Thoracotomy

Prepared by: Hanna Faye Beredo

Thoracotomy
incision of the chest wall, to provide an opening for the purpose of drainage. It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, the esophagus or thoracic aorta, or for access to the anterior spine such as is necessary for access to tumors in the spine. The incision may range from just under 5 in (12.7 cm) to 10 in (25 cm). Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia.

Thoracotomy scar

Purpose
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).

Nursing Responsibilities
Before Surgery: 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. 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.

After Surgery:
The skin around the drainage tube to the thoracic cavity must be kept clean, and the tube must be kept unblocked. In order to prevent chest infection after surgery, patients are encouraged to be actively involved in early mobilization and chest physiotherapy. Pain assessment, obtaining a description of the pain and its site, as well as what makes it worse or better. Pain scores should be documented, acted upon, re-evaluated and measured when the patient is at rest and, more importantly, during activity.

Procedure
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. A segmentectomy , or wedge resection, removes a wedgeshaped piece of lung smaller than a lobe. Alternatively, the entire lung may be removed during a pneumonectomy .

Procedure
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.

A. The patient lies on his or her side with one arm raised B. An incision is cut into the skin of the ribcage . C. Muscle layers are cut, and a rib may be removed to gain access to the cavity. D. Retractors hold the ribs apart, exposing the lung .E. After any repairs are made, the cut rib is replaced and held in place with special materials . Layers of muscle and skin are stitched.

Rationale
To

provide an opening for the purpose of chest drainage. Allows for study of the condition of the lungs. Removal of Tumors and Metastatic growths. May be performed to resuscitate a patient who is near death as a result of a chest injury. (for emergency thoracotomy)

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