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surgical incision into the chest walls opening up the pleural cavity

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2012/12/16 11:15:51」(JST)

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Thoracotomy is an incision into the pleural space of the chest.^[1] 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.

Thoracotomy is a major surgical maneuver—it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer—and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation.

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.

Approaches

There are many different approaches to thoracotomy. The most common modalities of thoracotomy follow.

Median sternotomy provides wide access to the mediastinum and is the incision of choice for most open-heart surgery and access to the anterior mediastinum.

Posterolateral thoracotomy is an incision through an intercostal space on the back, and is often widened with rib spreaders. It is a very common approach for operations on the lung or posterior mediastinum, including the esophagus. When performed over the fifth intercostal space, it allows optimal access to the pulmonary hilum (pulmonary artery and pulmonary vein) and therefore is considered the approach of choice for pulmonary resection (pneumonectomy and lobectomy).

Anterolateral thoracotomy is performed upon the anterior chest wall; left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic cardiac arrest. Anterolateral thoracotomy, like most surgical incisions, requires the use of tissue retractors—in this case, a "rib spreader" such as the Tuffier retractor.

Bilateral anterolateral thoracotomy combined with transverse sternotomy results in the "clamshell" incision, the largest incision commonly used in thoracic surgery.

Upon completion of the surgical procedure, the chest is closed. One or more chest tubes—with one end inside the opened pleural cavity and the other submerged under saline solution inside a sealed container, forming an airtight drainage system—are necessary to remove air and fluid from the pleural cavity, preventing the development of pneumothorax or hemothorax.

Complications

In addition to pneumothorax, complications from thoracotomy include air leaks, infection, bleeding and respiratory failure. Postoperative pain is universal and intense, generally requiring opioids, and does interfere with the recovery of respiratory function.

In nearly all cases a chest tube, or more than one chest tube is placed. These tubes are used to drain air and fluid until the patient heals enough to take them out (usually a few days). Complications such as pneumothorax, tension pneumothorax, or subcutaneous emphysema can occur if these chest tubes become clogged. Furthermore, complications such as pleural effusion or hemothorax can occur if the chest tubes fail to drain the fluid around the lung in the pleural space after a thoracotomy. Clinicians should be on the look out for chest tube clogging as these tubes have a tendency to become occluded with fibrinous material or clot in the post operative period, and when this happens, complications ensue.

In the long term post operatively chronic pain can develop known as thoracotomy pain syndrome, this can last from a few years to a lifetime of continued pain and discomfort. Treatment to aid pain relief for this condition includes intra thoracic nerve blocks/opiates and epidurals although results vary from person to person and are dependent on many numerous factors.

VATS

Video-assisted thoracic surgery (VATS) is a less invasive alternative to thoracotomy in selected cases, much like laparoscopic surgery. Like laparoscopic surgery, its applications are rapidly expanding. Robotic surgery is a new but rarely used innovation with questionable advantages.

References

^ "thoracotomy" at Dorland's Medical Dictionary

UpToDate Contents

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English Journal

Reducing tidal volume and increasing positive end-expiratory pressure with constant plateau pressure during one-lung ventilation: effect on oxygenation.

Rozé H, Lafargue M, Perez P, Tafer N, Batoz H, Germain C, Janvier G, Ouattara A.SourceCentre Hospitalier Universitaire (CHU) de Bordeaux, Service d'anesthésie réanimation 2, F-33600 Pessac, France.
British journal of anaesthesia.Br J Anaesth.2012 Jun;108(6):1022-7. Epub 2012 Mar 30.
BACKGROUND: /st> It is no longer safe to use large tidal volumes (V(T)) (>8 ml kg(-1)) for one-lung ventilation (OLV), and limiting plateau pressure should be a major objective. Due to the specificity of OLV, the use of positive end-expiratory pressure (PEEP) remains controversial. This study
PMID 22466821

Ward-based, nurse-led, outpatient chest tube management: analysis of impact, cost-effectiveness and patient safety.

Tcherveniakov P, De Siqueira J, Milton R, Papagiannopoulos K.SourceDepartment of Thoracic Surgery, St James's University Hospital, Leeds, UK.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.Eur J Cardiothorac Surg.2012 Jun;41(6):1353-6. Epub 2012 Feb 17.
OBJECTIVES: Prolonged drainage and air leaks are recognized complications of elective and acute thoracic surgery and carry significant burden on inpatient stay and outpatient resources. Since 2007, we have run a ward-based, nurse-led clinic for patients discharged with a chest drain in situ. The aim
PMID 22342975

Japanese Journal

エンドループを利用して胸腔鏡下核出術を施行した巨大食道平滑筋腫の一例

蜂谷修,藤本博人,矢野充泰,佐藤多未笑,山岸岳人,高須直樹,木村理
山形大学紀要. 医学 : 山形医学 33(1), 41-45, 2015-02-15
… Therefore, for tumors more than 5 cm diameter, open thoracotomy is generally recommended. …
NAID 110009889047

右小開胸による低侵襲開心術 (特集低侵襲心臓・大血管手術)

杭ノ瀬昌彦
胸部外科 = The Japanese journal of thoracic surgery 68(1), 11-15, 2015-01
NAID 40020304588

Evaluation of Aortic Valve Replacement via the Right Parasternal Approach without Rib Removal

, , , , , ,
Annals of Thoracic and Cardiovascular Surgery 21(2), 139-145, 2015
… Our RPA employs thoracotomy with bending rib cartilages and wound closure performed by repositioning the ribs with underlying sheet reinforcement. …
NAID 130005065139