Thoracotomy is a surgical procedure where the surgeon cuts through the chest wall (the sternum) with a knife or scalpel to remove part of the heart. There are two types of thoracotomies: open and closed. Open thoracotomies involve cutting through both the sternum and ribs; they allow surgeons to access organs such as the liver, spleen, stomach, intestines and other internal organs. Closed thoracotomies only involve cutting through the sternum and ribs.
Open thoracotomies have been used since the early 20th century, but were rarely performed because of their high risk of infection and complications such as blood clots. Today, open thoracotomies are still done occasionally when there is no alternative. They are most commonly used in cases where it would be too risky to perform a traditional open operation.
Closed thoracotomies are usually reserved for patients whose hearts cannot be saved due to their condition. Patients may undergo these procedures if they have a history of cardiac disease, or if they have had a previous closed thoracotomy without success. These operations are often considered experimental and not covered by insurance companies.
The heart is a muscle located in the center of your chest between your lungs. It pumps blood through the body by sending it to the lungs, where carbon dioxide is exchanged for oxygen. The blood then travels through the rest of the body and back to the heart, where waste is removed and oxygenated blood is sent out to the body again.
During a closed thoracotomy, the surgeon makes a cut in the middle of the chest and exposes the heart. The sternum, or the bone in the center of the chest, is sawed in half. It is then spread open with a set of blunt tipped forceps and hinged open like the doors of a treasure chest. Sometimes, doctors may also use hooks to hold open the chest without cutting through ribs. This allows the chest to be spread open wider without the risk of cutting internal organs or damaging veins and arteries.
Sometimes a procedure called VATS, or video-assisted thoracic surgery is used. This procedure involves using a video camera to see inside the chest and operate small instruments to dissect and seal off the vessels that are bleeding. This procedure is considered less invasive than traditional open surgery because it only requires small incisions rather than one large incision. It is also not as risky as open surgery because it decreases the chance of puncturing internal organs, which can lead to infection.
After the chest is opened and the source of bleeding is located, it is clamped off and tied off. The incision is then closed with stitches and covered with a bandage. In some rare cases, a patch may be used to close the wound.
A closed thoracotomy may also be performed in patients with gunshot or knife wounds to the chest. This procedure involves making two smaller incisions (called ports) in the patient’s chest. The organs inside the chest are not disturbed and surgeons can operate through the ports to remove bullets or debris in the chest without disturbing the surrounding organs. After the source of bleeding is located and clamped off, the incisions are closed.
After the procedure, patients are usually unable to take a deep breath and may have some pain in their chest. This will gradually go away as the incision heals and the muscles stretch. A drain may be placed to remove any fluid from inside the chest. This drain is removed after a few days. Most patients are able to leave the hospital after 3-5 days depending on how well they are healing.
Patients are usually advised to avoid coughing or strenuous activity for six weeks after the surgery. They may be advised to avoid smoking for several months after the surgery to decrease the risk of developing a blood clot.
Most patients make a full recovery from this surgery, although some complications can occur including:
Internal bleeding in the chest
Heart rhythm abnormalities
Breathing difficulties due to damage to the lungs
Damage to the pericardium, the sac that surrounds the heart
Pneumonia, a lung infection caused by breathing in bacteria in the air
Infection at the site of incision or inside the chest
Patients who smoke are at an increased risk of developing blood clots, heart rhythm abnormalities, and pneumonia after this surgery. Obesity also increases the risk of some complications.
Patients who are in good health before surgery have the lowest risk of complications.
Risks from the anesthesia used for this surgery are also possible, including:
Respiratory depression (can’t breath)
Heart rhythm abnormalities
Nausea and vomiting
While most people who have this surgery make a full recovery, some patients do not. Discuss with your doctor what the risks are for you and how to best prepare for this surgery.
Sources & references used in this article:
Esophagectomy without thoracotomy by MB Orringer, H Sloan – The Journal of thoracic and cardiovascular surgery, 1978 – Elsevier
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Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy by RJ Landreneau, SR Hazelrigg, MJ Mack… – The Annals of thoracic …, 1993 – Elsevier
Muscle-sparing posterolateral thoracotomy by DM Bethencourt, EC Holmes – The Annals of thoracic surgery, 1988 – Elsevier
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