transfer to the operating room rather than being treated surgically in the ER.

Local anesthetic nerve block

Local anesthetic nerve block is a short-term nerve block involving the injection of local anesthetic as close to the nerve as possible for pain relief. The local anesthetic bathes the nerve and numbs the area of the body that is supplied by that nerve. The goal of the nerve block is to prevent pain by blocking the transmission of pain signals from the surgical site. The block provides pain relief during and after the surgery. The advantages of nerve blocks over general anesthesia include faster recovery, monitored anesthesia care vs. intubation with an airway tube, and much less postoperative pain.

Thoracic endometriosis is a rare form of endometriosis where endometrial-like tissue is found in the lung parenchyma and/or the pleura. It can be classified as either pulmonary, or pleural, respectively. Endometriosis is characterized by the presence of tissue similar to the lining of the uterus forming abnormal growths elsewhere in the body. Usually these growths are found in the pelvis, between the rectum and the uterus, the ligaments of the pelvis, the bladder, the ovaries, and the sigmoid colon. The cause is not known. The most common symptom of thoracic endometriosis is chest pain occurring right before or during menstruation. Diagnosis is based on clinical history and examination, augmented with X-ray, CT scan, and magnetic resonance imaging of the chest. Treatment options include surgery and hormones.

References

  1. " thoracotomy " at Dorland's Medical Dictionary
  2. Ashrafian H, Athanasiou T (December 2010). "Emergency prehospital on-scene thoracotomy: a novel method". Collegium Antropologicum. 34 (4): 1449–52. PMID   21874737.
  3. Attar S, Hankins JR, Turney SZ, Krasna MJ, McLaughlin JS (June 1995). "Paraplegia after thoracotomy: report of five cases and review of the literature". The Annals of Thoracic Surgery. 59 (6): 1410–5, discussion 1415-6. doi:10.1016/0003-4975(95)00196-R. PMID   7771819.
  4. Brodbelt AR, Miles JB, Foy PM, Broome JC (March 2002). "Intraspinal oxidised cellulose (Surgicel) causing delayed paraplegia after thoracotomy--a report of three cases". Annals of the Royal College of Surgeons of England. 84 (2): 97–9. PMC   2503802 . PMID   11995773.
  5. Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, et al. (June 2018). "Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children". The Cochrane Database of Systematic Reviews. 6: CD007105. doi:10.1002/14651858.CD007105.pub4. PMC   6377212 . PMID   29926477.
  6. Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F, et al. (Cochrane Anaesthesia Group) (February 2016). "Paravertebral block versus thoracic epidural for patients undergoing thoracotomy". The Cochrane Database of Systematic Reviews. 2: CD009121. doi:10.1002/14651858.CD009121.pub2. PMC   7151756 . PMID   26897642.
  7. 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. doi : 10.1016/S0034-7094(11)70067-8.