Last updated
Emergency Thoracotomy.png
A left anterolateral thoracotomy exposing the heart and lung. A Harken retractor (rib spreader) is being used to increase visibility
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). 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. [9] 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. [10] [11]

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. [12] 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. [13] 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. [14] 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. [15]


Video-assisted thoracoscopic surgery (VATS) is a less invasive alternative to thoracotomy in selected cases, much like laparoscopic surgery. 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. [16]

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. [17] 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). [18]

See also

Related Research Articles

<span class="mw-page-title-main">Pneumothorax</span> Abnormal collection of air in the pleural space

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.

<span class="mw-page-title-main">Cardiothoracic surgery</span> Medical specialty involved in surgical treatment of organs inside the thorax

Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart, lungs, and other pleural or mediastinal structures.

<span class="mw-page-title-main">Spinal anaesthesia</span> 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 opiod 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 (sympathetic) 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 sympathetic 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.

<span class="mw-page-title-main">Epidural administration</span> 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.

<span class="mw-page-title-main">Chest tube</span> Type of surgical drain

A chest tube is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum. The insertion of the tube is sometimes a lifesaving procedure. The tube can be used 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.

<span class="mw-page-title-main">Hemothorax</span> 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 pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Pneumonectomy</span> Surgical removal of a lung

A pneumonectomy 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.

<span class="mw-page-title-main">Nerve block</span> Deliberate inhibition of nerve impulses

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.

<span class="mw-page-title-main">Nuss procedure</span> 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.

<span class="mw-page-title-main">Rib fracture</span> 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.

<span class="mw-page-title-main">Triangle of auscultation</span>

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.

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.

<span class="mw-page-title-main">Pulmonary laceration</span> Medical condition

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.

<span class="mw-page-title-main">Subcutaneous emphysema</span> Medical condition

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. 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.

<span class="mw-page-title-main">Video-assisted thoracoscopic surgery</span>

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.

Minimally invasive cardiac surgery, encompasses various aspects of cardiac surgical procedures that can be performed with minimally invasive approach either via mini-thoracotomy or mini-sternotomy. MICS CABG or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy.

Raja Michael Flores is an American thoracic surgeon and former 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.

<span class="mw-page-title-main">Mediastinal shift</span> Medical condition

Mediastinal shift is an abnormal movement of the mediastinal structures toward one side of the chest cavity. A shift indicates a severe imbalance of pressures inside the chest. Mediastinal shifts are generally caused by increased lung volume, decreased lung volume, or abnormalities in the pleural space. Additionally, masses inside the mediastinum or musculoskeletal abnormalities can also lead to abnormal mediastinal arrangement. Typically, these shifts are observed on x-ray but also on computed tomography (CT) or magnetic resonance imaging (MRI). On chest x-ray, tracheal deviation, or movement of the trachea away from its midline position can be used as a sign of a shift. Other structures like the heart can also be used as reference points. Below are examples of pathologies that can cause a mediastinal shift and their appearance.

<span class="mw-page-title-main">Lung surgery</span>

Lung surgery is a type of thoracic surgery involving the repair or removal of lung tissue, and can be used to treat a variety of conditions ranging from lung cancer to pulmonary hypertension. Common operations include anatomic and nonanatomic resections, pleurodesis and lung transplants. Though records of lung surgery date back to the Classical Age, new techniques such as VATS continue to be developed.


  1. "thoracotomy" at Dorland's Medical Dictionary
  2. Martin-Ucar A, Socci L (2017). "Thoracic incisions for open surgery" . Shanghai Chest. 1: 20. doi: 10.21037/shc.2017.05.11 .
  3. Ziyade S, Baskent A, Tanju S, Toker A, Dilege S (August 2010). "Isokinetic muscle strength after thoracotomy: standard vs. muscle-sparing posterolateral thoracotomy". The Thoracic and Cardiovascular Surgeon. 58 (5): 295–298. doi:10.1055/s-0030-1249829. PMID   20680907. S2CID   260341562.
  4. Li S, Feng Z, Wu L, Huang Q, Pan S, Tang X, Ma B (June 2014). "Analysis of 11 trials comparing muscle-sparing with posterolateral thoracotomy". The Thoracic and Cardiovascular Surgeon. 62 (4): 344–352. doi:10.1055/s-0033-1337445. PMID   23546873. S2CID   21882249.
  5. Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P (March 1999). "Clamshell or sternotomy for double lung or heart-lung transplantation?". European Journal of Cardio-Thoracic Surgery. 15 (3): 333–339. doi: 10.1016/s1010-7940(99)00009-3 . PMID   10333032.
  6. Germain A, Monod R (1956). "[Bilateral transversal anterior thoracotomy with sternotomy; indications and technics]". Journal de Chirurgie. 72 (8–9): 593–611. PMID   13367123.
  7. Bains MS, Ginsberg RJ, Jones WG, McCormack PM, Rusch VW, Burt ME, Martini N (July 1994). "The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor". The Annals of Thoracic Surgery. 58 (1): 30–2, discussion 33. doi:10.1016/0003-4975(94)91067-7. PMID   8037555.
  8. Ashrafian H, Athanasiou T (December 2010). "Emergency prehospital on-scene thoracotomy: a novel method". Collegium Antropologicum. 34 (4): 1449–1452. PMID   21874737.
  9. Sengupta S (September 2015). "Post-operative pulmonary complications after thoracotomy". Indian Journal of Anaesthesia. 59 (9): 618–626. doi: 10.4103/0019-5049.165852 . PMC   4613409 . PMID   26556921.
  10. 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.
  11. 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): 97–99. PMC   2503802 . PMID   11995773.
  12. Javadpour H, Sidhu P, Luke DA (2003). "Bronchopleural fistula after pneumonectomy". Irish Journal of Medical Science. 172 (1): 13–15. doi:10.1007/BF02914778. PMID   12760456. S2CID   37409582.
  13. Light RW, Macgregor MI, Luchsinger PC, Ball WC (October 1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Annals of Internal Medicine. 77 (4): 507–513. doi:10.7326/0003-4819-77-4-507. PMID   4642731.
  14. Ökmen K (April 2019). "Efficacy of rhomboid intercostal block for analgesia after thoracotomy". The Korean Journal of Pain. 32 (2): 129–132. doi:10.3344/kjp.2019.32.2.129. PMC   6549589 . PMID   31091512.
  15. 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 (6): CD007105. doi:10.1002/14651858.CD007105.pub4. PMC   6377212 . PMID   29926477.
  16. Al-Ameri M, Bergman P, Franco-Cereceda A, Sartipy U (June 2018). "Video-assisted thoracoscopic versus open thoracotomy lobectomy: a Swedish nationwide cohort study". Journal of Thoracic Disease. 10 (6): 3499–3506. doi: 10.21037/jtd.2018.05.177 . PMC   6051874 . PMID   30069346.
  17. 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 (2): CD009121. doi:10.1002/14651858.CD009121.pub2. PMC   7151756 . PMID   26897642.
  18. 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.