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. There are different types of thoracotomy as well as newer minimally invasive alternatives such as video-assisted thoracoscopic surgery. Learn about why a thoracotomy may be done, the potential risks and complications, and questions you should ask your doctor before your surgery.

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

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.

Before having a thoracotomy you will have a careful history and physical performed. Your doctor may also recommend that you have tests done to evaluate your lung function (pulmonary function tests), as well as your heart. If your thoracotomy is being done for lung cancer, it may also be important to get a second opinion. If you smoke, even quitting for a day or two (though longer is ideal) may reduce your risk of complications.

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. In this procedure, several small incisions are made in the chest and surgery is performed by inserted a scope with a camera. VATS may be used even for some larger procedures such as a lobectomy, but cannot be performed in all locations.

The recovery is usually more rapid with a VATS procedure, as long as it is done by a surgeon with significant experience, and a 2016 study found that people experienced less postoperative pain with a VATS procedure than an anterolateral thoracotomy. Since outcomes of lung cancer surgery are better at cancer centers that perform a large volume of these surgeries, a second opinion at a National Cancer Institute designated cancer center may be a good idea before scheduling your surgery.

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.

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.

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.

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 thoractomies done in the past, but are still often needed in certain situations.