Thoracotomy Types and Complications

A thoracotomy is a major surgical procedure that allows surgeons to access the chest cavity during surgery. An incision is made in the chest wall, and access to organs of the chest cavity is made by cutting through and possibly removing a portion of a rib. The procedure is performed in the operating room under general anesthesia.

Reasons to Undergo One

A thoracotomy may be done for several reasons, not just the removal of a cancer.

Opening and exposing the chest cavity and mediastinum ( the area between the lungs) can give surgeons access to the heart, lungs, esophagus, the upper part (thoracic) or the aorta, and the front (anterior part) of the spine. Some indications include:

Lung cancer surgery
Esophageal cancer surgery
Heart/aortic surgery
Chest trauma
Persistent pneumothorax (collapsed lung)
Management of COPD
Tuberculosis
Biopsy and evaluation of an unknown mediastinal mass
Surgery to the anterior spine
Resuscitative thoracotomy (emergency thoracotomy) - This is a procedure done in the emergency room for life-threatening emergencies such as chest hemorrhage

Types of Procedures

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

Posterolateral thoracotomy - This is the most common procedure and the usual method of gaining access to the lungs to remove a lung or a portion of a lung to treat lung cancer. 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.
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.

Planning and Preparation

Before having a thoracotomy you will have a careful history and physical performed, and may also have studies to check on your heart and lung function. If your thoracotomy is being done for lung cancer, it may also be important to get a second opinion. Studies suggest that people who have these surgeries done at cancer centers which perform larger volumes of these procedures may have better outcomes. For some people, a less invasive procedure known as video-assisted thoracoscopic surgery (VATS) may be used instead of a thoracotomy, but this is not available at all hospitals.

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.

Possible Complications

Some people go through a thoracotomy without experiencing any complications, whereas others may encounter one or more setbacks. It's important to talk carefully with your surgeon about your specific surgery and what to expect. Certainly, those who are healthier in general prior to the procedure will likely have an easier course than those who are coping with additional medical concerns. And as with any surgery, smoking can increase the risk of serious complications.

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
Postpneumonectomy syndrome or post-thoracotomy pain syndrome - Pain in the region of a thoracotomy may sometimes persist for a long time after surgery

Questions to Ask Beforehand

Consider asking your doctor 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 3 years from now?
Who should I call if I experience any problems after returning home?

Examples: Jim's surgeon told him he would perform a thoracotomy to gain access to his lungs and perform his lobectomy for lung cancer.

_Sources:

_{Bendixen, M., Jorgensen, O., Kronborg, C., Andersen, C., and P. Licht. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateralthoracotomy for early stage lung cancer: a randomized controlled trial. Lancet Oncology. 2016. 17(6):836-44.}

_{Fernandez, R., Kosinski, A., Burfeind, W. et al. The Society of Thoracic Surgeons Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes. Annals of Thoracic Surgery. 2016 May 19. (Epub ahead of print).}

_{Sengupta, S. Post-operative pulmonary complications after thoracotomy. Indian Journal of Anaesthesia. 2015. 59(9):618-26.}

_{University of Michigan Healthcare System. Preparing for Your Thoracotomy. http://surgery.med.umich.edu/thoracic/pdf/preparingforyourthoracotomy.pdf}