Thoracotomy

A thoracotomy is a surgical procedure that involves cutting open the chest wall to gain access into the pleural cavity, It is mostly performed by specialist cardiothoracic surgeons, although emergency physicians or paramedics occasionally also perform the procedure under life-threatening circumstances.

The procedure is performed under general anesthesia with double-lumen intubation, and commonly with epidural analgesia set up pre-sedation for postoperative pain management. The procedure starts with controlled cutting through the skin, intercostal muscles and then parietal pleura, and typically involves transecting at least one rib with a costotome due to the limited range of bucket handle movement each rib has without fracturing. The incised wound is then spread and held apart with a retractor (rib spreader) to allow passage of surgical instruments and the surgeon's hand. Traditional thoracotomy is thus a highly invasive procedure, with bacterial pneumonia, hemothorax/pleural effusion/air leak and intercostal neuralgia being common postoperative complications. However, some recent techniques can perform achieve thoracic access with a smaller incision (usually less than 10 cm or 3.9 in) and no rib cutting, and are often called a mini-thoracotomy (not to be confused with the minimally invasive thoracoscopy).

The purpose of thoracotomy is to gain direct-vision access to intrathoracic organs, most commonly the lungs, the heart and/or the esophagus, as well as access to the thoracic aorta, the anterior spine or even merely to resect portions of the chest wall for neoplasms (e.g. mesothelioma, sarcoma or fibroma) and deformities (e.g. flail chest, pectus carinatum or excavatum). It is the first step in common thoracic surgeries including lobectomy or pneumonectomy for lung cancer, drainage and decortication for empyema, diaphragm repairs, or to gain thoracic access in major trauma. Postoperative care of thoracotomy typically involves intensive care monitoring, chest tube drainage and chest physiotherapy.