Thoracotomy: Everything You Need to Know

Thoracotomy surgery is a major procedure that surgeons perform in order to access organs in the chest cavity, for a variety of lung, heart, and related conditions such as lung cancer.

There are different types of thoracotomy, including minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS). These surgeries are done in an operating room under general anesthesia.

This article discusses the reasons for why thoracotomy surgery is done, the potential risks and complications, and questions you should ask your healthcare provider before your surgery.

Reasons for a Thoracotomy

A thoracotomy may be done for several reasons, and removal of cancer is just one of them.

Opening and exposing the chest cavity and mediastinum, an area between the lungs, can give surgeons access to major organs. These organs include the heart, lungs, esophagus, the thoracic aorta, and the front (anterior part) of the spine.

Some reasons for a thoracotomy include surgeries to treat:

• Lung cancer
• Esophageal cancer
• The heart and aorta
• Chest trauma
• Persistent pneumothorax (collapsed lung)
• COPD
• Tuberculosis
• An unknown mediastinal mass (biopsy)
• The anterior spine
• Emergencies requiring resuscitation, such as a chest hemorrhage

Types of Thoracotomy Surgery

There are several different types of thoracotomy that can be performed, depending on the reason for surgery and the condition being treated.

Posterolateral thoracotomy

This is the most common thoracic surgery procedure used to access the lungs, typically to remove part or all of a lung in lung cancer care.

An incision is made along the side of the chest towards the back between the ribs. The ribs are then spread apart (a rib may also be removed) to visualize the lungs. Surgeons may then remove a lung (pneumonectomy), a lobe of one of the lungs (lobectomy), or a smaller portion of the lung (wedge resection).

Median thoracotomy

In a median thoracotomy, surgeons make an incision through the sternum (the breastbone) to gain access to the chest. This procedure is commonly done to perform surgery on the heart, as with open heart surgery.

Axillary thoracotomy

In an axillary thoracotomy, surgeons gain access to the chest through an incision near the armpit. This is commonly done for treating a pneumothorax (collapsed lung), but may also be performed for some heart and lung surgeries.

Anterolateral thoracotomy

This procedure is an emergency procedure involving an incision along the front of the chest. It may be done following major chest trauma, or to allow direct access to the heart after a cardiac arrest.

Thoracotomy vs. VATS

Thoracotomy is a traditional approach when treating several conditions, with lung cancer accounting for at least 90% of the activity of thoracic surgery departments.

Some people may be candidates for alternative treatments, including a less invasive procedure known as video-assisted thoracoscopic surgery (VATS).

In this procedure, several small incisions are made in the chest and surgery is performed by using an inserted scope with a camera. VATS is now used to perform between 30% and 40% of lobectomies in the United States.

The VATS procedure is associated with shorter recovery times and fewer pain-related complications. This may lead to improved outcomes, because VATS may limit the effects on breathing that lead to atelectasis (collapsed lung) or pneumonia when compared with thoracotomy.

What to Expect 

Before having a thoracotomy, your healthcare provider will complete a careful medical history and physical examination.

It's likely they will order tests, such as a pulmonary function test, to assess your lung health. They also may order blood, imaging, and other tests to evaluate heart function.

The Procedure

A thoracotomy is usually performed under general anesthesia in the operating room. A long incision is made along one side of the chest, and the ribs are separated to gain access to the chest.

Throughout the procedure, vital signs are carefully monitored to make sure you are tolerating the procedure well. When the surgery is completed, a chest tube is usually placed in the chest cavity and left in place for a period of time.

Questions to Ask Beforehand 

Consider asking your healthcare provider the following questions, and write down other questions you may have.

• Who will be performing the surgery?
• How many of these procedures have you done?
• What are some complications I may expect?
• How long will the procedure take?
• How long will I likely be in the hospital after the surgery?
• How quickly can I return to work?
• Do you recommend that I have pulmonary rehabilitation after surgery?
• What can I expect over the long term, say, a year from now or three years from now?
• Who should I call if I experience any problems after returning home?

After Thoracotomy Surgery

After a thoracotomy surgery, you are likely to experience pain at the site of the procedure for several days to a few weeks. Your healthcare provider likely will prescribe medication to treat thoracotomy surgery pain.

Your pain is likely to occur when taking deep breaths, so breathing exercises also may be recommended. This will help you to recover while preventing the development of pneumonia. You'll also need to protect the affected area with a pillow or other splinting when you need to cough.

Complications

Complications after thoracotomy surgery are not uncommon, but overall health and other factors, such as smoking, may contribute to their development.

The risk of complications also depends on the type of procedure and technique, whether VATS or open thoracotomy. For example, one common complication is postpneumonectomy syndrome, also called post-thoracotomy pain syndrome. This involves pain at the thoracotomy site that persists for a long time after surgery.

One study of 311 people who had thoracotomy surgery found improvement with this complication when a specific surgical technique was used instead of the traditional method of closing the chest wall to complete the surgery.

It's important to talk with your surgeon about your specific surgery and what to expect. Some possible side effects and complications of a thoracotomy may include:

• Prolonged need for ventilatory assistance after surgery
• Persistent air leak resulting in a prolonged need for a chest tube after surgery 
• Infection
• Bleeding
• Blood clots - Deep vein thrombosis (blood clots) and pulmonary emboli (blood clots that break off and travel to the lungs) are a common and serious complication of chest surgery.
• Complications of general anesthesia
• Heart attack or arrhythmias
• Vocal cord dysfunction or paralysis
• Bronchopleural fistula - This is a complication in which an abnormal passageway forms between a bronchial tube and the space between the membranes (pleura) lining the lungs.
  

A Word From Verywell

A thoracotomy is a major surgery that gives surgeons access to the chest cavity, and may be done for a number of reasons. Newer and less invasive procedures are replacing some of the thoracotomies done in the past, but are still often needed in certain situations.