Thoracotomy

The principal indications for thoracotomy are:

• Lobectomy

• Pneumonectomy

Both lobectomy and pneumonectomy are performed most commonly to treat lung cancer.

Video-assisted thoracoscopic surgery has largely replaced thoracotomy for open pleural and lung biopsies.

Contraindications to thoracotomy are those general to surgery and include:

• Acute cardiac ischemia

• Bleeding disorder or anticoagulation that cannot be corrected

• Instability or insufficiency of major organ systems

Four basic approaches are used:

• Limited anterior or lateral thoracotomy: A 6- to 8-cm intercostal incision is made to approach the anterior structures.

• Posterolateral thoracotomy: The posterolateral approach gives access to pleurae, hilum, mediastinum, and the entire lung.

• Sternal splitting incision (median sternotomy): When access to both lungs is desired, as in lung volume reduction surgery, a sternal splitting incision is used.

• Clamshell thoracotomy (also known as bilateral anterolateral thoracotomy): A clamshell thoracotomy is used to provide exposure of the entire thoracic cavity, including the heart, mediastinum, and lungs. This approach can be performed in emergency situations for resuscitation.

Complications of thoracotomy are greater than those for any other pulmonary procedures because of the risks of general anesthesia, surgical trauma, and a longer hospital stay with more postoperative discomfort. The greatest hazards are:

• Bronchopleural fistula

• Hemorrhage

• Infection

• Pneumothorax

• Reactions to anesthetics