Thoracotomy
Thoracotomy is a surgical procedure that involves making an incision in the chest wall to access the lungs, esophagus, or heart. This operation can be performed on either side of the chest or through the midline, depending on the specific medical needs. Common reasons for performing a thoracotomy include biopsying or removing tumors, closing lung blebs, and draining abscesses. Prior to the surgery, patients undergo preparation that includes blood work and an electrocardiogram, and they must fast after midnight on the day of the procedure.
The procedure typically involves the insertion of an intravenous line and connecting the patient to a heart monitor before sedation and intubation. Surgeons may use different techniques, such as video-assisted thoracoscopic surgery (VATS) or robot-assisted thoracic surgery (RATS), which are less invasive alternatives that use smaller incisions and provide improved visualization, potentially leading to reduced complications and better outcomes in lung cancer patients. Post-surgery, patients are closely monitored in an intensive care unit, with an expected hospital stay of five to ten days. While thoracotomy can be effective, it also carries risks, including lung collapse, infection, bleeding, and significant postoperative pain. Ultimately, the goal of the procedure is to ensure that the lungs fully inflate and that any tumors are adequately addressed.
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Subject Terms
Thoracotomy
ALSO KNOWN AS: Lung surgery
DEFINITION: A thoracotomy is the surgical opening of the chest wall so that the lungs, esophagus, or heart may be accessed. It can be performed on the right or left side or the midline of the chest.
Cancers diagnosed or treated: Lung cancer, esophageal cancer, cancer of the heart
Why performed: A thoracotomy is performed to biopsy or remove a tumor, to close a bleb (blister) in the external wall of the lung, or to drain an abscess.
Patient preparation: Several days before the thoracotomy, the patient will require blood work and an electrocardiogram (EKG). The patient will have to fast after midnight on the day of the procedure.
Steps of the procedure: Before the thoracotomy, the patient will have an intravenous (IV) line inserted and be hooked up to a heart monitor. After the patient is sedated, an endotracheal tube is placed through the patient’s nose or mouth into the trachea and attached to a ventilator, which breathes for the patient.
A midline thoracotomy is performed for surgery on the heart or esophagus. The patient lies on the back, and the surgeon splits the sternum to gain access to the chest. A right or left thoracotomy is used for surgery on the lungs. The patient lies on the opposite side with the arm over the head, and the surgeon makes an over the fifth intercostal (between the ribs) space.
After the surgery and before the chest wall is closed, one or two chest tubes are placed through the chest wall into the pleural space. They are necessary to reestablish the negative pressure in the chest. The chest tubes are attached to a drainage unit with a water seal to keep air from entering the pleural space.
Video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) have emerged as less-invasive thoracotomy techniques. In VATS, a smaller incision is used, and a camera and scope allow for viewing of the chest cavity. Because RATS allows for even smaller incisions and uses a three-dimensional (3D) visualization system, it has been shown to reduce complications and allow for longer survival rates in lung cancer patients.
After the procedure: The patient is sent to an intensive care unit (ICU) for close monitoring of vital signs, breathing, heart rhythm, and chest drainage. The patient will remain in the hospital for five or ten days. Usually, the chest tubes can be removed after three to five days.
Risks: The risks of a thoracotomy are pneumothorax (collapse of the lung), air leaks, infection, bleeding, local nerve damage, and respiratory failure. After a thoracotomy, the patient may have severe pain with breathing.
Results: The lungs should be fully inflated. The tumor should be removed, and the local lymph nodes evaluated.
Bibliography
Deslauriers, Jean, F. Griffith Pearson, and Farid M. Shamji, eds. Thoracic Surgery Clinics: Lung Cancer, Part II; Surgery and Adjuvant Therapies, vol. 23.3, 2013, pp. 273–452.
Dienemann, Hendrik C., Hans Hoffmann, and Frank C. Detterbeck, eds. Chest Surgery. Berlin: Springer, 2015.
Ferguson, Mark K. Difficult Decisions in Thoracic Surgery: An Evidence-Based Approach. 3rd ed., London: Springer, 2014.
Kim, Dohun, et al. "The Uncomfortable Truth: Open Thoracotomy versus Minimally Invasive Surgery in Lung Cancer: A Systematic Review and Meta-Analysis." Cancers, vol. 15, no. 9, 2023, doi.org/10.3390/cancers15092630. Accessed 23 June 2024.
Roth, Jack A., Waun Ki Hong, and Ritsuko U. Komaki. Lung Cancer. 4th ed. Hoboken: Wiley, 2014.
Sugarbaker, David J., et al., eds. Adult Chest Surgery. 2nd ed. New York: McGraw, 2015.
“Thoracotomy: What It Is, Purpose, Procedure & Recovery.” Cleveland Clinic, my.clevelandclinic.org/health/treatments/22981-thoracotomy. Accessed 23 June 2024.
Yutaka, Yojiro, and Calvin S. Hang Ng. "Editorial: Recent Advances in Minimally Invasive Thoracic Surgery." Frontiers in Surgery, vol. 10, 2023, doi.org/10.3389/fsurg.2023.1182768. Accessed 23 June 2024.