Thoracotomy

A thoracotomy is an incision through the chest wall into the chest cavity. It is the open route to the lungs, esophagus, the descending aorta and sometimes the heart, and the steps for opening and closing the chest are much the same whatever operation is done inside. Lung cancer and other lung diseases, esophageal disease, aortic problems and injuries are common reasons. Many lung operations are now done by VATS, but a thoracotomy is still used when open exposure is needed or a VATS case has to be converted. The most common incision is the posterolateral thoracotomy, done with the patient on the side: it curves from under the breast around the tip of the shoulder blade, and the chest is entered through an intercostal space. Anterolateral incisions above or below the breast are done with the side tilted up, and a muscle-sparing vertical incision under the arm avoids cutting the big back muscles. A rib is occasionally removed for more room. The ribs are spread with a Finochietto retractor and, at the end, brought back together with heavy pericostal sutures and a rib approximator. Bleeding (especially from the vessels under each rib), infection, air leaks and fluid in the chest, shoulder stiffness and long-lasting pain along the incision are the main problems after a thoracotomy. Chest tubes connected to a water-seal drainage unit are left in to drain air and fluid.