Overview of Thoracotomy
A thoracotomy is a type of surgery where a cut is made in the chest wall to reach inside the chest cavity. This procedure can be categorized into two types – anterolateral thoracotomies and posterolateral thoracotomies. To make these terms simpler, “anterolateral” means the cut is made towards the front side and side of the chest, while “posterolateral” means towards the back side and side of the chest.
These types can be further broken down into supra-mammary and infra-mammary, which just means whether the cut is made above (supra-) or below (infra-) the breast area. And, obviously, this surgery can be performed on either the right or left side of the chest. Each type of cut is chosen based on the specific situation or the part of the chest that needs to be accessed during the surgery.
Anatomy and Physiology of Thoracotomy
The chest area, known as the thoracic cavity, contains several critical organs such as the heart, large blood vessels, lungs, esophagus (the tube that connects your throat to your stomach), and trachea (the tube that allows air to pass to your lungs). This cavity is confined by the opening at the top of your rib cage, the diaphragm at the bottom, the sternum or breastbone in the front, and the vertebral bodies or spine at the back.
The thoracic cavity can be divided into smaller sections, specifically the pleural cavities and the mediastinum. The mediastinum is a compartment in the middle of the chest cavity that houses the heart, large blood vessels, thymus (a small organ that makes white blood cells), esophagus, and trachea. On the other hand, the pleural cavities are spaces that envelop your lungs.
It’s worth noting in this context that most of the heart is located in the middle and slightly to the left within the chest cavity.
Why do People Need Thoracotomy
A thoracotomy is a type of surgery performed to treat various health conditions. It involves a large incision in the chest to access the heart, lungs, esophagus, and aorta. This surgical procedure is common for certain types of problems with the aorta (the main artery that carries blood from your heart to the rest of your body’s organs), heart, lungs, and esophagus.
For the aorta, a thoracotomy may be necessary if you have an aortic dissection (a serious condition where the inner layer of the aorta tears), rupture (a burst in the aorta), or aneurysmal disease (a bulging or ballooning part on the aorta).
Various heart problems may also call for a thoracotomy, including defects that are present from birth like a hole in the heart (atrial septal defect), irregularities in the aortic, mitral, or tricuspid valves (the “doors” that control blood flow in the heart), specific locations of coronary artery disease (blockages in the arteries that supply blood to your heart), disease affecting the pericardium (the sac that surrounds your heart), and certain heart and pericardium tumors (abnormal growth). If redoing a different surgery called a sternotomy (a type of surgery where an incision is made along the middle of the chest) is risky, a thoracotomy could be a safer option.
For lung problems, a thoracotomy can be used similarly to a procedure called video-assisted thoracoscopic surgery (VATS). These problems can include lung cancer, whether it originated in the lung (primary) or spread from other parts of the body (metastasis), cancer that has spread to the lung’s lining, lung collapses (pneumothoraces), or lung infection/abscess (empyema).
Esophageal issues that might be addressed through a thoracotomy include esophageal cancer in adults and congenital conditions like a tracheoesophageal fistula (an abnormal connection between the trachea and esophagus) in infants. Depending on the location of the problem in the esophagus, the incision might be made on the right or left side of your chest. In some cases, the surgeon might access the esophagus from a lower part of the chest, a method known as a trans-hiatal approach.
Overall, a thoracotomy is a versatile surgical procedure that can be performed to address various health conditions related to the major organs housed within the chest.
When a Person Should Avoid Thoracotomy
There are some reasons why a person might not be able to have a thoracotomy surgery, which is a surgery where a doctor makes a large incision in the chest. These reasons can depend on the person’s medical condition and the specific situation.
If a person has already had one of these surgeries in the same spot before, they may not be able to have another one, because it could be too dangerous to go back into the same area.
If a person is too weak or unwell to go through anesthesia, which is the medicine that makes you sleep during the surgery, they may not be able to have a thoracotomy.
Finally, if the surgery would not help improve the person’s health or their condition, then it may not be the right option for them.
Equipment used for Thoracotomy
For a thoracotomy, which is a surgical procedure to access parts inside the chest, certain medical tools must be present. This includes a scalpel, which is a small surgical knife, long curved Mayo scissors, and a Finochietto retractor, an instrument used to hold open the incision. In addition, long curved Metzenbaum scissors, long tissue forceps, and curved hemostats, which are tools used to control bleeding, are required. The surgical team also uses electrocautery, a device that uses electric current to cut and coagulate tissue, and toothed forceps, that are used for gripping.
Other materials may be needed based on what is planned for the operation after the thoracotomy but are not listed here. It’s crucial that all anticipated equipment needed for the surgery is available before starting the procedure. By having all the necessary tools on hand, this ensures the surgery can proceed safely and efficiently.
Who is needed to perform Thoracotomy?
A set of specialized medical professionals are necessary for a procedure known as a thoracotomy, which is a surgical operation to open the chest. This team involves a surgeon, who is the one who actually performs the operation, an anesthesiologist, who is responsible for making sure you are asleep and pain-free during the operation, and nurses who fall into two categories: a scrub nurse or tech, who assist the surgeon during the operation, and a circulating nurse, who helps in the operating room but does not directly assist in the surgery. Sometimes, other team members like a surgical assistant, resident, or fellow may also be present to aid in your care.
Preparing for Thoracotomy
Before a patient has surgery involving the chest (or thoracotomy), the doctor needs to consider the patient’s specific health condition and any potential challenges. This process is called a preoperative evaluation. However, in emergency cases, this evaluation may not be as comprehensive.
Imaging (like x-rays or scans) can play a big role in helping the doctor decide the best surgical approach, whether to do a thoracotomy (a surgical cut in the chest) or sternotomy (a surgical cut in the middle of the chest). This is especially helpful for patients who’ve already had sternotomy surgeries.
Depending on the surgery, the patient may be positioned differently on the operating table. This includes places like supra-mammary anterolateral thoracotomy (a cut above the breast on the side), infra-mammary anterolateral thoracotomy (a cut below the breast on the side), and posterolateral thoracotomy (a cut on the back and side).
Before the surgery, it’s important for the surgical team to make sure all the necessary steps have been followed and that the patient’s skin has been cleaned properly. This includes cleaning the skin from the chin to the toes using either an iodine or chlorhexidine gluconate solution, which are special solutions used to clean the skin and prevent infection during surgery.
How is Thoracotomy performed
There are three types of surgical procedures: supra-mammary anterolateral thoracotomy, submammary anterolateral thoracotomy, and a muscle-sparing thoracotomy. All of these procedures require the patient to be placed on their side with their arm at their side.
The supra-mammary anterolateral thoracotomy begins with an incision between the second and third ribs. The two major chest muscles are divided with an electrical device that cuts and coagulates tissue. A special tool may be used to detach and move the third rib for a better view of the area the surgeon is operating on. During the procedure, the surgeon must take care not to damage the nerve, artery, and vein bundle that runs along the lower edge of the rib cage to prevent bleeding and maintain a clear view of the surgical area.
The submammary anterolateral thoracotomy also starts with the patient positioned on their side. A knife is used to divide the skin along the breast crease. Then an electrical device is used to divide the chest and side muscles. In this procedure, the surgeon divides one of the spaces between the ribs to access the chest cavity. The surgeon needs to be very careful during this process to avoid harming the nerve, artery, and vein that run along the rib.
The muscle-sparing thoracotomy requires the patient to be positioned on their side, with their arm lifted and positioned above their head. The incision starts along the breast crease and extends to a point below the tip of the shoulder blade. It is then extended upward between the spine and the edge of the shoulder blade. The shoulder and back muscles are divided with an electrical device. The chest muscle is then divided along the upper border of the ribs to access the chest cavity. In another approach, a vertical mid-side incision may be made. This procedure involves more cutting, but spares the muscles which can reduce recovery time.
Regardless of the type of surgery, the goal is to protect the nerve, artery, and vein bundle that run along the rib. This helps to prevent potential complications such as bleeding and nerve damage.
Possible Complications of Thoracotomy
After having a thoracotomy, a surgery involving a large cut in the chest, there can be several complications including bleeding and infections. Bleeding occurs if the blood vessels and nerves under the ribs are accidentally damaged during the surgery, making it a potentially serious issue. It can also be problematic during certain surgical approaches if certain arteries aren’t correctly identified.
Infection can occur in different areas such as the surgery site itself, or in the lungs causing pneumonia or in the chest cavity creating pus (empyema). Other possible complications include pneumothorax, which happens when the lung or its surrounding membrane gets punctured causing the lung to collapse. Another issue is pleural effusion, where excess fluid builds up in the chest cavity. Doctors usually leave drainage tubes after thoracotomy to help avoid this.
Pain and shoulder dysfunction are also possible complications after the surgery. Pain, though generally expected after surgery, can be considered a complication if there’s damage to the nerves while opening or closing the chest. Long-lasting pain, known as post-thoracotomy pain syndrome, is when the pain near the surgical site doesn’t go away even after two months from the operation. Shoulder dysfunction tends to occur when bundles of nerves or muscles get cut during the surgery. Pain can make it hard for a patient to take deep breaths or cough, which in turn can increase their risk of infections.
What Else Should I Know About Thoracotomy?
Most patients who need a non-emergency surgical procedure involving an incision in the chest (thoracotomy), whether for heart or lung-related surgeries, often have multiple health conditions and may be weaker. These surgeries could significantly lower their heart and lung capacity, which increases the risk of complications after the surgery. This could lead to a higher chance of illness or even death.
It’s very important to remember this when taking care of someone who has had a thoracotomy. Each detail in the patient’s care can greatly impact their recovery. So, it’s important to be thorough and careful to ensure the patient gets better as quickly and safely as possible.
