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). A thoracotomy is the first step in 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 one or more chest tubes 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 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.
Pain following a thoracotomy may be treated by the use of a nerve block known as a rhomboid intercostal block.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 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.
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 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).
The pleural cavity, pleural space, or interpleural 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 enable lubrication between the membranes, and also to create a pressure gradient.
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. This leads to a type of shock called obstructive shock, which can be fatal unless reversed. 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.
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 usually performed by anesthesiologists that 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 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.
A chest tube is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substances such as air (pneumothorax), excess fluid, blood (hemothorax), chyle (chylothorax) or pus (empyema) from the intrathoracic space. An intrapleural chest tube is also known as a Bülau drain or an intercostal catheter (ICC), and can either be a thin, flexible silicone tube, or a larger, semi-rigid, fenestrated plastic tube, which often involves a flutter valve or underwater seal.
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.
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.
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 is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.
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.
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 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 resembling the pneumatosis seen in pulmonary emphysema. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of Crepitus.
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 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.
A resuscitative thoracotomy is a thoracotomy performed to resuscitate a major trauma patient who has sustained severe thoracic or abdominal trauma and who has entered cardiac arrest because of this. The procedure allows immediate direct access to the thoracic cavity, permitting rescuers to control hemorrhage, relieve cardiac tamponade, repair or control major injuries to the heart, lungs or thoracic vasculature, and perform direct cardiac massage or defibrillation. For most persons with thoracic trauma the procedure is not necessary; only 15% of those with thoracic injury require the procedure.
Intercostal nerve block is a nerve block which temporarily or permanently interrupts the flow of signals along an intercostal nerve, usually performed to relieve pain.
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 affected area. Nerve blocks have a number of uses including treating headache disorders and providing anesthesia during surgery. The pain relief provided by the block is present during the surgery and continues to last after the procedure. This can lead to a reduction in the amount of opiates needed for pain control. 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.
Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal, thoracic or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment, usually by the replacement of the affected segment with a prosthetic graft. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States.
The pulmonary pleurae are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.