Editing Thoracotomy

{{Short description|Surgical procedure to access the interior of the chest}}
{{More medical citations needed|date=February 2022}}

{{Infobox interventions |
  Name        = Thoracotomy |
  Image       = Emergency Thoracotomy.png |
  Caption     = A left anterolateral thoracotomy exposing the heart and lung. A Harken retractor ([[rib spreader]]) is being used to increase visibility |
  ICD10       = |
  ICD9        = {{ICD9proc|34.02}} |
  MeshID      = D013908 |
  OPS301      = |
  OtherCodes  = |
}}
A '''thoracotomy''' is a [[surgical procedure]] that involves [[cutting]] open the [[chest wall]] to gain access into the [[pleural cavity]],<ref>{{DorlandsDict|eight/000108415|thoracotomy}}</ref> It is mostly performed by specialist [[cardiothoracic]] [[surgeon]]s, although [[emergency physician]]s or [[paramedic]]s occasionally also perform the procedure under [[resuscitative thoracotomy|life-threatening circumstances]].

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

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

==Approaches==
There are many different surgical approaches to performing a thoracotomy. Some common forms of thoracotomies include:
* '''Posterolateral thoracotomy''' is the most common and traditional approach for gaining access to the chest. It is an incision through an [[intercostal space]] on the back, and is often widened with [[Retractor (medical)|rib spreaders]]. Patient has to be placed in a lateral decubitus position for this approach. All pressure points should be padded. A pillow should be placed between the two legs. Both arms should be flexed and maintained in "prayer position". A roll can be placed under the 5th intercostal space or the table can be broken at the same level so as to open the intercostal space widely for easy access.<ref>{{Cite journal | vauthors = Martin-Ucar A, Socci L |date=2017 |title=Thoracic incisions for open surgery |url=http://shc.amegroups.com/article/view/3819/4597 |journal=Shanghai Chest |volume=1 |pages=20 |doi=10.21037/shc.2017.05.11 |doi-access= free|url-access=subscription }}</ref> It is a very common approach for operations on the [[lung]] or [[posterior mediastinum]], including the [[esophagus]]. When performed over the fifth intercostal space, it allows optimal access to the pulmonary [[hilum of lung|hilum]] ([[pulmonary artery]] and [[pulmonary vein]]) and therefore is considered the approach of choice for pulmonary resection ([[pneumonectomy]] and  [[lobectomy]]). Another variant is the "muscle sparing posterolateral thoracotomy" which preserves the Lattisimus Dorsi and Serratus muscles. This leads to less shoulder dysfunction and also allows for these muscles for any future use in case of a complication.<ref>{{cite journal | vauthors = Ziyade S, Baskent A, Tanju S, Toker A, Dilege S | title = Isokinetic muscle strength after thoracotomy: standard vs. muscle-sparing posterolateral thoracotomy | journal = The Thoracic and Cardiovascular Surgeon | volume = 58 | issue = 5 | pages = 295–298 | date = August 2010 | pmid = 20680907 | doi = 10.1055/s-0030-1249829 | s2cid = 260341562 }}</ref><ref>{{cite journal | vauthors = Li S, Feng Z, Wu L, Huang Q, Pan S, Tang X, Ma B | title = Analysis of 11 trials comparing muscle-sparing with posterolateral thoracotomy | journal = The Thoracic and Cardiovascular Surgeon | volume = 62 | issue = 4 | pages = 344–352 | date = June 2014 | pmid = 23546873 | doi = 10.1055/s-0033-1337445 | s2cid = 21882249 }}</ref>
* '''Anterolateral thoracotomy''' is performed upon the anterior chest wall. The skin incision is performed starting from the posterior axillary line in front of the tip of the scapula towards the submammary crease. The anterior intercostal spaces are wider as compared to the posterior spaces hence provide better exposure while minimising the need for excess rib spreading. It gives a very adequate exposure of lungs, pericardium and diaphragm. Left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic [[cardiac arrest]]. 
* '''Bilateral anterior thoracotomy with transverse sternotomy''', or clamshell incision, is the incision of choice for bilateral lung transplantation.<ref>{{cite journal | vauthors = Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P | title = Clamshell or sternotomy for double lung or heart-lung transplantation? | journal = European Journal of Cardio-Thoracic Surgery | volume = 15 | issue = 3 | pages = 333–339 | date = March 1999 | pmid = 10333032 | doi = 10.1016/s1010-7940(99)00009-3 | doi-access = free }}</ref> It is also a valuable tool in trauma settings.<ref>{{cite journal | vauthors = Germain A, Monod R | title = [Bilateral transversal anterior thoracotomy with sternotomy; indications and technics] | journal = Journal de Chirurgie | volume = 72 | issue = 8–9 | pages = 593–611 | date = 1956 | pmid = 13367123 | url = https://pubmed.ncbi.nlm.nih.gov/13367123 }}</ref> Large mediastinal tumours extending into both hemi-thorax and bilateral pulmonary tumours are also easily accessible via a clamshell incision.<ref>{{cite journal | vauthors = Bains MS, Ginsberg RJ, Jones WG, McCormack PM, Rusch VW, Burt ME, Martini N | title = The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor | journal = The Annals of Thoracic Surgery | volume = 58 | issue = 1 | pages = 30–2; discussion 33 | date = July 1994 | pmid = 8037555 | doi = 10.1016/0003-4975(94)91067-7 }}</ref>
* The [[Hutan Ashrafian|Ashrafian thoracotomy]]  was devised to give rapid access to the heart and pericardium through an incision that consists of an anterior thoracic incision followed in a vertical direction along the costo-chondral (rib-cartilage) junction.<ref>{{cite journal | vauthors = Ashrafian H, Athanasiou T | title = Emergency prehospital on-scene thoracotomy: a novel method | journal = Collegium Antropologicum | volume = 34 | issue = 4 | pages = 1449–1452 | date = December 2010 | pmid = 21874737 }}</ref>

Upon completion of the surgical procedure, the [[chest]] is closed. One or more [[chest tube]]s—with one end inside the opened [[pleural cavity]] and the other submerged under saline solution inside a sealed container, forming an airtight drainage system—are necessary to remove air and fluid from the [[pleural cavity]], preventing the development of [[pneumothorax]] or [[hemothorax]].

==Complications==
In addition to [[pneumothorax]], complications from thoracotomy include air leaks, [[infection]], bleeding and [[respiratory failure]].<ref>{{cite journal | vauthors = Sengupta S | title = Post-operative pulmonary complications after thoracotomy | journal = Indian Journal of Anaesthesia | volume = 59 | issue = 9 | pages = 618–626 | date = September 2015 | pmid = 26556921 | pmc = 4613409 | doi = 10.4103/0019-5049.165852 | doi-access = free }}</ref> Postoperative pain is universal and intense, generally requiring the use of [[opioid]] [[analgesic]]s for moderation, as well as interfering with the recovery of respiratory function. Paraplegia complicating thoracotomy is rare but catastrophic.<ref>{{cite journal | vauthors = Attar S, Hankins JR, Turney SZ, Krasna MJ, McLaughlin JS | title = Paraplegia after thoracotomy: report of five cases and review of the literature | journal = The Annals of Thoracic Surgery | volume = 59 | issue = 6 | pages = 1410–5; discussion 1415–6 | date = June 1995 | pmid = 7771819 | doi = 10.1016/0003-4975(95)00196-R | doi-access = free }}</ref><ref>{{cite journal | vauthors = Brodbelt AR, Miles JB, Foy PM, Broome JC | title = Intraspinal oxidised cellulose (Surgicel) causing delayed paraplegia after thoracotomy--a report of three cases | journal = Annals of the Royal College of Surgeons of England | volume = 84 | issue = 2 | pages = 97–99 | date = March 2002 | pmid = 11995773 | pmc = 2503802 }}</ref>

In nearly all cases, one or more [[chest tube]]s are placed. These tubes are used to drain air and fluid until the patient heals enough to take them out (usually a few days).  Complications such as [[pneumothorax]], [[tension pneumothorax]], or [[subcutaneous emphysema]] can occur if these chest tubes become clogged.<ref>{{cite journal | vauthors = Javadpour H, Sidhu P, Luke DA | title = Bronchopleural fistula after pneumonectomy | journal = Irish Journal of Medical Science | volume = 172 | issue = 1 | pages = 13–15 | date = 2003 | pmid = 12760456 | doi = 10.1007/BF02914778 | s2cid = 37409582 }}</ref>  Furthermore, complications such as pleural effusion or [[hemothorax]] can occur if the chest tubes fail to drain the fluid around the lung in the pleural space after a thoracotomy.<ref>{{cite journal | vauthors = Light RW, Macgregor MI, Luchsinger PC, Ball WC | title = Pleural effusions: the diagnostic separation of transudates and exudates | journal = Annals of Internal Medicine | volume = 77 | issue = 4 | pages = 507–513 | date = October 1972 | pmid = 4642731 | doi = 10.7326/0003-4819-77-4-507 }}</ref>  Clinicians should be on the look out for [[chest tube]] clogging as these tubes have a tendency to become occluded with fibrinous material or clot in the post operative period, and when this happens, complications ensue.

Pain following a thoracotomy may be treated by the use of a [[nerve block]] known as a [[rhomboid intercostal block]].<ref name="Ökmen">{{cite journal | vauthors = Ökmen K | title = Efficacy of rhomboid intercostal block for analgesia after thoracotomy | journal = The Korean Journal of Pain | volume = 32 | issue = 2 | pages = 129–132 | date = April 2019 | pmid = 31091512 | pmc = 6549589 | doi = 10.3344/kjp.2019.32.2.129 }}</ref> In the long term, post-operative chronic pain can develop, known as thoracotomy pain syndrome, and may last from a few years to a lifetime. Treatment to aid pain relief for this condition includes intra-thoracic nerve blocks/opiates and [[epidural]]s, although results vary from person to person and are dependent on numerous factors. A recent [[Cochrane review]] concluded that there is moderate-quality evidence that [[regional anaesthesia]] may reduce the risk of developing persistent postoperative pain three to 18 months after thoracotomy.<ref>{{cite journal | vauthors = Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH | display-authors = 6 | title = Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children | journal = The Cochrane Database of Systematic Reviews | volume = 6 | issue = 6 | pages = CD007105 | date = June 2018 | pmid = 29926477 | pmc = 6377212 | doi = 10.1002/14651858.CD007105.pub4 }}</ref>

==VATS==
[[Video-assisted thoracoscopic surgery]] (VATS) is a less invasive alternative to thoracotomy in selected cases, much like [[laparoscopic surgery]]. There are lesser postoperative complications and better long-term survival following VATS lobectomy compared to open thoracotomy lobectomy for NSCLC. VATS lobectomy does not compromise patient safety or the oncological efficacy.<ref>{{cite journal | vauthors = Al-Ameri M, Bergman P, Franco-Cereceda A, Sartipy U | title = Video-assisted thoracoscopic versus open thoracotomy lobectomy: a Swedish nationwide cohort study | journal = Journal of Thoracic Disease | volume = 10 | issue = 6 | pages = 3499–3506 | date = June 2018 | pmid = 30069346 | pmc = 6051874 | doi = 10.21037/jtd.2018.05.177 | doi-access = free }}</ref>

==Post-thoracotomy pain==
Thoracic epidural analgesia or paravertebral blockade have shown to be the most effective methods for post-thoracotomy pain control. However, contraindications to neuraxial anesthesia include hypovolemia, shock, increase in ICP, coagulopathy or thrombocytopenia, sepsis, or infection at puncture site. Comparing thoracic epidural analgesia and paravertebral blockade, paravertebral blockade reduced the risks of developing minor complications, however paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain.<ref>{{cite journal | vauthors = Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F | title = Paravertebral block versus thoracic epidural for patients undergoing thoracotomy | journal = The Cochrane Database of Systematic Reviews | volume = 2 | issue = 2 | pages = CD009121 | date = February 2016 | pmid = 26897642 | pmc = 7151756 | doi = 10.1002/14651858.CD009121.pub2 | collaboration = Cochrane Anaesthesia Group }}</ref> [[Transcutaneous electrical nerve stimulation]] has also shown to be useful in the management of post-thoracotomy pain. Specifically, it has been found to be a good adjunct in the management of moderate to severe post-thoracotomy pain and effective as a lone modality in mild post-thoracotomy pain (e.g. after video-assisted thoracoscopy).<ref>Ferreira, FC, et al. Assessing the effects of transcutaneous electrical nerve stimulation (TENS) in post-thoracotomy analgesia. Rev Bras Anestesiol. 2011 Sep-Oct;61(5):561-7, 308-10. {{doi|10.1016/S0034-7094(11)70067-8}}.</ref>

== See also ==
* [[List of surgeries by type]]

== References ==
{{reflist}}

== External links ==
* {{Commons category-inline|Thoracotomies}}

{{Respiratory system surgeries and other procedures}}

[[Category:Pulmonary thoracic surgery]]
[[Category:Thoracic surgical procedures]]
[[Category:Surgical incisions]]