Thoracotomy

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Thoracotomy
A left anterolateral thoracotomy exposing the heart and lung. A Harken retractor (rib spreader) is being used to increase visibility
ICD-9-CM	34.02
MeSH	D013908
[edit on Wikidata]

A thoracotomy is a surgical procedure to gain access into the

• Posterolateral thoracotomy is the most common and traditional approach for gaining access to the chest. It is an incision through an
  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.^[3][4]
• 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.
• The Clamshell incision or bilateral anterior thoracotomy with transverse sternotomy is the incision of choice for bilateral lung transplantation.^[5] It is also a valuable tool in trauma settings.^[6] Large mediastinal tumours extending into both hemi-thorax and bilateral pulmonary tumours are also easily accessible via a clamshell incision.^[7]
• The 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.^[8]

Upon completion of the surgical procedure, the

In addition to pneumothorax, complications from thoracotomy include air leaks, infection, bleeding and respiratory failure.^[9] Postoperative pain is universal and intense, generally requiring the use of opioid analgesics for moderation, as well as interfering with the recovery of respiratory function. Paraplegia complicating thoracotomy is rare but catastrophic.^[10][11]

In nearly all cases one or more

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.[17] 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).^[18]

See also

• List of surgeries by type

References