THEME

26 Session 2

Dept. Cardiothoracic Surgery
Cardiothoracic Surgical Procedures


Thoracotomy
The most popular thoracic incision, with which most thoracic surgeons are familiar, is the
thoracotomy (see the image below).



Basic thoracic incisions. Standard thoracotomy incision shown, which can be modified
and minimized.

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Basic thoracic incisions. Standard thoracotomy incision shown, which can be modified and
minimized.

1. Definition
A standard posterolateral thoracotomy transects the latissimus dorsi; an anterolateral
thoracotomy transects the serratus anterior. No specific written definitions for each
type of thoracotomy exist, but it still is probably useful to define the standard
thoracotomies according to their relation to the latissimus dorsi, which is arbitrarily
considered lateral. Incisions completely anterior to the latissimus dorsi are referred to
as anterior thoracotomies; those posterior to it are referred to as posterior
thoracotomies.

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The latissimus dorsi muscle. The latissimus dorsi muscle defines the nomenclature for
standard thoracotomy incisions, with incisions through it arbitrarily defined as lateral.

The advantage of a thoracotomy is that it is extremely versatile and flexible and provides
excellent exposure of the entire ipsilateral hemithorax, including the lung, esophagus,
mediastinum, and cardiac structures. Its major disadvantages are related to the division of
main muscle groups, with the attendant postoperative pain (especially ipsilateral shoulder
pain and detrimental effect on pulmonary function. Also, a significant potential exists for poor
exposure if the wrong interspace is chosen to enter the thorax and if single-lung anesthesia is
not possible.

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 Posterolateral thoracotomy

Historically, the posterolateral thoracotomy has been the standard thoracotomy for most
procedures; however, in current practice, there is a preference for using smaller incisions that
result in less functional disability and postoperative pain.
The patient is placed in a full lateral decubitus position with appropriate pressure-point
padding. Soft rolls, bean bags, and straps of 2-in. adhesive tape are used to secure the
patient to the table. The lower leg is flexed at the hip and knee, while the upper leg is kept
straight with pillows in between the legs.
The dependent arm is flexed, as is the superior arm, to yield the so-called praying position.
Safely preventing the upper arm from hanging over onto the chest is important because such
overhang can limit the space within which the surgeon is maneuvering instruments within the
bony thorax.

Sternotomy

Median sternotomy

For most cardiac surgical operations, the median sternotomy is the incision of choice. It offers excellent
exposure of the heart, pericardium, great vessels, thymus, anterior mediastinal structures, lower
trachea, and carina and is well suited for bilateral pulmonary procedures such as resection of bilateral
pulmonary metastasis.

Left-lower-lobe pulmonary resection is quite challenging from this approach, and access to posterior
mediastinal structures (eg, esophagus and distal descending thoracic aorta) is not possible.

The advantages of this incision are that it is quick to perform, especially in hemodynamic emergencies,
and that it produces less pain than a traditional thoracotomy. The main drawback is cosmetic, and a
risk of sternal mal-union exists, which is usually associated with a postoperative infection.

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Pleurectomy
Background

Pleurectomy is a type of surgery in which part of the pleura is removed. This procedure helps
to prevent fluid from collecting in the affected area and is used for the treatment
of mesothelioma, a pleural mesothelial cancer. Pleurectomy provides symptomatic relief but
does not appear to benefit survival rates.

Malignant pleural effusions generally result from metastatic spread of disease to the pleura
and are commonly seen in the course of many tumors. Less frequently, effusions are
associated with primary tumors of lung, pleura, or mediastinum.

Many nonsurgical methods have been proposed to control effusion and to improve respiratory
function. Nonetheless, many studies have demonstrated the benefits of pleurectomy in
patients with malignant effusions secondary to various cancers.
Pleurectomy reduces the risk of symptomatic pleural effusions and recurrence of
spontaneous pneumothorax.

Indications

Pleurectomy is most commonly indicated for mesothelioma. However, other less common
indications include the following:
• Primary pneumothorax
• Pneumothorax secondary to chronic obstructive pulmonary disease (COPD)
• Traumatic pneumothorax
• Malignant pleural effusions

Outcomes

Pleurectomy can be safely performed and effectively controls the symptoms of pleural
effusion that develops with malignant pleural mesothelioma. The addition of postoperative
phototherapy or intra-pleural chemotherapy does not improve long-term survival, but
pleurectomy does result in symptom palliation.

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Pneumonectomy

Background

The lungs are highly dynamic thoracic structures that are essential for respiration, pH
equilibrium, enzyme production, and host defense, among many other functions. Thus, the
lungs are susceptible to a wide variety of pathologic conditions, both malignant and benign,
that may require pneumonectomy (complete resection of a lung).

Extrapleural pneumonectomy is an expanded procedure that includes resection of the parietal

and visceral pleurae, diseased lung, ipsilateral hemi-diaphragm, ipsilateral pericardium, and
mediastinal lymph nodes.

While the procedure carries a risk of morbidity, including cardiac and pulmonary
complications, it can be beneficial in patients with malignant mesothelioma and
extensive thymomas.

This surgical approach is often coupled with radiation and chemotherapy to improve survival
in both diseases.

Sarot described the first extrapleural pneumonectomy in 1949, and it was initially used in the
treatment of tuberculosis empyema but became more commonly used in the 1980’ s and
1990’ s in the treatment of mesothelioma.

Indications

In general, pneumonectomy is indicated for both malignant and benign diseases.

Malignant indications for pneumonectomy include the following:

• Pulmonary metastasis (uncommon)

• Non-small cell lung carcinoma
Benign indications for pneumonectomy include the following:

• Chronic lung infection (multiple abscesses, bronchiectasis, fungal infection, tuberculosis)

• Traumatic lung injury
• Bronchial obstruction with destroyed lung
• Congenital lung disease

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While the most common indication for an extrapleural pneumonectomy is malignant mesothelioma, the
technique can also be used to treat disseminated thymomas and occasionally tuberculosis in a more
limited fashion.

Contraindications

The patient’s pulmonary function should be assessed and a ventilation-perfusion scan

considered for any patient with a forced expiratory volume in 1 second (FEV1) of less than 2
L. The combined results of these tests can be used to adequately predict postoperative lung
function. Patients with a predicted postoperative FEV1 of less than 0.8 L are often treated
with other means and not considered for pneumonectomy.

Echocardiography may also be performed before the procedure to evaluate for valvular
disease, pulmonary hypertension, and ventricular function. Severe valvular disease,
confirmed severe pulmonary hypertension, and poor ventricular function may preclude
surgery.

Positron emission tomography and CT scanning of the chest are used to assess the extent of
disease involvement.

Surgery is prohibited in patients with disease extending past the diaphragm to be intra-
abdominal, to the contralateral hemithorax, invading into structures of the mediastinum or,
most commonly, invading the ribs. Since chest MRI and CT scanning are unreliable
determinates of chest wall invasion, this is also assessed intraoperatively.

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