THORACOTOMY

T.SUNIL KUMAR
• Thoracotomy is the most common approach
used in any lung and for closed heart surgery.

Definition
• Thoracotomy is the process of making of an
incision into the chest wall to gain access to
the chest cavity. Reasons for the entry are
varied.
• Thoracotomy allows for visual study of the
condition of the lungs; removal of whole 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
 Types and Description
Thoracotomy incisions can of three types:

1. Standard or posterolateral axillary thoracotomy—

commencing at the costovertebral margin, commonly
passing through the 4th to 8th intercostal space,
along the side of the rib cage upto the anterior
axillary fold (Posterolateral Thoracotomy)
2. Anterolateral axillary thoracotomy—
commencing from sternocostal margin passing
under the breast upto the posterior axillary fold
(Anterolateral thoracotomy)
3. Median sternotomy—on the front of the
chest, vertically through the breastbone (median
sternotomy).
Anterolateral thoracotomy median sternotomy
• The exact location of the incision depends on the
level of the lung tissue to be removed. In most cases
of lung surgeries and in case of closed heart
operation, the incision may range from just under 5
inches (12.7 cm) to 10 inches (25 cm) long and is
located at a level exactly opposite to the organ to be
operated upon.
• Median sternotomy splits the sternum vertically into
two halves and is the incision of choice in case of
open heart and mediastinal surgeries
• During thoracotomy, a tube is passed through
the trachea up to the bronchial division, to
keep the airway open for adequate gas
exchange through the sound lung. The
affected lung is deflated for examination and
surgery, while the sound one is inflated with
the assistance of a mechanical positive
pressure ventilator
• Once the surgical procedure is completed, the
chest wall is closed in layers.
• The layers of skin, muscle, and other tissues
are closed with stitches or staples. If the
sternum is divided vertically, as in the case of a
median sternotomy, it is stitched back
together with steel wire or staples
Common Indications for Thoracotomy

• Thoracotomy is most frequently done to treat

lung cancer. Tumors and metastatic growths
localized in a small area of the lung can be
removed through this incision by a procedure
called segmental resection
• A tissue sample from a lung tumor, can also be
taken through this incision, and examined
under a microscope for evidence of abnormal
cells. This procedure is called a wedge
resection. In case lung cancer is detected in
the biopsy, the whole lobe (Lobectomy) or the
whole lung (pneumonectomy) may be
performed through similar incision.
• Thoracotomy is also indicated for removal of
consolidated and fibrosed lung lobe following
severe unresolved lobar pneumonia.
• Thoracotomy may also be used to resect a
section of distorted airway along with its
attendant lung segment in cases with severe
bronchiectasis with persistent infection. This
surgery is called sleeve resection.
• A resuscitative or emergency thoracotomy may
sometimes 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 stab-injury related bleeding
from the heart, or to relieve pressure on the heart
caused by cardiac tamponade—an accumulation
of blood in the pericardial space, leaking through
sutures on the heart wall after open heart surgery.
• 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
manually to restart pumping; the surgeon 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 restart
the heart beat. Injuries to the heart wall
causing the bleeding may be closed with
either staples or stitches.
 Preoperative Preparation
• Patients are told not to eat after midnight
before surgery. This is important because
vomiting during surgery, while under GA, can
cause serious complications or death. For
surgeries in which a general anesthesia is
used, the gag reflex is often lost for several
hours, making it much more likely that food
particles will enter the lungs if vomiting occurs
(Aspiration).
• Preanesthetic check should provide all
information about all known allergies so that
the safest anesthetics can be selected.
• Older patients must be evaluated for pre-
existing heart ailments before surgery to
assess the ability of their heart to cope with
additional strain of surgical shock.
 Preoperative Physiotherapy
• All candidates for cardiothoracic suregry and
smokers in particular, need to be evaluated
thoroughly regarding their pulmonary
competence and respiratory reserve. This is
usually done on an outpatient basis, much before
the surgery by the physiotherapist attached to
the cardiothoracic surgery team.
• Pre-existing COPD needs to treated and
respiratory function optimized well before the
operation through extensive respiratory
physiotherapy.
• Any pre-existing disorder such as periarthritis
of the shoulder on the side to operated needs
to be addressed by the physiotherapist before
the operation.
• After the operation the shoulder movements
on the operated side is likely to be inhibited
due to pain. Any pre-existing PA will most
certainly worsened if not corrected before the
operation.
 Procedure
For a standard thoracotomy, the patient lies on his or
her side with one arm raised
• (A) an incision is marked into the skin of the ribcage,
• (B) skin and muscle layers are cut, and one or more
ribs may be removed to gain access to the cavity,
• (C) retractors hold the ribs apart, exposing the lung,
• (D) after surgery, the periosteum of cut ribs are
stiched back in place, and
• (E) new ribs will grow enetually from this periosteum.
• Layers of muscle and skin are stitched in layers to
close the wound (F).
 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
make it possible for the lungs to expand and
contract.
• If the pressure in the chest cavity changes
abruptly, the lungs can collapse. Any air or fluid
that collects in the pleural cavity puts a patient at
risk for pleural effusion, or even collapse of the
lung due to collection of air, called pneumothorax.
• Thus, any entry to the chest cavity requires that
chest drainage tubes remain in place for several
days to drain trapped air and exudate 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 major risk in lung surgeries;
a blood transfusion may become necessary
during surgery.
• General anesthesia carries inherent risks such as
nausea, vomiting, headache, unstable blood
pressure, 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
 New 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 percent of patients with a penetrating
chest wound can be successfully managed
with a thoracostomy.
 Common Surgeries of the Lungs
A number of different procedures may be
performed on the lungs through a thoracotomy
incision
• A lobectomy removes an entire lobe of a lung, the
right lung having three and the left lung two
lobes.
• Lobectomy may be done to remove a small and
localized cancer lesion that is contained by a lobe
or a consolidated lobe following lobar pneumonia.
• When only the affected lobe of the lung is
removed, the remaining healthy tissue is spared
to maintain adequate lung function.
• A segmentectomy or wedge resection,
removes a wedge-shaped piece of lung
segment that is smaller than a lobe.
• Alternatively, the entire lung may be removed
during a pneumonectomy.
• Bullectomy: After entring the thoracic cavity
using one of the thoracotomy, the whole lung
surface, particularly at the apex and the lung
edges, are carefully searched for
emphysematous bullae. Apical wedge resection
or segmentectomy may be necessary to
remove the diseased or damaged lung tissue.
This is then followed by stapling or suturing to
seal the affected area with fibrin sealant to
reduce chance of postoperative leakage of air.
• Pleurodesis: After entering the thoracic cavity,
mechanical abrasion of the pleural membrane
is done to induce intrapleural inflammation
that causes the parietal and the visceral pleura
to stick togather, obliterating the pleural
space. Without a space to become lodged, the
problem of air entrapment in repeated
pneumothorax is eliminated. Pleurodesis also
can be done chemically, though less preferred
to mechanical variety
• Pleurectomy (removal of the pleura): The
procedure may be done via a large
thoracotomy or median sternotomy or by a
small lateral incision in the fifth or sixth
intercostal space. The procedure involves the
complete removal of the pulmonary bullae
and as complete as possible stripping of the
parietal pleura.
• Exploratory thoracotomy: Opening of the
chest wall for direct visualization of the lungs
and other chest structures when there is
evidence of an abnormality or disease that has
not been verified by other diagnostic
methods.
 Common Causes for Lung Surgeries
Conditions of the lungs for which a lobectomy may be
performed include the following:
• Tuberculosis (TB)—it is a chronic bacterial infection that
usually infects the lungs, although other organs may also
be affected.
• TB is primarily an airborne disease that is spread by
droplets from infected people when they cough or
sneeze. In most cases TB is well controlled by medication.
• In case of drug resistant bacteria, TB causes destruction
of lung parenchyma resulting in formation of cavities
within the lungs. Such cavities are filled with creamy
necrotic material, usually walled off from the remaining
lung tissue by a tough fibrous wall.
• The type of surgery done for TB is called thoracoplasty.
• The purpose of such surgery is to remove the infected
lobe of the lung as completely as possible and create a
limited collapse of cavities within the lung, through
resection of ribs over the affected area, and allowing
the chest wall to collapse inwards and adhere to the
visceral pleura, eliminating the tubercular cavity in this
process, eliminating oxygen supply to any residual TB
bacterium that may have escaped resection and causes
their destruction.
• The patient is then put on a multidrug antitubercular
regime to complete the cure.
• Lung abscess—it is a localized collection of pus
following any non-tubercular infection that may
form in the lung. If the abscess does not resolve
with antibiotic therapy, it may “wall off” within a
fibrous tissue pocket within the lungs so that it
does not infect the rest of the body.
• Such surgery is done to remove this pocket of
infective material, with minimal collateral damage
to healthy lung tissue.
• Emphysema—it is a chronic illness that results from
the breakdown of the elastic fibers in the lungs,
interfering with expansion and contraction of the lungs
and formation of large cavities in the, called bullae, in
the alveolar parenchyma of the lungs. Bullae may
occasionally rupture, causing air to leak in to the
pleural space, creating a spontaneous pneumothorax.
• Though Bullae may be removed by Bullectomy,
Lobectomy may be needed sometimes to remove
damaged lung lobe completely is the cavitation is wide
spread and the loss of elastic recoil of the affected lobe
is creating problems in the expansion and contraction
of the remaining lung
• Benign tumor—it is a noncancerous mass,
occupies space and causes compression of
surrounding healthy lung issue, interfering with
lung function. The type of surgery needed to
remove this mass is either a segmental resection
or a lobectomy, depending on the size of the
tumor.
• Lung cancer—it is a group of cancers that may
affect the bronchi, one or more lobes of the lungs,
the pleural lining, and/or other lung tissue.
• In lung cancers, whenever operable, a lobe may be
removed in very early stage of the disease and in
later stages the entire lung needs to be removed in
through Pneumonectomy.
• Aim of such surgery is to remove the affected lobe
or the entire lung, along with all the lymph ducts
and glands supplying the diseased lung, to prevent
further spread of cancer.
• Fungal infections—fungi are a group of organisms
that, although rare, may cause infections in various
parts of the body, including the lungs.
• Fungal infections of lungs are diffuse, difficult to
diagnose and treat. In few cases, badly involved
lung segments in a lobe may need to be surgically
removed through lobectomy.
 Potential Complications of the Procedure
As with any surgical procedure, complications may
occur following lung surgeries. Some possible
complications include the following:
• Chest infection or generalized septicemia leading
to shock.
• Tension pneumothorax—air becomes trapped in
the pleural space, causing the lung to collapse.
• Haemorrhage.
• Bronchopleural fistula—an opening between the
bronchus and pleural space causing leakage of air
or fluid into the pleural space.
• Bronchopulmonary fistula—an opening between
the stump of a bronchus and empty pulmonary
space after pneumonectomy, causing siphoning of
surgical exudates into the healthy lung.
• Hydrothorax—collection of fluid in the pleural
space, causing the lung to collapse.
• Empyema—an accumulation of pus in the pleural
cavity.
Postoperative Care after Lung Surgeries
• After a minor procedure like thoracoscopy, most
people can go home within 24 hours after the chest
drains have been removed.
• After a major procedure like thoracotomy, the
patient may need to stay in the hospital for a week or
more depending on the extent of surgical shock and
secondary complications that may develop after the
surgery.
• After minor lung surgery, the patient will most
likely go to a general care floor for one or two
days, before being discharged. However after
major thoracic surgery, a patient may need to be
nursed in an intensive care unit until his condition
is stable.
 Pain Management
• The patient will have pain near the incision and
general soreness of the entire chest wall. Primary
aim of postoperative nursing should be to make
the patient feel as comfortable as possible.
• It is very important that the pain is managed
aggressively well, so that the patient can cough, do
deep breathing exercises, and move more easily in
the bed.
• The medicine works better if started before the
pain becomes too severe.
• Hence communication between the nurse and
patient must be frequent and the patient feedback
regrading intensity of pain must be given due
importance.
• During early recovery, an anesthesiologist may
implement any of the following two pain control
options.
• A patient controlled analgesia (PCA) pump is a
pump that releases pain medicine into patient’s
veins. The patient will be able to control the
amount of pain medicine he receives by pressing a
button.
• An epidural catheter may be placed in the spine
and delivers a constant amount of pain medicine.
• Once eating and drinking, the patient will be able
to take pain killers by mouth.
• The physiotherapist may apply TENS along the suture
line. This is very effective in controlling postoperative
pain. The TENS can be started on a patient
immediately after surgery.
• This however should be done in consultation with the
surgeon or the intensivist in charge of the patient.
• Therapeutic measures such as breathing exercises
and assisted coughing must be done only after
adequate analgesia has been achieved, because if the
patient feels pain while doing exercises he is not likely
to cooperate with the therapist.
 Care of Drainage Tubes and Catheters after Surgery
The patient may have a variety of tubes, drains, and
equipment attached to the body immediately after
surgery.
• Drainage tubes: In thoracotomy, a pair of chest
drainage tubes are placed within the pleural cavity
on completion of surgery.
• When the surgeon opens the chest wall, the
normal negative intrapleural pressure, which keeps
the lung expanded, is lost.
• To reinflate the lung, a chest tube is put in the
upper part of pleural space (apical drain), between
the lung and chest wall linings, to draw out the
trapped air.
• The other tube is placed at the base of the pleural
cavity (basal drain) to collect blood and secretions
that ooze out after the surgery.
• Both tubes are hooked to drainage bottles that
collect trapped air, fluid and blood.
• Traditionally, under water sealed drainage system,
under suction, is used for draining trapped air and
fluid from the pleural space.
• The drainage tubes, with glass end piece, end
under water within drainage bottles, connected to
suction by another glass tube above water.
• Suction helps to draw out the air trapped in the
pleural space. The water in the bottle prevents air
from re-entering the chest cavity. This type of
drainage bottles are placed on the floor below the
hospital bed to allow the gravity to draw out the
surgical exudates.
How to do Self-care of the Lungs?
• The patient must be encouraged to deep breathe,
cough, and use the ‘lung exerciser’ called an incentive
spirometer as frequently as he can. This helps toning
muscles of inspiration, open up the alveoli in the
lungs and keeps airways clear of secretions.
How to Restore Normal Activity?
• It is important that the patient becomes active as
soon as possible, since this is the best antidote for
most of the secondary complications.
• The physiotherapist is the key person in planning
the return of the patient to fullest possible activity.
However the extent of activity allowed will depend
on the clinical background of the patient and
presence of any complication.
• Usually on the day of surgery, the patient will be
allowed to sit up in bed.
• The 1st postoperative day the patient may be
allowed out of bed to walk a few steps around the
bed.
• On the 2nd postoperative day he may be allowed to
walk within the ward.
• From 3rd day onwards he walks longer and longer
distances, till by the time stiches are removed and he
goes home on 7th–10th day, he should be able to
walk in the hall 3–4 times a day, as well as climb up
and down one flight of stairs.
 Care at Home
• Care of the incision,
• Management of pain,
• Maintain activity level and
• Self care.
 Common Surgeries of the Heart
Most common surgeries of the heart in an adult
concern with the:
• Removal of a blockage in the coronary arteries and
restoring normal circulation
• Repair and replacement of defective heart valves
• Transplanting a severely damaged heart with a
healthy heart from a recently dead individual
In children heart surgeries are done mostly to:
• Repair congenital defects in the heart septa
(muscular partitions between chambers of the
heart)
• Dilate narrowed heart valves
• Correct malposition of the great vessels (the aorta
and the vena cava) of the heart
Thank You