THORACOTOMY..............................pdf

Thoracotomy

1. THORACOTOMY
JEEVAN KUMAR

2. DEFINTION
TYPES OF INCISIONS
SITE OF INCISION
MUSCLES INVOLVED
COMPLICATIONS

3. DEFINITON





Procedure allowing surgeons to access the chest cavity
Incision is made in the chest wall, and access to
organs of the chest cavity is made by cutting through
and possibly removing a portion of a rib

Performed in OR under GA

Throughout the procedure, vitals signs are carefully
monitored
Post-operativelychest tube is usually placed in the chest cavity

4. The standard thoracotomy incisions are defined with respect to the
lattisimus dorsi muscle which arbitrarily is considered lateral
Extremely versatile and flexible
Excellent exposure to the ipsilateral hemithorax-lung, oesophagus,
mediastinum and cardiac structures.

5. Disadvantage  division of main muscle groups resulting in
postoperative pain and detrimental effect on pulmonary
function

Potential risk of poor exposure if the wrong interspace is
chosen

6. Why?

Opening and exposing the chest cavity and mediastinumaccess to:
Heart
Lungs
Oesophagus
Thoracic aorta
Anterior spine
Ca Lung
Ca Oesophagus
Heart/aortic surgeries
Chest Trauma
Persistent Pneumothorax
Biopsy and evaluation of an unknown mediastinal mass
Resuscitative thoracotomy

7. Emergency thoracotomy





Internal cardiac massage
Control of haemorrhage from injury to heart or lung
Control of intrathoracic haemorrhage due to other causes
Control of massive air leak

Mostly anterolateral or median sternotomy

8. Anatomy



Lateral chest wall :
lattisimus dorsi / serratus anterior
Anterior incisions :
pectoralis major /rectus abdominis
Posterior chest wall :
Trapezius / rhomboid /paraspinous

9. Types





Posterolateral thoracotomy-incision slanting from the back to the side
Median thoracotomy- incision on the front through the breastbone
Axillary thoracoctomy-incision in the underarm
Anterolateral thoracotomy-incision line below the breast

Exact location of the cuts depends on the indication for the surgery

10. Posterolateral thoracotomy




Right posterolateral –access to thoracic oesophagus
Left posterolateral- access to descending thoracic aorta

Elective- incision depends on the level of pathology
Emergency – 5
th
intercostal space

11. Positioning




Full lateral decubitus , pressure point padding
Lower leg is flexed at the hip and knee
Upper leg is straight with pillow in between the legs
The dependent arm and the superior arm is flexed to attain the ‘praying
position’

12. Incision is through the skin and LATTISIMUS DORSI- two finger breadths below the
level of scapula

Posteriorly- skin incision divides the angle between the spine and medial edge of
scapula
Anteriorly-submammary fold
To create more space TRAPEZIUS can also be involved .
SERRATUS ANTERIOR is dissected in a deeper plane near its attachment

Rib separation can be done through divison of costotransverse ligament-prevents
rib fracture while rib spreading

13. Once the intercostal muscles are traversed, the operative site lung can be
made to collapse with the help of the double lumen airway creating a
valuable operative field.

Rib appostion post op thorugh pericostal sutures.

The chest wall muscles are approximated with absorbable
sutures.
Not generally used in emergencies due to the difficulty
in positioning

14. Anterolateral thoracotomy





Transects the serratus anterior muscle

Incision of choice for open lung biopsy
Preferred in patients who cannot tolerate single lung ventilation

Skin incision-lateral to the sternal edge and follows the inframammary
crease upto the anterior axillary line
Pectoralis majior and minor, medial edge od serratus anterior muscles are
cut.

15. Left anterolateral thoracocotomy





Structures accessed
Left lung and lung hilum
Thoracic aorta
Origin of left subclavian artery
Left side of the heart
Lower oesophagus

16. Incision of choice for emergency access to heart
Preludes CLAMSHELL thoracotomy(bilateral anterolateral thoracotomy)

Access to left ventricle posterolateral aspect is superior to one achieved
with median sternotomy
Faster and safer approach

17. Right anterolateral thoracotomy






Right lung and lung hilum
Azygous vein
Superior vena cava
Infracardiac inferior vena cava
Upper oesophagus
Thoracic trachea

18. Clamshell thoracotomy



Left 5
th
space anterolateral thoracotomy can be extended by a transverse/
oblique division of sternal body to 4
th
/5
th
interspace .
Preferred approach to heart and chest cavity in extreme emergency

Blunt trauma- incison initiated on the left side for
rapid access to pericardium and heart.

19. Axillary thoracotomy





Initially used for procedures on the thoracic sympathetic nervous system

First rib resection
Apical bullous lung disease
Management of spontaneous pneumothorax with apical pleurectomy

Muscles involved
Anterior border of lattisimus dorsi
Posterior border of pectoralis major

20. Advantage-
Ease of performing
Scar hidden under the arm
Minimal muscle transection

Drawback :
Exposure is limited to upper half of the chest
Potential nerve injury to the intercostobrachial nerve and long thoracic
nerve

21. Median sternotomy







Anterior aspect of heart
Pericardium
Anterior mediastinum
Ascending aorta and arch of aorta
Pulmonary arteries
Carina of the trachea

Well suited for bilateral pulmonary procedures; resection of bilateral
pulmonary metastasis

22. Advantage
Quick to perform
Lesser pain

Drawbacks
Mediastinitis is the most severe complication

Poor cosmesis
Sternal malunion
Access to oesophagus and descending aorta not possible

23. Performed most frequently in elective cardiac surgery
Excellent access to heart and anterior mediastinum

Preferred in emergency when injury to heart or greater vessels
of superior mediastinum is suspected

24. Incisionsuprasternal notch to xiphisternum
Extended to the neck along the anterior border of SCM
Laterally above the clavicle for access to subclavian root
injury
The pectoral fascia (muscles aslo if present) should be
separated

25. Rib retraction should be slow to avoid neurologic insult to the
brachial plexus.
Meticulous control of bleeding
Postoperatively drains are placed on either sides of the
pericardium and one in the anterior mediastinum

Stainless steel wires used to appose the two halves of the
sternum

26. Why a chest tube?




Lungs expand and contract with the pressure gradient created by the
muscular diaphragm
If pressure within the chest cavity changes abruptly, the lungs will tend to
collapse
Any fluid collecting in the chest cavity increased risk for infection
Reduced lung function collapse(pneumothorax)

Timing of chest tube removal is also uncertain due to the likely onset of
pneumothoirax

27. Chest tube removal should be timed after ensuring proper breathing
function

Removal should be at end inspiration or end expiration

Deep breathing exercises should be taught to ensure better healing and
preventing pneumonia

28. complications






Prolonged need for ventilator support
Persistent air leakprolonged chest tube
Infection
Bleeding
DVT and Pulmonary emboli
Cardiac arrest or arrhythmias

29. Post operative care



Hospital stay of about 5-7days
Multilayered approach: skin/muscles/nerves/bone

Skin around the chest drain to be kept clean and patent

30. Thank you!Thank you!