General anesthesia is used. Video-assisted thoracoscopy is a minimally invasive approach to intrathoracic surgical conditions. It involves the formation of several (usually 2–3) thoracoscopy ports. This involves creating 0.5–1-cm skin incisions, with dissection through the intercostal spaces and, thus, into the pleural space. The exact location of these thoracoscopy ports is dictated by the intrathoracic problem in question. For pulmonary parenchymal resections (e.g., lung biopsies), two 1-cm ports are made in the 5th intercostal space, the first in the anterior axillary line and the second in the midaxillary line. A further 5-mm port is made in the 4th intercostal space in the posterior axillary line. These port placements can also be used for resection of anterior mediastinal lesions such as germ cell tumors or thymic masses. To approach the posterior mediastinum, the ports must be made in the 3rd, 4th, and 6th intercostal spaces in a vertical line in a position between the mid and anterior axillary lines. Pleural conditions requiring resection or biopsy (e.g., for the management of malignant pleural effusions) can be approached simply by two ports in the 6th or 7th intercostal space between the mid and anterior axillary lines. These ports are placed in a lower intercostal space than for pulmonary or mediastinal lesions, such that drains can be placed in a more dependent position to allow more complete drainage of pleural fluid (e.g., to allow for an effective pleurodesis in malignant effusions).

The abovementioned thoracoscopy sites may have to be varied depending on the position of the lesion to be resected or biopsy to be taken. In particular, lower lobe pulmonary parenchymal lesions often necessitate the use of ports placed in the 6th or 7th intercostal spaces. Pleural adhesions are not uncommon and may prevent successful thoracoscopic surgery. If the pleural space is obliterated, then thoracoscopy will be impossible and the surgeon would need to resort to open thoracotomy. With a partially obliterated pleural space, pleural adhesions can be dissected and allow enough mobilization of the lung to permit the procedure to be carried out thoracoscopically.

See Table 7.2. A significant number of intrathoracic surgical procedures are now performed using the thoracoscopic approach. The main limitation of the thoracoscopic approach involves the fact that, by virtue of the inability to palpate intrathoracic organs, small pulmonary parenchymal lesions not evident on visual inspection of the lung alone, may be difficult to locate and thus resect. Serious complications are relatively rare.

The most serious complication of the thoracoscopic approach to intrathoracic pathology is bleeding from the intercostal vessels. This can usually be controlled through the thoracoscopy port but rarely will require a minithoracotomy (in the same intercostal space) to control the bleeding. Intercostal neuralgia can occur following thoracoscopy but is significantly less frequent than following open thoracotomy. Inadvertent injury to the lung is also possible especially in the presence of dense pleural adhesions, and occasionally, pneumothorax or persistent air leak may result. Complications specific to the underlying problem and reason for the thoracoscopy may occur. Basal atelectasis and sometimes secondary lung infection are not uncommon and may affect either lung. Empyema and abscess formation are very rare but are severe if they occur leading to prolonged hospital stay and other sequelae. Multisystem organ failure is extremely serious, the incidence being most related to the underlying lung pathology and other comorbidities.

General anesthesia is used. A thoracotomy can be anterolateral, lateral, posterolateral, full, or manubriosternal depending on the intrathoracic pathology being attended to. Lateral thoracotomy involves a full-thickness incision into the pleural space by way of the intercostal space, with or without removal of rib(s). Thoracotomy alone is typically used for exploration, diagnosis, biopsy, decortication, pleurodesis, and the like.

An anterolateral thoracotomy involves an incision between the midclavicular line and the anterior axillary line, usually through the 5th intercostal space.

A true lateral thoracotomy involves an incision situated between the anterior and posterior axillary lines usually in the 5th or 6th intercostal space, incising through serratus anterior and the anterior border of the latissimus dorsi muscles. A full lateral thoracotomy extends around the chest through the entire intercostal space.

A posterolateral thoracotomy involves extension of the lateral thoracotomy skin incision below the tip of the scapula and extending posterosuperiorly between the medial border of the scapula and the vertebral spinous processes. The incision extends through serratus anterior muscle and latissimus dorsi and can also extend to involve the trapezius and paraspinal group of muscles.

An anterior thoracotomy involves an incision extending from the parasternal intercostal space to the midaxillary line, usually in the fifth intercostal space. It requires dissection through the serratus anterior muscle and the intercostal muscles.

Once the intercostal muscles and parietal pleura have been dissected, then a retractor is placed between the ribs and opened. To facilitate the opening of the intercostal space (particularly in the older patient with osteoarthritic costovertebral and costochondral joints), a short segment of the posterior rib (either above or below) can be resected. This increases the thoracotomy opening and reduces the incidence of rib fractures and intercostal nerve traction injury in spaces above and below.

A median sternotomy involves a skin incision located between the suprasternal notch and the xiphisternum. A midline division of the manubrium, sternal body, and xiphisternal process is then performed, using a bone saw. This incision allows access to the pericardium and medial aspect of both pleural spaces.

There are few anatomical variants that affect this procedure; however, chest wall deformities such as pectus excavatum and scoliosis may alter the ease of approach and therefore the complications. Acquired anatomical changes due to disease, including trauma or previous surgery, can also affect the ease and results of surgery. The intercostal nerves are applied closely to the undersides of each rib and are vulnerable to direct trauma or traction trauma during spreading of the ribs.