Definition & Overview
Thoracotomy is a medical procedure that involves making a large incision on the chest to open up the chest wall and gain access to the chest cavity. It is mainly used to perform surgery on any of the organs in the chest area, including the lungs, heart, trachea, aorta, and diaphragm.
The incision can be on the right, left, or centre of the chest depending on the location of the affected organ. As a serious invasive procedure, a thoracotomy is performed only when deemed necessary, such as when there are serious health risks affecting the chest cavity organs or in cases of life-threatening situations.
Who Should Undergo and Expected Results
Thoracotomy can be performed on patients who require surgical intervention for the treatment of conditions affecting the lungs, heart, trachea, aorta, and diaphragm. These treatments may include:
- Wedge resection
- Segmentectomy or segment resection
- Rib removal
- Tissue biopsy
- Blood vessel repair
- Lung tissue re-inflation
- Blood clot removal
- Tumour or lymph node removal
- Pleurectomy or decortication
Patients who require the above procedures are commonly those who suffer from the following medical conditions:
- Lung cancer
- Swollen lymph nodes
- Blood clots
- Chest infection
- Collapsed lung tissue
- Metastatic growths
- Windpipe disorders
- Pleural mesothelioma
A thoracotomy is also sometimes performed as an emergency procedure in an attempt to resuscitate a patient usually in cases involving serious chest injury. Studies show that a large number of emergency room thoracotomy is due to gunshot or stab wounds in the chest area. These emergency thoracotomies have a survival rate of 18 to 33%, with the rates higher among patients who suffered from stab wounds compared to those who suffered from gunshot wounds.
In emergency cases, the procedure’s main goals are to control bleeding from the chest cavity and restore normal heart rhythm to prevent or stop cardiac compressions. If the patient suffers from a cardiac tamponade, or when fluid accumulates in the space between the heart’s outer lining and its muscle, a thoracotomy can also relieve the pressure this causes on the heart.
How is the Procedure Performed?
Before a thoracotomy, patients usually undergo a thorough physical examination, as well as blood and urine tests, x-rays, chest CT and MRI scans, and pulmonary and heart function tests to determine whether the procedure is necessary and to ensure that the patient is fit to undergo the procedure.
Thoracotomy is performed under general anaesthesia. An incision, which typically ranges between 12cm to 25cm, is then created between the two ribs, starting from the front and the back, to open up the chest wall. The surgeon then gains access to the chest cavity to perform the surgery required based on the patient’s medical condition.
Different techniques can be used when performing thoracotomy depending on the specific area or organ that needs to be accessed. These include:
- Posterolateral thoracotomy, or when the surgeon requires access to the entire lung, the pleurae, the hilum, or the mediastinum
- Sternal splitting incision or median sternotomy, which is usually used when the surgeon requires access to both lungs
- Limited anterior or lateral thoracotomy, which involves making a 6 to 8 cm intercostal incision (between the ribs), a technique known to help minimise cutting through bone, nerves, and muscles
Following the procedure, chest tubes are placed to drain blood and air from the surgical site before the chest wall is closed. The incision is likewise closed with staples or sutures. The surgical wound is then covered with a bandage to protect it as it heals and to help prevent infection. Antibiotics and pain medications are also provided.
The whole procedure typically takes 3 to 4 hours and is followed by a hospital stay, (1 to 2 days for a limited thoracotomy and up to 10 days for a complete thoracotomy). The hospital stay may be extended if complications arise.
In some cases, a spirometer is used to help keep patient’s lungs clear during the recovery period.
Possible Risks and Complications
A thoracotomy is a highly invasive procedure requiring a large incision and gaining access to vital organs in the body. Thus, it carries a number of serious risks mainly due to the combination of general anaesthesia, surgical trauma, and extended hospital stay. These include:
- Bleeding or haemorrhage
- Bronchopleural fistula
- Collapsed lung
- Allergic reaction to anaesthesia
- Accumulation of air or gas in the chest
- Organ damage
- Chronic pain syndrome, or when the patient continues to feel burning pain in the surgical area even after the wound has healed
The risk of these complications occurring is higher among patients who are:
- Heavy smokers
- Survivors of major bodily trauma
- Stroke survivors
- Heart attack survivors
- Sufferers of chronic medical conditions
Keller D., Kulp H., Maher Z., Santora TA., Goldberg AJ., Seamon MJ. “Life after near death: long-term outcomes of emergency department thoracotomy survivors.” J Trauma Acute Care Surg. 2013 May; 74(5): 315-20. http://www.ncbi.nlm.nih.gov/pubmed/23609284
Moore EE., Knudson MM., Burlew CC., Inaba K., et al. “Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.” J Trauma. 2011 Feb; 70(2): 334-9. http://www.ncbi.nlm.nih.gov/pubmed/21307731