Overview of Thoracotomy
A thoracotomy is a surgical procedure where a cut is made in the chest wall to reach the organs inside the chest. There are two main types of this surgery, known as anterolateral and posterolateral thoracotomies. They can be performed either above or below the breast, and on either the right or left side of the chest. The type of thoracotomy used depends on the specific situation and needs of the patient.
Anatomy and Physiology of Thoracotomy
The chest area, also known as the thoracic cavity, is home to important body parts like the heart, large blood vessels, lungs, food pipe, and windpipe. The chest area is enclosed by the upper chest opening at the top, the big muscle used for breathing at the bottom, the breastbone in the front, and the backbones at the back.
Inside, the chest area can be divided into smaller parts called the pleural cavities and the mediastinum. The mediastinum is located in the middle of the chest area. It contains the heart, the large blood vessels, the thymus (a gland in your neck that helps with your immune system), the food pipe, and the windpipe. The pleural cavities are the areas that contain the lungs themselves.
For this explanation, it’s important to note that most of the heart is located in the middle and a little to the left within the chest area.
Why do People Need Thoracotomy
A thoracotomy, which is a surgical procedure in which a cut is made in the chest wall, is often used to treat a variety of conditions related to the aorta, heart, esophagus, and lungs. Some of these conditions that might require a thoracotomy include issues with the lower part of the thoracic aorta like dissections, ruptures, or aneurysms, which are swollen or bulging parts of the aorta.
There are also certain heart-related issues that might require a thoracotomy. These may include congenital heart defects like an atrial septal defect (a hole in the part of the heart that separates the two upper chambers), problems with the aortic, mitral, or tricuspid valves of the heart, certain locations of coronary artery disease (disease of the blood vessels that supply blood to the heart), diseases of the pericardium (the sac that surrounds the heart), and specific types of tumors in the heart and pericardium (the membrane that surrounds the heart).
While many of these heart-related conditions can also be treated with a surgery called a median sternotomy, which involves a cut down the middle of the chest, a thoracotomy might be chosen instead if the median sternotomy is thought to be risky. This includes cases where a person has previously had a sternotomy and needs another one, as these situations are often considered to carry a higher risk.
Pulmonary diseases, which are diseases of the lungs, can also be treated with a thoracotomy. Previously, this type of surgery was commonly performed using video-assisted thoracoscopic surgery (VATS), however, a thoracotomy can also be a chosen approach. Conditions that might require this type of surgery can include lung cancers (both primary, which starts in the lungs, and metastases, which spreads to the lungs from other parts of the body), cancers of the lining of the lungs (pleural malignancies), collapsed lungs (pneumothoraces), or infections in the lungs (empyema).
Esophageal diseases, which are conditions that affect the esophagus (the tube that connects the throat and the stomach), can also be treated with a thoracotomy. These might include esophageal cancer in adults or abnormal connections between the trachea and esophagus in infants (tracheoesophageal fistulas). Depending on the part of the esophagus that is affected, the surgeon might decide to make the cut on the right side of the chest (best for diseases that affect the middle part of the esophagus) or the left side of the chest (which might provide better access to the lower part of the esophagus). In some cases, a trans-hiatal approach might be used, which involves a cut made in both the chest and the abdomen.
When a Person Should Avoid Thoracotomy
There are certain conditions that can make thoracotomy (a surgical procedure to open the chest) either not recommended or possibly unsafe. These can be straightforward or they can depend on the situation. A person who has already had thoracotomy surgery in the same location may be at risk because going back into that same area could be dangerous. Also, the procedure might not be advisable for people who are too weak or unwell to handle the effects of anesthesia, which is a medicine that helps you sleep and not feel pain during surgery. Lastly, thoracotomy may not be recommended if the patient is not expected to benefit from the surgery.
Equipment used for Thoracotomy
For a surgical procedure such as a thoracotomy, which opens up the chest wall, various tools are needed. These include a scalpel (a small, sharp knife used in surgeries), long curved Mayo scissors (used for cutting), Finochietto retractor (a device to hold open the wound or incision), long curved Metzenbaum scissors (used for more delicate tissue dissection), long tissue forceps (tweezers for grasping tissue), curved hemostats (clamp-like tools for controlling bleeding), electrocautery (device that uses heat to stop bleeding), and toothed forceps (used for holding tissue firmly).
There may also be additional tools and equipment needed, depending on what needs to be done after the chest has been opened. For example, if a lung needs to be repaired or removed, there will be other, specific tools needed for that. Unfortunately, this article does not include a list of those additional tools.
One thing to note is that all equipment that might be needed should be available prior to the surgery. This ensures that everything runs smoothly during the procedure and that there are no delays while waiting for necessary surgical tools.
Who is needed to perform Thoracotomy?
A thoracotomy, which is a surgical procedure on the chest, involves a team of healthcare professionals. This includes a surgeon, who is the chief doctor performing the surgery. An anesthesiologist, who is responsible for making sure you are asleep and not feeling pain during the surgery. Also, there’s a scrub nurse or technician, who aids the surgeon by providing necessary tools and keeping the surgical area clean. Additionally, a circulating nurse is there to manage the overall nursing care in the operating room.
Sometimes, there may be other people like a surgical assistant who helps the surgeon, and a resident or fellow who are trainee doctors gaining practical experience in surgeries. All these professionals work together to ensure your surgery goes smoothly and you recover well.
Preparing for Thoracotomy
Before a chest surgery, or thoracotomy, doctors need to assess a patient’s health and the specifics of their illness. This is true unless the surgery is deemed urgent, in which case the pre-surgery check may be less elaborate. Medical images such as X-rays can greatly help the doctors while deciding the best method of surgery. Doctors might also look at any previous surgeries the patient may have had.
What follows next is the positioning of the patient for the surgery. There are different ways to position a patient depending on the type of thoracotomy, which can be above the breast from the side (supra-mammary anterolateral), below the breast from the side (infra-mammary anterolateral), or from the side and back (posterolateral).
A crucial step before any surgery includes filling out a pre-surgery checklist. Also, it’s important for the patient’s skin to be cleaned from the chin down to the toes. This is done by using either an iodine solution or a chlorhexidine gluconate solution to help prevent infection.
How is Thoracotomy performed
To explain simply, a supra-mammary anterolateral thoracotomy is a type of surgical procedure performed on your chest area. In preparation for the procedure, you’ll be positioned on your side, slightly elevated at about 30 to 45 degrees. The arm on the side of your body to be operated on will be positioned at your side. The surgeon makes an incision between your second and third ribs along the top edge of the third rib.
Next, you have two muscles, called the pectoralis major and minor, which are separated using a device that uses heat to cut tissues (electrocautery). There’s a bundle of nerves and blood vessels (neurovascular bundle) running along the bottom edge of your ribs. To avoid harming this, muscles between your ribs (intercostal muscles) are separated along the top edge of your rib. At this point, the third rib can be separated from your breastbone using a sort of power saw and moved to provide a better view. Alternatively, a thoracoscope, a medical tool equipped with a mini-camera, can be used instead of moving the rib.
A key point is that a blood vessel called the internal mammary artery needs to be located and sealed off to prevent unwanted bleeding. For a submammary anterolateral thoracotomy, the process is the same except that the initial cut along the skin is made under the breast fold, over the fifth rib, instead of between the second and third ribs.
Another type of procedure is the posterolateral thoracotomy, for which, you’ll be positioned on your side. Your arm on the surgical side is lifted and positioned in front of your head. The surgeon then makes an incision starting from under the breast fold and moves under the shoulder blade’s tip. It’s then further extended a short distance between the spine and the edge of the shoulder blade. Two muscles are identified and moved aside (retracted). The surgeon then enters the chest cavity.
In some cases, a vertical cut may be made on the side for a muscle-preserving thoracotomy. Here, you’ll be lying on your side and your arm is raised to 90 degrees. The surgeon makes a vertical cut just under the armpit going down to the ninth space between your ribs. Soft tissues are then separated to visualize the muscle borders. They will then retract a particular muscle called latissimus dorsi to the back. Next, a muscle called serratus anterior is detached from the ribs until there’s enough exposure. The surgeon then separates more muscles and applies a rib spreader to widen the space.
Possible Complications of Thoracotomy
After a surgery known as thoracotomy (an incision into the chest wall), some people may experience complications. These can include bleeding, infection, pneumothorax (collapsed lung), pleural effusion (fluid accumulation around the lungs), shoulder dysfunction, and persistent pain.
Bleeding can be severe and may happen during the surgery if the group of nerves and blood vessels along the bottom part of the ribs is damaged. It can also be a major issue if the internal mammary arteries – blood vessels located near your chest wall – are not properly recognised during a specific thoracotomy approach.
Infections, too, are a possibility, affecting the cut from the surgery, leading to pneumonia (a lung infection), or causing empyema (pus in the space between the lung and chest wall). If the covering of the lung (pleura) or lung tissue gets damaged during surgery, it can lead to a pneumothorax, or collapsed lung. Pleural effusions, excess fluid collection around the lungs, are also a possibility, though doctors try to lower this risk by leaving in drainage tubes after the surgery.
You can expect to feel pain at the site of the cut after a thoracotomy, but if the surgeon damages the nerves and blood vessels when accessing or closing the thoracic (chest) cavity, this can lead to more severe persistent pain. Shoulder dysfunction can happen if nerves, blood vessels, and muscles are cut during the incision. Pain from the cut may cause people to limit their breathing and coughing, which in turn can increase the risk of getting an infection.
What Else Should I Know About Thoracotomy?
Many patients who need a thoracotomy, which is a surgical procedure in the chest area, often have multiple existing health problems and may be weaker or more fragile. These types of chest surgeries can significantly lower their heart and lung function, making them more likely to experience issues after the surgery and increasing their chances of serious illness or even death.
It is crucial to remember this when taking care of a patient who’s undergone thoracotomy. Even the smallest details in their care can significantly impact their health outcomes. This means that their recovery process and any follow-up treatment need to be tailored carefully to prevent complications, ensure their comfort, and improve their overall health after the surgery.