Thoracotomy is the process of making of an incision (cut) into the chest wall.
Purpose
A physician gains access to the chest cavity by cutting through the chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the condition of the lungs, or removal of a lung or part of a lung, removal of a rib, and examination, treatment or removal of any organs in the chest cavity. Thoracotomy also gives access to the heart, esophagus, diaphragm and the portion of the aorta that passes through the chest cavity (thorax).
Lung cancer is the most common cancer for which a thoracotomy is necessary. Tumors and metastatic growths can be removed through the incision. A biopsy, or tissue sample for study, can also be taken through the incision.
Precautions
Patients must tell their physicians about all known allergies so that the safest anesthetics can be selected for the surgery. Older patients must be evaluated for heart ailments (usually with an electrocardiogram) before surgery because the anesthesia, as well as the thoracotomy, put an additional strain on the heart.
Description
The chest cavity can be entered from the side (laterally) or the front (also known as anterior or sternal aspect) or the back (also known as posterior aspect). The exact place in which the cut is made depends on why the surgery is being done. In some cases, the physician is able to make the incision between ribs (called an inter-costal approach) to minimize the cuts through bone, nerves and muscle.
The incision is quite long, about seven inches. During the surgery, a tube is passed through the trachea. It
usually has a branch to each lung. One lung is deflated so that it can be examined or surgery performed on it. The other lung remains expanded, and the patient breathes with the assistance of a mechanical device (a ventilator).
The pressure differences that are set up in the thoracic cavity by the movement of the diaphragm (the large muscle at the base of the thorax) make it possible for the lungs to expand and contract. The phases of expansion and contraction move air in and out of the lungs. If the pressure in the chest cavity changes abruptly, the lungs can collapse. Any fluid that collects in the cavity puts a patient at risk for infection and for reduced lung function, even collapse (pneumothorax). Thus, any entry to the chest usually requires that a chest tube remain for several days after the incision is closed.
Preparation
Patients are told not to eat after midnight the night before, or at least 12 hours before surgery. The advice is important because vomiting during surgery can cause serious complications and death. For surgery in which a general anesthetic is used, the gag reflex is often lost for several hours or longer, making it much more likely that food will enter the lungs if vomiting occurs.
Aftercare
Opening the chest cavity means cutting through muscle, nerves and often, ribs. It is a major procedure. Consequently, it most often involves a hospital stay as long as 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 first two days after surgery may be spent in the intensive care unit 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, or uncontrolled bleeding, a risk. General anesthesia is required in most cases, and carries a risk, particularly unanticipated 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 a chest tube is removed, a patient is vulnerable to lung collapse (pneumothorax). Physicians aim 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 and coughing should be emphasized as an important way patients can help themselves and prevent pneumonia.
