Thoracotomy

Definition

Thoracotomy is the process of making of an incision (cut) into the chest wall.

Purpose

A physician gains access to the chest cavity (called the thorax) by cutting through the chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the condition of the lungs; removal of a lung or part of a lung; removal of a rib; and examination, treatment, or removal of any organs in the chest cavity. Thoracotomy also provides access to the heart, esophagus, diaphragm, and the portion of the aorta that passes through the chest cavity.

Lung cancer is the most common cancer requiring a thoracotomy. Tumors and metastatic growths can be removed through the incision (a procedure called resection). A biopsy, or tissue sample, can also be taken through the incision, and examined under a microscope for evidence of abnormal cells.

A resuscitative or emergency thoracotomy may be performed to resuscitate a patient who is near death as a result of a chest injury. An emergency thoracotomy provides access to the chest cavity to control injury-related bleeding from the heart, cardiac compressions to restore a normal heart rhythm, or to relieve pressure on the heart caused by cardiac tamponade (accumulation of fluid in the space between the heart's muscle and outer lining).

Demographics

Thoracotomy may be performed to diagnose or treat a variety of conditions; therefore, no data exist as to the overall incidence of the procedure. Lung cancer, a common reason for thoracotomy, is diagnosed in approximately 172,000 people each year and affects more men than women (91,800 diagnoses in men compared to 80,100 in women).

Description

The thoracotomy incision may be made on the side, under the arm (axillary thoracotomy); on the front, through the breastbone (median sternotomy); slanting from the back to the side (posterolateral thoracotomy); or under the breast (anterolateral thoracotomy). The exact location of the cut depends on the reason for the surgery. In some cases, the physician is able to make the incision between ribs (called an intercostal approach) to minimize cuts through bone, nerves, and muscle. The incision may range from just under 5 in (12.7 cm) to 10 in (25 cm).

During the surgery, a tube is passed through the trachea. It usually has a branch to each lung. One lung is deflated for examination and surgery, while the other one is inflated with the assistance of a mechanical device (a ventilator).

A number of different procedures may be commenced at this point. A lobectomy removes an entire lobe or section of a lung (the right lung has three lobes and the left lung has two). It may be done to remove cancer that is contained by a lobe. A segmentectomy , or wedge resection, removes a wedge-shaped piece of lung smaller than a lobe. Alternatively, the entire lung may be removed during a pneumonectomy .

In the case of an emergency thoracotomy, the procedure performed depends on the type and extent of injury. The heart may be exposed so that direct cardiac compressions can be performed; the physician may use one hand or both hands to manually pump blood through the heart. Internal paddles of a defibrillating machine may be applied directly to the heart to restore normal cardiac rhythms. Injuries to the heart causing excessive bleeding (hemorrhaging) may be closed with staples or stitches.

Once the procedure that required the incision is completed, the chest wall is closed. The layers of skin, muscle, and other tissues are closed with stitches or staples. If the breastbone was cut (as in the case of a median sternotomy), it is stitched back together with wire.

Diagnosis/Preparation

Patients are told not to eat after midnight the night before surgery. The advice is important because vomiting during surgery can cause serious complications or death. For surgery in which a general anesthetic is used, the gag reflex is often lost for several hours or longer, making it much more likely that food will enter the lungs if vomiting occurs.

For a thoracotomy, the patient lies on his or her side with one arm raised (A). An incision is cut into the skin of the ribcage (B). Muscle layers are cut, and a rib may be removed to gain access to the cavity. (C). Retractors hold the ribs apart, exposing the lung (D). After any repairs are made, the cut rib is replaced and held in place with special materials (E). Layers of muscle and skin are stitched. (

Illustration by GGS Inc.

)

Patients must tell their physicians about all known allergies so that the safest anesthetics can be selected. Older patients must be evaluated for heart ailments before surgery because of the additional strain on that organ.

Aftercare

Opening the chest cavity means cutting through skin, muscle, nerves, and sometimes bone. It is a major procedure that often involves a hospital stay of five to seven days. The skin around the drainage tube to the thoracic cavity must be kept clean, and the tube must be kept unblocked.

The pressure differences that are set up in the thoracic cavity by the movement of the diaphragm (the large muscle at the base of the thorax) make it possible for the lungs to expand and contract. If the pressure in the chest cavity changes abruptly, the lungs can collapse. Any fluid that collects in the cavity puts a patient at risk for infection and reduced lung function, or even collapse (called a pneumothorax). Thus, any entry to the chest usually requires that a chest tube remain in place for several days after the incision is closed.

The first two days after surgery may be spent in the intensive care unit (ICU) of the hospital. A variety of tubes, catheters, and monitors may be required after surgery.

Risks

The rich supply of blood vessels to the lungs makes hemorrhage a risk; a blood transfusion may become necessary during surgery. General anesthesia carries such risks as nausea, vomiting, headache, blood pressure issues, or allergic reaction. After a thoracotomy, there may be drainage from the incision. There is also the risk of infection; the patient must learn how to keep the incision clean and dry as it heals.

After the chest tube is removed, the patient is vulnerable to pneumothorax. Physicians strive to reduce the risk of collapse by timing the removal of the tube. Doing so at the end of inspiration (breathing in) or the end of expiration (breathing out) poses less risk. Deep breathing exercises and coughing should be emphasized as an important way that patients can improve healing and prevent pneumonia.

Normal results

The results following thoracotomy depend on the reasons why it was performed. If a biopsy was taken during the surgery, a normal result would indicate that no cancerous cells are present in the tissue sample. The procedure may indicate that further treatment is necessary; for example, if cancer was detected, chemotherapy, radiation therapy, or more surgery may be recommended.

Morbidity and mortality

One study following lung cancer patients undergoing thoracotomy found that 10–15% of patients experienced heartbeat irregularities, readmittance to the ICU, or partial or full lung collapse; 5–10% experienced pneumonia or extended use of the ventilator (greater than 48 hours); and up to 5% experienced wound infection, accumulation of pus in the chest cavity, or blood clots in the lung. The mortality rate in the study was 5.8%, with patients dying as a result of the cancer itself or of postoperative complications.

Alternatives

Video-assisted thoracic surgery (VATS) is a less invasive alternative to thoracotomy. Also called thoracoscopy, VATS involves the insertion of a thoracoscope (a thin, lighted tube) into a small incision through the chest wall. The surgeon can visualize the structures inside the chest cavity on a video screen. Such instruments as a stapler or grasper may inserted through other small incisions. Although initially used as a diagnostic tool (to visualize the lungs or to remove a sample of lung tissue for further examination), VATS may be used to remove some lung tumors.

An alternative to emergency thoracotomy is a tube thoracostomy, a tube placed through chest wall to drain excess fluid. Over 80% of patients with a penetrating chest wound can be successfully managed with a thoracostomy.

See also ; Thoracoscopy .

Resources

BOOKS

Bartlett, Robert L. "Resuscitative Thoracotomy." (Chapter 17). In Clinical Procedures in Emergency Medicine. Philadelphia: W. B. Saunders Company, 1998.

Townsend, Courtney M., et al. "Thoracic Incisions." (Chapter 55). In Sabiston Textbook of Surgery. Philadelphia: W. B. Saunders Company, 2001.

PERIODICALS

Blewett, C.J. et al. "Open Lung Biopsy as an Outpatient Procedure." Annals of Thoracic Surgery (April 2001): 1113-5.

Handy, John R., et al. "What Happens to Patients Undergoing Lung Cancer Surgery? Outcomes and Quality of Life Before and After Surgery." Chest 122, no.1 (August 14, 2002): 21-30.

Swanson, Scott J. and Hasan F. Batirel. "Video-Assisted Thoracic Surgery (VATS) Resection for Lung Cancer." Surgical Clinics of North America 82, no.3 (June 1, 2002): 541-9.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org .

Society of Thoracic Surgeons. 663 N. Saint Clair St., Suite 2320, Chicago, IL 60611-3658. (312) 202-5800. http://www.sts.org .

OTHER

"Detailed Guide: Lung Cancer." American Cancer Society. [cited April 28, 2003]. http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=26 .

Diane M. Calabrese Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Thoracotomy may be performed by a thoracic surgeon, a medical doctor who has completed surgical training in the areas of general surgery and surgery of the chest area, or an emergency room physician (in the case of emergency thoracotomy). The procedure is generally performed in a hospital operating room , although emergency thoracotomies may be performed in an emergency department or trauma center.

QUESTIONS TO ASK THE DOCTOR

• Why is thoracotomy being recommended?
• What diagnostic tests will be performed to determine if thoracotomy is necessary?
• What type of incision will be used and where will it be located?
• What type of procedure will be performed?
• How long will is the recovery time and what is expected during this period?
• If a biopsy is the only reason for the procedure, is a thoracoscopy or a guided needle biopsy an option (instead of thoracotomy)?