Thoracotomy
- Thoracotomy allows access to the chest cavity
- Position of incision depends on intended operation or procedure
- Two different approaches exist
- Lateral thoracotomy
- Median sternotomy
- Lateral thoracotomy can be carried out in three different positions
- Posterolateral
- Anterolateral
- Lateral or axillary
- Median sternotomy allows access to the anterior and superior mediastinum
- Sternum is divided with oscillating or Gigli saw or Lebske knife
- Ooze from the bone marrow may be stopped with bone wax
- Sternum is usually closed with steel wire
Intrathoracic bleeding
- Usually occurs from lung parenchyma or bronchial vessels
- May present with clinical features of hypovolaemia
- Usually detectable from mediastinal or pleural drains
- Drains may however a block and haemothorax may be detected on chest x-ray
- Can often be treated conservatively with transfusion
- Re-operation required if:
- Rapid blood loss via chest drain
- Significant intrapleural collection on chest x-ray
- Persistent hypovolaemia despite transfusion
- Hypoxia due to compression of underlying lung
Sputum retention and atelectasis
- Failure to clear bronchial secretions can result in:
- Bronchial obstruction
- Atelectasis
- Lobar collapse
- Secondary pulmonary infection
- Presents as tachypnoea and hypoxia
- Examination usually shows reduced bilateral basal air entry
- Prevention is preferred to treatment
- Risk of sputum retention can be reduced by:
- Preoperative cessation of smoking
- Adequate postoperative pain relief
- Chest physiotherapy
- Humidification of inspired oxygen
- Bronchodilator therapy
- Early mobilisation after surgery
- Treatment required formal chest physiotherapy
- Mini-tracheostomy and suction may be required
- Antibiotics should be reserved for those with proven pneumonia
Air leak
- Following lung resection residual lung tissue expands to fill pleural cavity
- Raw area can result in an air leak into the pleural cavity
- Presents as persist air leak or bubbling of chest drain
- Usually settles spontaneously over 2-3 days
- May require suction on pleural drains
- Apposition of lung to parietal pleura encourages efficient healing
Bronchopleural fistula
- Results from major air leak from pneumonectomy bronchial stump
- Seen in 2% of patients undergoing pneumonectomy
- Airway thus directly communicates with pleural space
- Usually occurs as a result form a leak from a suture line
- Occurs particularly in those with factors impairing wound healing
- Most commonly occurs 7-10 days after surgery
- Presents with sudden breathlessness and expectoration of bloodstained fluid
- Fluid is that which normally fills the postpneumonectomy space
- Emergency treatment consists of lying patient with operated side downwards
- Providing oxygen and draining the pleural space
- Thoracotomy and repair of fistula may be required
- Repair may be reinforced with omental or intercostals muscle patch
- Thoracoplasty may be required to obliterate the postpneumonectomy space
Bibliography
Deschamps C, Pairolero P C, Allen M S, Trasteck V F. Management of postpneumonectomy empyema and
bronchopleural fistula. Chest Surg Clin N Am 1996; 6: 519-527. |