Definition

A thoracotomy is a surgical procedure for opening the chest wall to access the lungs, esophagus, trachea, aorta, heart, and diaphragm. Depending on the disease location, thoracotomy may be done on the right or left chest. Sometimes, a small thoracotomy can be done in the front part of the chest

Parts of the Body Involved

A thoracotomy will involve the chest, lungs, and back.

Reasons for Procedure

• Confirm diagnosis of a lung or chest disease
• Repair the heart or the vessels of the lung and the heart
• Treat complications due to emphysema
• Treat disorders of the trachea
• Remove a portion of the lung or the entire lung to treat lung cancer
• Treat disorders of the esophagus
• Reinflate lung tissue that has collapsed due to disease or trauma
• Remove pus from the chest (empyema)
• Remove blood clots from the chest (hemothorax)

Risk Factors for Complications During the Procedure

• Major trauma involving multiple body parts
• Age
• Heavy smoker
• Previous stroke
• Severe chronic lung disease
• Prior radiation therapy
• Underlying chronic medical problems, such as:
  • Heart disease
  • Uncontrolled diabetes
  • Renal failure
  • HIV
  • Immunodeficiencies

What to Expect

Prior to Procedure

Your doctor will likely do some or all of the following:

• Physical exam
• Blood and urine tests
• Imaging tests of the chest, such as x-ray, CT scan, or MRI scan
• Pulmonary function tests to assess the capacity of your lungs to undergo surgery
• Assess your heart to ensure that you can withstand the surgery
• Check your blood and see if you are maintaining adequate oxygenation and excretion of carbon dioxide
  • To minimize your complications, you must stop smoking at least 2 to 3 weeks before surgery
• Undergo pulmonary rehabilitation to exercise your lungs

The day before and the day of surgery:

• Use an enema to clear your colon so that your abdomen does not become distended during surgery.
• Do not eat or drink anything after midnight.
• Your doctor may recommend a sleeping pill so that you'll get adequate rest the night before the surgery.
• Before going to the hospital, remove all jewelry, contact lenses, dentures, wigs, and nail polish.

During Procedure

Anesthesia and pain medication will be administered.

Anesthesia

General anesthesia will be given. You may also be given pain medication through a spinal/epidural (a thin tube placed along the spinal column in your back).

Description of the Procedure

For a thoracotomy, you will be placed on your side with your arm elevated. The doctor makes an incision between two ribs from front to back. The chest wall is opened, which provides access to the lungs. The doctor removes the tissue and/or tumor from the lungs, or works with other structures in the chest as necessary. To make sure that your lungs stay inflated and that there is no collection of blood or air in the chest, the surgeon will place one or more catheters (chest tubes). These catheters are brought out onto the skin and will be hooked up to a suction bottle.

There are three main approaches to thoracotomy:

Median sternotomy

This approach involves the surgeon making a vertical incision along the sternum, and then dividing the sternum to gain access to the heart and lungs. Most open-heart surgeries use this procedure.

Posterolateral thoracotomy

This is the traditional approach for operations on the lungs. An incision is often made in the bed of the 5th rib (5th intercostals space), which allows the surgeon to access the pulmonary artery and pulmonary vein.

Anterolateral thoracotomy

A large surgical incision that is made on the anterior chest wall. Left anterolateral thoracotomy may be used after cardiac arrest to perform open chest massage.

Video-Assisted Thoracic Surgery (VATS)

VATS is a less invasive alternative than the previously described open procedures. The surgeon can perform VATS in select cases, and is also able to diagnose and observe from within the chest cavity (avoiding a large incision and thus decreasing pain after the operation).

	Left Lung Mass With Thoracotomy
	© 2008 Nucleus Medical Art, Inc.

After Procedure

The incision is closed with stitches or staples, and bandaged to prevent infection. You will be sent to the intensive care unit for recovery. After surgery, you will have numerous intravenous lines and tubes in and around your body. As you improve and eat and walk, most of these will be removed. You will have several catheters that include:

• Urinary catheter to measure urine output and avoid the need to urinate in the bathroom
• Endotracheal tube in the trachea to assist breathing
  • A machine called a ventilator, which is usually connected to an endotracheal tube, that can breathe for you
• Chest tube to remove air, blood, or fluid from the pleural space
• Nasogastric tube, which is inserted through the nose and into the stomach, to remove stomach secretions

You may be given antibiotics, pain medication, or antinausea drugs after surgery.

How Long Will It Take?

The surgery typically takes 3 to 4 hours.

Will It Hurt?

Anesthesia prevents pain during the procedure. You may have some discomfort after the surgery.

Possible Complications

• Bleeding in the lung cavity (hemothorax)
• Infection on the skin wound
• Infection inside the chest cavity
• Persistent pain (only in a few cases)
• Reaction to anesthesia
• Failure to completely expand the lung
• Continued drainage from the chest tubes
• Collection of air or gases in the lung cavity (pneumothorax)

Average Hospital Stay

The hospital stay is typically 5 to 10 days.

Postoperative Care

Once you leave the hospital:

• Do coughing and deep breathing exercises as instructed by the nurse or physical therapist 3 to 4 times daily to help keep your lungs clear.
• Get out of bed often and sit in a chair. Increase your activity as much as tolerated.
• Stay well-hydrated.
• Do not smoke.
• Avoid environments that expose you to germs, smoke, or chemical irritants.

Outcome

The outcome will depend on the reason for the procedure.

Call Your Doctor If Any of the Following Occurs

• Difficulty breathing
• New pain in the chest
• Stitches or staples come apart
• Bandage becomes soaked with blood
• Cough up mucus that is yellow, green, or bloody
• Signs of infection, including fever and chills
• Redness, swelling, increasing pain, excessive bleeding, or discharge at the incision site
• Cough, shortness of breath, chest pain, or severe nausea or vomiting
• Pain, burning, urgency or frequency of urination, or persistent bleeding in the urine

RESOURCES:

American Thoracic Society
http://www.thoracic.org/

Society of Thoracic Surgeons
http://www.sts.org/

CANADIAN RESOURCES:

Canadian Society for Vascular Surgery
http://csvs.vascularweb.org/

The Lung Association
http://www.lung.ca/

References:

Athanassiadi K, Kakaris S, Theakos N, Skottis I. Muscle-sparing versus posterolateral thoracotomy: a prospective study. Eur J Cardiothorac Surg. 2007;31:496-500.

Medical encyclopedia: lung surgery. Medline Plus website. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002956.htm. Accessed October 14, 2005.

Ohbuchi T, Morikawa T, Takeuchi E, Kato H. Lobectomy: video-assisted thoracic surgery versus posterolateral thoracotomy. Jpn J Thorac Cardiovasc Surg. 1998 Jun;46(6):519-22.

Saint Mary's Hospital, Saginaw website. Available at: http://www.hospitalsoup.com/rn/asp/HospitalID.11842/pt/hospitaldetails3.asp. Accessed October 14, 2005.

University of Southern California, Cardiothoracic Surgery website. Available at: http://www.cts.usc.edu/videoassistedthoracoscopicsurgery.html. Accessed June 15, 2007.

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