Thoracotomy

General principles of surgical approach

Operations on the thoracic cavity organs require mandatory mechanical ventilation. Anesthetic management involves the use of long single-lumen or double-lumen endotracheal tubes (for separate intubation).

An important condition for the surgeon's work is the ability to temporarily exclude the lung from ventilation on the operative side (collapse). This increases the workspace for manipulations and facilitates the procedure.

According to Kocher's principle, surgical access should represent a balance between good exposure and minimal possible trauma. The classification of accesses to the thoracic cavity is based on the patient's position on the operating table:

• Anterior (patient supine);
• Posterior (prone);
• Lateral (in the lateral decubitus position).

Types of intercostal approaches

Wide intercostal incisions are one of the main types of thoracotomy.

Anterolateral thoracotomy (anterior approach) Performed with the patient in the supine position, with the arm on the operative side flexed and elevated. The incision begins from the parasternal line at the level of the 3rd rib cartilage, outlines the nipple or mammary gland, and runs along the 4th intercostal space to the posterior axillary line. Layer-by-layer dissection involves the skin, subcutaneous tissue, fascia, and partial transection of the pectoralis major and serratus anterior muscles. The latissimus dorsi muscle is retracted. The intercostal incision (fascia and parietal pleura) must be wider than the skin incision: from the sternum to the scapular line. It is important not to damage the internal thoracic vessels (a. et v. thoracica interna).

Posterolateral thoracotomy (posterior approach) The patient lies in the prone position with the head turned to the opposite side. The incision curves around the angle of the scapula, beginning from the spinous processes of the 3rd–4th thoracic vertebrae and ending at the middle or anterior axillary line. The trapezius, rhomboid, latissimus dorsi, and serratus anterior muscles are transected. The pleura is opened through the intercostal space or the bed of a resected rib.

Lateral approach (standard thoracotomy) Considered the most frequent and provides good exposure with low trauma. The patient lies on the healthy side with a slight backward tilt. The incision runs along the ribs from the mid-clavicular line (4th–5th intercostal space) to the posterior axillary line. When opening the pleura, the intercostal tissue incision is made very wide—from the sternal margin to the spine.

Sternotomy

Median access, or sternotomy, is used for operations on the heart, anterior mediastinal organs, and great vessels. Total longitudinal, partial, longitudinal-transverse, and transverse sternotomies are distinguished.

Total longitudinal sternotomy:

1. Soft tissues are transected along the entire length of the sternum.
2. A tunnel is created behind the sternum from the manubrium and xiphoid process.
3. The bone is transected with a sternotome, saw, or ultrasound (to reduce blood loss).
4. The periosteal edges are cauterized, and bone wax with paraffin is rubbed into the spongy substance.
5. The sternum is spread apart with a retractor.

For access to the upper parts of the anterior mediastinum, a partial sternotomy is used (incision up to the 3rd intercostal space). The longitudinal-transverse modification improves exposure. Transverse sternotomy (transpleural bilateral) requires ligation of vasa thoracica interna and is rarely used due to high trauma.

To close the access, the sternum is fixed with sutures around or through the bone using wire, synthetic threads, or staple suture.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Method of sternal osteosynthesis after sternotomy
• Features of pulley sutures for rib approximation
• Tunneling technique in longitudinal sternotomy
• Prevention of internal thoracic vessel injury during thoracotomy
• Steps of layered wound closure in a lateral intercostal approach

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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