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A thoracotomy incision performed through the fourth or fifth intercostal space with rib spreaders to increase visibility of the pleural cavity
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest.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.
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.
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.
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.
Video-assisted thoracoscopic 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 rapidly growing alternative that uses advanced technology with proven advantages.
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. 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).
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, 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.
A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess fluid can impair breathing by limiting the expansion of the lungs. Various kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the pleural space, are hydrothorax, hemothorax (blood), urinothorax (urine), chylothorax (chyle), or pyothorax (pus) commonly known as pleural empyema. In contrast, a pneumothorax is the accumulation of air in the pleural space, and is commonly called a "collapsed lung".
Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thorax —generally treatment of conditions of the heart and lungs. In most countries, cardiac surgery and general thoracic surgery are separate surgical specialties; the exceptions are the United States, Australia, New Zealand, and some EU countries, such as the United Kingdom and Portugal.
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.
A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax include chest pain and difficulty breathing, while the clinical signs include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury but 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.
A chylothorax is an accumulation of lymphatic fluid in the space surrounding the lung. Lymph formed in the digestive system is called chyle and accumulates in the pleural space due to either disruption or obstruction of the thoracic duct. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains triglycerides. It is important to distinguish a chylothorax from a pseudochylothorax, which has a similar appearance, but is caused by more chronic inflammatory processes, and requires a different treatment.
Thoracentesis, also known as thoracocentesis, pleural tap, needle thoracostomy, or needle decompression is an invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852.
Hemopneumothorax, or haemopneumothorax is the condition of having air in the chest cavity (pneumothorax) and blood in the chest cavity (hemothorax). A hemothorax, pneumothorax, or the combination of both can occur due to an injury to the lung or chest.
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.
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.
A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, emergency response nurses, and paramedics, usually via needle thoracostomy, or with a thoracostomy tube.
A pulmonary laceration is a chest injury in which lung tissue is torn or cut. An injury that is potentially more serious than pulmonary contusion, pulmonary laceration involves disruption of the architecture of the lung, while pulmonary contusion does not. Pulmonary laceration is commonly caused by penetrating trauma but may also result from forces involved in blunt trauma such as shear stress. A cavity filled with blood, air, or both can form. The injury is diagnosed when collections of air or fluid are found on a CT scan of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.
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.
Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.
Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via small incisions. The surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports". These small ports are advantageous because the chance for infection and wound dehiscence are drastically reduced. This allows for a faster recovery by the patient and a greater chance for the wound to heal.
Video-assisted thoracoscopic surgery (VATS) lobectomy is an approach to lung cancer surgery.
Raja Michael Flores, M.D., is an American thoracic surgeon, 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.
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.
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.