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Definition

Thoracotomy is the process of making of an incision (cut) into the chest wall.

Purpose

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A physician gains access to the chest cavity (called the thorax) by cutting through the
chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the
condition of the lungs; removal of a lung or part of a lung; removal of a rib; and
examination, treatment, or removal of any organs in the chest cavity. Thoracotomy also
provides access to the heart, esophagus, diaphragm, and the portion of the aorta that
passes through the chest cavity.
Lung cancer is the most common cancer requiring a thoracotomy. Tumors and
metastatic growths can be removed through the incision (a procedure called resection).
A biopsy, or tissue sample, can also be taken through the incision, and examined under
a microscope for evidence of abnormal cells.

A resuscitative or emergency thoracotomy may be performed to resuscitate a patient


who is near death as a result of a chest injury. An emergency thoracotomy provides
access to the chest cavity to control injury-related bleeding from the heart, cardiac
compressions to restore a normal heart rhythm, or to relieve pressure on the heart
caused by cardiac tamponade (accumulation of fluid in the space between the heart's
muscle and outer lining).

Demographics
Thoracotomy may be performed to diagnose or treat a variety of conditions; therefore,
no data exist as to the overall incidence of the procedure. Lung cancer, a common
reason for thoracotomy, is diagnosed in approximately 172,000 people each year and
affects more men than women (91,800 diagnoses in men compared to 80,100 in
women).

Description
The thoracotomy incision may be made on the side, under the arm (axillary
thoracotomy); on the front, through the breastbone (median sternotomy); slanting from
the back to the side (posterolateral thoracotomy); or under the breast (anterolateral
thoracotomy). The exact location of the cut depends on the reason for the surgery. In
some cases, the physician is able to make the incision between ribs (called an intercostal
approach) to minimize cuts through bone, nerves, and muscle. The incision may range
from just under 5 in (12.7 cm) to 10 in (25 cm).

During the surgery, a tube is passed through the trachea. It usually has a branch to each
lung. One lung is deflated for examination and surgery, while the other one is inflated
with the assistance of a mechanical device (a ventilator).
A number of different procedures may be commenced at this point. A lobectomy
removes an entire lobe or section of a lung (the right lung has three lobes and the left
lung has two). It may be done to remove cancer that is contained by a lobe.
Asegmentectomy , or wedge resection, removes a wedge-shaped piece of lung smaller
than a lobe. Alternatively, the entire lung may be removed during a pneumonectomy .

In the case of an emergency thoracotomy, the procedure performed depends on the type
and extent of injury. The heart may be exposed so that direct cardiac compressions can
be performed; the physician may use one hand or both hands to manually pump blood
through the heart. Internal paddles of a defibrillating machine may be applied directly
to the heart to restore normal cardiac rhythms. Injuries to the heart causing excessive
bleeding (hemorrhaging) may be closed with staples or stitches.

Once the procedure that required the incision is completed, the chest wall is closed. The
layers of skin, muscle, and other tissues are closed with stitches or staples. If the
breastbone was cut (as in the case of a median sternotomy), it is stitched back together
with wire.

Diagnosis/Preparation
Patients are told not to eat after midnight the night before surgery. The advice is
important because vomiting during surgery can cause serious complications or death.
For surgery in which a general anesthetic is used, the gag reflex is often lost for several
hours or longer, making it much more likely that food will enter the lungs if vomiting
occurs.
For a thoracotomy, the patient lies on his or her side with one arm raised
(A). An incision is cut into the skin of the ribcage (B). Muscle layers are cut,
and a rib may be removed to gain access to the cavity. (C). Retractors hold
the ribs apart, exposing the lung (D). After any repairs are made, the cut rib
is replaced and held in place with special materials (E). Layers of muscle
and skin are stitched. (
Illustration by GGS Inc.
)

Patients must tell their physicians about all known allergies so that the safest
anesthetics can be selected. Older patients must be evaluated for heart ailments before
surgery because of the additional strain on that organ.

Aftercare
Opening the chest cavity means cutting through skin, muscle, nerves, and sometimes
bone. It is a major procedure that often involves a hospital stay of five to seven days. The
skin around the drainage tube to the thoracic cavity must be kept clean, and the tube
must be kept unblocked.

The pressure differences that are set up in the thoracic cavity by the movement of the
diaphragm (the large muscle at the base of the thorax) make it possible for the lungs to
expand and contract. If the pressure in the chest cavity changes abruptly, the lungs can
collapse. Any fluid that collects in the cavity puts a patient at risk for infection and
reduced lung function, or even collapse (called a pneumothorax). Thus, any entry to the
chest usually requires that a chest tube remain in place for several days after the incision
is closed.

The first two days after surgery may be spent in the intensive care unit (ICU) of the
hospital. A variety of tubes, catheters, and monitors may be required after surgery.

Risks
The rich supply of blood vessels to the lungs makes hemorrhage a risk; a
blood transfusion may become necessary during surgery. General anesthesia carries
such risks as nausea, vomiting, headache, blood pressure issues, or allergic reaction.
After a thoracotomy, there may be drainage from the incision. There is also the risk of
infection; the patient must learn how to keep the incision clean and dry as it heals.

After the chest tube is removed, the patient is vulnerable to pneumothorax. Physicians
strive to reduce the risk of collapse by timing the removal of the tube. Doing so at the
end of inspiration (breathing in) or the end of expiration (breathing out) poses less risk.
Deep breathing exercises and coughing should be emphasized as an important way that
patients can improve healing and prevent pneumonia.

Normal results
The results following thoracotomy depend on the reasons why it was performed. If a
biopsy was taken during the surgery, a normal result would indicate that no cancerous
cells are present in the tissue sample. The procedure may indicate that further treatment
is necessary; for example, if cancer was detected, chemotherapy, radiation therapy, or
more surgery may be recommended.

Morbidity and mortality


One study following lung cancer patients undergoing thoracotomy found that 10–15% of
patients experienced heartbeat irregularities, readmittance to the ICU, or partial or full
lung collapse; 5–10% experienced pneumonia or extended use of the ventilator (greater
than 48 hours); and up to 5% experienced wound infection, accumulation of pus in the
chest cavity, or blood clots in the lung. The mortality rate in the study was 5.8%, with
patients dying as a result of the cancer itself or of postoperative complications.

Alternatives
Video-assisted thoracic surgery (VATS) is a less invasive alternative to thoracotomy.
Also called thoracoscopy, VATS involves the insertion of a thoracoscope (a thin, lighted
tube) into a small incision through the chest wall. The surgeon can visualize the
structures inside the chest cavity on a video screen. Such instruments as a stapler or
grasper may inserted through other small incisions. Although initially used as a
diagnostic tool (to visualize the lungs or to remove a sample of lung tissue for further
examination), VATS may be used to remove some lung tumors.

An alternative to emergency thoracotomy is a tube thoracostomy, a tube placed through


chest wall to drain excess fluid. Over 80% of patients with a penetrating chest wound
can be successfully managed with a thoracostomy.

Read more: Thoracotomy - procedure, recovery, blood, tube, removal, complications,


time, infection, heart, cells, risk, cancer, nausea, rate, Definition, Purpose,
Demographics, Description http://www.surgeryencyclopedia.com/St-
Wr/Thoracotomy.html#ixzz0wlr30Ku0

Introduction
The mechanics of ventilation relate to the negative intrathoracic pressure that draws air into the lungs
during spontaneous respiration. This negative pressure is best maintained in the pleural space, which is
the potential space between the parietal and visceral layers of the pleura. Collections of air, fluid, or blood
in the pleural space not only compress the lung tissue but also cause the pleural pressures to become
positive, causing inappropriate ventilation.

Chest drains are inserted to remove pathological collections of air or fluid in the pleural space, to allow the
re-creation of the essential negative pressures in the chest, and to permit complete expansion of the lung,
thereby restoring normal ventilation. Chest drains are very simple and effective tools in the management
of thoracic and pleural pathology. They need proper safe insertion and correct management. Chest drains
are lifesaving in critical care.

Chest drainage systems work by combining the following 3 efforts:

• Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough,
Valsalva maneuver).
• Gravity helps fluid drainage as long as the chest drainage system is placed below the level of the
patient’s chest.
• Suction can improve the speed at which air and fluid are pulled from the chest.
Any catheter inserted through the chest wall to remove air or fluid from the pleural space may be called a
chest tube or chest drain. Crosswell Hewitt is credited as being the first to use a chest drain, in 1876,
when he used a red rubber catheter to drain an empyema thoracis.1 Ideally, the chest tubes (also
called thoracic catheters) must be nontoxic, nonthrombogenic, and soft but with thick resilient walls. The
traditional red rubber tubes have most of these features but, being opaque, tend to be quickly occluded by
encrustation and fibrinous secretions.

Today, chest tubes are made of clear plastic (vinyl or silastic). They are available in varying diameters,
sized in multiples of 4 on the French scale (eg, 12F, 16F, 20F, up to 36F). They have multiple side holes
to allow effective drainage and have length markers to help note the distance of the lowest hole from the
skin surface. A radiopaque strip lines the tube to help easy visualization on chest radiography.2 Some
tubes are mounted on stylets or trocars that act as guides to help insertion and proper placement of
tubes. Improper management of inserted chest tubes results in premature removal or delayed removal,
both of which lead to increased hospital stay and costs.

When caring for and maintaining a patient with a chest tube, the following steps are important: Keep chest
tubes patent, note the presence of drainage and fluctuations, and observe the patient's vital signs and
levels of comfort. The chest dressing status and type of suction must be noted.

Indications

Indications for chest drains include the following:

• Pneumothorax (spontaneous, tension, iatrogenic, traumatic)


• Pleural collection
○ Pus (empyema)
○ Blood (hemothorax)
○ Chyle (chylothorax)
○ Malignant effusions (pleurodesis)
• Postoperative
○ Thoracotomy
○ Video-assisted thoracic surgery (VATS)

Contraindications

When a chest drain is needed for any of the indications listed above, no absolute contraindications exist
for chest drain insertion.

Tube Thoracostomy (Emergency Medicine)


Editor(s): Todd W Thomsen, MD | Gary S Setnik, MD, FACEP
Contributor(s): Adapted from

PRE-PROCEDURE

INDICATIONS

• Pneumothorax spontaneous (closed) pneumothorax


• Traumatic open pneumothorax
• Tension pneumothorax
• Hemothorax
• Empyema/Effusions
• Chylothorax
CONTRAINDICATIONS

• For unstable injured patients with a pneumothorax or hemothorax, no absolute contraindications


to a tube thoracostomy are known.
• In the stable patient, relative contraindications include multiple pleural adhesions,
emphysematous blebs, or scarring.
• Consider clotting factor replacement for coagulopathic patients before inserting a chest tube.
EQUIPMENT

• Sterile drapes
• 10- to 20-mL syringe and assorted needles
• No. 10 scalpel
• Forceps
• Large, straight and curved scissors
• Large clamps (Kelly) (2)
• Needle holder
• No. 1 or 1-0 silk on large cutting needles
• Gauze pads
• Local anesthetic
• Antiseptic solution
• Adhesive tape—cloth backed
• Clear, sterile plastic tubing in 6-foot lengths, ½-inch diameter
• Hard plastic serrated connectors
• Drainage apparatus with sterile water for water seal
• Y connectors
• Chest tubes
• Drainage and suction systems
ANATOMY

• Chest wall
○ Each rib is associated with a neurovascular bundle. The bundle lies just inferior to the rib
and is composed of an intercostal artery and vein and the intercostal nerve.

PROCEDURE

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• Clinical pearls providing practical clinical tips from medical experts
• Patient safety guidelines consistent with Joint Commission and OHSA standards
• Links to medical evidence and related procedures

POST-PROCEDURE

CARE

• Further evaluation of spontaneous pneumothorax


○ The underlying lung pathology of a patient with a spontaneous pneumothorax is best
evaluated by CT scan. Often the scan is followed by diagnostic or therapeutic visual
inspection of the lung and pleural space by thoracoscopy.
• Hemothorax
○ Monitor the amount and speed of blood output, which determine the need for additional
interventions, including a thoracotomy.
• Empyema
○ Immediate intervention is indicated because the fluid can become loculated within hours.
The tube is left in place until the volume of the pleural drainage becomes clear yellow and
the output volume falls to <150 mL per 24 hours.
• Pain management
○ Local anesthetic may be administered through the chest tube. Use parenteral analgesic
agents as needed to control the pain.
• Prophylactic antibiotics
○ The use of prophylactic antibiotics for patients with a chest tube placed in the ED is
controversial.
COMPLICATIONS

• The most common complications of chest tube insertion include infection, laceration of an
intercostal vessel, laceration of the lung, and intra-abdominal or solid organ placement of the chest
tube. Local infection at the insertion site is common and is related to the emergency nature of the
procedure.
• Subcutaneous air leak
• Hemorrhage
• Failure to correct the pneumothorax
• Pulmonary edema

Tube Thoracostomy

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Tube thoracostomy is insertion of a tube into the pleural space. It is used to drain air or
fluid from the chest (eg, for large or recurrent effusion refractory to thoracentesis,
pneumothorax, complicated parapneumonic effusions, empyema, hemothorax) and to
do pleurodesis or fibrinolytic adhesiolysis.

Procedure: Chest tube insertion is best done by a physician trained in the procedure.
Other physicians can handle emergency situations (eg, tension pneumothorax) using a
needle and syringe. Tube insertion requires 1 or 2 hemostats or Kelly clamps, a silk
suture, gauze dressing, and a chest tube. Recommended tube sizes are 16 to 24
French (F) for pneumothorax; 20 to 24 F for malignant pleural effusion; 28 to 36 F for
bronchopleural fistula, complicated parapneumonic effusions, and empyema; and 32 to
40 F for hemothorax.

The insertion site and patient position depend on whether air or fluid is being drained.
For pneumothorax, the tube is usually inserted in the 4th intercostal space and for other
indications in the 5th or 6th intercostal space, in the midaxillary line with the ipsilateral
arm abducted above the head.

No specific patient preparation is necessary except, in some cases, conscious sedation.


Under sterile conditions, the skin, subcutaneous tissue, rib periosteum, and parietal
pleura are locally anesthetized, more generously than for thoracentesis (see Diagnostic
and Therapeutic Pulmonary Procedures: Thoracentesis). Proper location is confirmed by
return of air or fluid in the anesthetic syringe. A purse-string suture can be placed but not
yet tied around the site while the anesthetic takes effect. A 2-cm skin incision is made,
and the intercostal soft tissue down to the pleura is then bluntly dissected by advancing
a clamped hemostat or Kelly clamp and opening it; the pleura is then perforated with the
clamped instrument and opened in the same way. A finger can be used to widen the
tract and confirm entry into the pleural space. The chest tube, with a clamp grasping the
tip, is inserted through the tract and directed inferoposteriorly for effusions, or apically for
pneumothorax, until all of the tube's holes are inside the chest wall. The purse-string
suture is closed, the tube is sutured to the chest wall, and a sterile dressing with
petroleum gauze to help seal the wound is placed over the site.

The tube is connected to water seal to prevent air from entering the chest through the
tube and to allow drainage without suction (for effusions or empyema) or with suction
(for pneumothorax). Posteroanterior and lateral chest x-rays are obtained after insertion
to check the tube's position.

The tube is removed when the condition for which it was placed resolves. In the case of
pneumothorax, suction is stopped and the tube is placed on water seal for several hours
to ensure that the air leak has stopped and that the lung remains expanded. At the
moment of removal, the patient is asked to take a deep breath and then to forcibly
exhale; the tube is removed during exhalation and the site is covered with petroleum
gauze, a sequence that reduces the chance of pneumothorax during removal. For
effusions or hemothorax, the tube is typically removed when the drainage is < 100
mL/day.

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