This incision is ideal for a wide variety of elective as well as emergency procedures. Through the left side, the left lung, heart, descending aorta, lower esophagus, vagus nerves, and diaphragmatic hiatus are well exposed, whereas both the vena cavas, the right lung, the superior exposure of the hepatic veins, and the upper esophagus are approached through the right chest.
The height of the incision on the chest wall varies with the nature of the procedure to obtain optimum exposure of either the apex, the middle, or the basal portions of the chest cavity. One or more ribs may be divided posteriorly and occasionally removed, depending on the mobility of the chest wall and the exposure required. For optimum exposure of the upper portion of the chest cavity, such as in closure of a patent ductus or resection of a coarctation, the chest is entered at the level of the fifth rib. This may be divided posteriorly, along with the fourth rib, if necessary. For procedures on the diaphragm and lower esophagus, the thoracic cavity should be entered at the level of the sixth or seventh rib. If still wider exposure is desired, one or two ribs above and below may be transected at the neck.
Preventative spirometry is preferably started preoperatively to improve compliance postoperatively. Patients should be advised not to smoke for several weeks before an elective operation. Pulmonary functions studies and a room air arterial blood gas analysis should be performed on all patients being considered for thoracotomy. A further evaluation can be obtained by noting the patient’s tolerance to climbing stairs. For practical purposes, any patient able to walk up three flights of stairs will tolerate a thoracotomy. When a patient has borderline pulmonary function, aggressive preoperative pulmonary rehabilitation may be appropriate. Because technical difficulties may arise necessitating more extensive resection than planned, the surgeon must be thoroughly familiar with the patient’s respiratory reserve.
Prior to undergoing a thoracotomy, all patients should undergo fibro-optic bronchoscopy at the beginning of the case via a single-lumen endotracheal tube to remove any secretions, verify the endobronchial anatomy, and survey for endobronchial masses. All thoracotomies require thoracic anesthetic expertise and include the insertion of a thoracic epidural for adequate pain control, an arterial line, and the capacity to perform single lung ventilation. Single lung ventilation can normally be achieved by way of a double-lumen endotracheal tube appropriately positioned or an endobronchial blocker. The position of the double-lumen tube or the endobronchial blocker must be verified prior to deployment with a fibro-optic bronchoscope.
The patient is placed in a lateral decubitus position with the hips secured to the table by wide adhesive tape (figure 1). The lower leg is flexed at the knee, and a pillow is placed between it and the upper leg, which is extended. A rolled sheet or blanket is placed under the axilla, referred to as an “axillary roll” to support the shoulder and upper thorax. The arm on the side of the thoracotomy is extended forward and upward and placed in a padded grooved arm holder in line with the head, permitting access to the veins. The lower arm is extended forward and rested on an arm board perpendicular to the operating table.
