Thoracotomy


A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. The purpose of a thoracotomy is the first step used to facilitate thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.

Approaches

There are many different surgical approaches to performing a thoracotomy. Some common forms of thoracotomies include:
Upon completion of the surgical procedure, the chest is closed. One or more chest tubes—with one end inside the opened pleural cavity and the other submerged under saline solution inside a sealed container, forming an airtight drainage system—are necessary to remove air and fluid from the pleural cavity, preventing the development of pneumothorax or hemothorax.

Complications

In addition to pneumothorax, complications from thoracotomy include air leaks, infection, bleeding and respiratory failure. 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.
In nearly all cases a chest tube, or more than one chest tube is placed. These tubes are used to drain air and fluid until the patient heals enough to take them out. Complications such as pneumothorax, tension pneumothorax, or subcutaneous emphysema can occur if these chest tubes become clogged. Furthermore, complications such as pleural effusion or hemothorax can occur if the chest tubes fail to drain the fluid around the lung in the pleural space after a thoracotomy. Clinicians should be on the look out for chest tube clogging as these tubes have a tendency to become occluded with fibrinous material or clot in the post operative period, and when this happens, complications ensue.
In the long term, post-operative chronic pain can develop, known as thoracotomy pain syndrome, and may last from a few years to a lifetime. Treatment to aid pain relief for this condition includes intra-thoracic nerve blocks/opiates and epidurals, although results vary from person to person and are dependent on numerous factors. A recent Cochrane review concluded that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing persistent postoperative pain after three to 18 months after thoracotomy.

VATS

is a less invasive alternative to thoracotomy in selected cases, much like laparoscopic surgery. Like laparoscopic surgery, its applications are rapidly expanding. Robotic surgery is a new but rapidly growing alternative that uses advanced technology with proven advantages.

Post-thoracotomy pain

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. 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.