Overview
Definition:
Anterolateral thoracotomy is a surgical incision made through the chest wall from the front to the side, typically along an intercostal space, to provide surgical access to the thoracic cavity
It allows visualization and manipulation of structures within the chest, including the lungs, pleura, heart, esophagus, and great vessels.
Epidemiology:
Thoracotomy, in general, is a common procedure in thoracic surgery
The specific incidence of anterolateral thoracotomy varies depending on the surgical indication, but it is a frequently utilized approach for procedures involving the anterior and lateral aspects of the chest
Indications are driven by the pathology requiring intervention within the hemithorax.
Clinical Significance:
Anterolateral thoracotomy is a crucial surgical approach enabling direct access to significant intrathoracic pathology
It is essential for resectional surgeries, emergency interventions, and diagnostic procedures, directly impacting patient outcomes and management strategies in a wide range of thoracic conditions
Understanding its indications, technique, and complications is vital for surgical residents preparing for DNB and NEET SS examinations.
Indications
Pulmonary Surgery:
Lobectomy, pneumonectomy, wedge resection for malignancy or benign tumors
decortication for empyema
management of bronchopleural fistula.
Pleural Procedures:
Pleurodesis, pleural biopsy, drainage of hemothorax or pneumothorax, management of spontaneous pneumothorax.
Cardiac And Great Vessel:
Aortic aneurysm repair, coronary artery bypass grafting (less common now with sternotomy), pericardiectomy, cannulation for cardiopulmonary bypass (in some contexts).
Esophageal Surgery:
Esophagectomy, repair of esophageal perforations (depending on location).
Trauma:
Emergency thoracotomy for hemothorax, cardiac tamponade, or massive bleeding from great vessels.
Diagnostic Purposes:
Exploratory thoracotomy for undiagnosed thoracic mass or pleural effusion.
Preoperative Preparation
Patient Assessment:
Thorough cardiopulmonary assessment, including pulmonary function tests (PFTs), echocardiogram, and cardiac stress tests
Assess for comorbidities like COPD, diabetes, and hypertension.
Imaging Studies:
Chest X-ray, CT scan of the chest with contrast, and PET-CT for oncological staging are essential to delineate the extent of disease and plan surgical approach.
Informed Consent:
Detailed discussion with the patient regarding the procedure, potential risks, benefits, alternatives, and expected recovery
Special emphasis on pain management and potential complications like prolonged air leak or infection.
Anesthesia Considerations:
General anesthesia with a double-lumen endotracheal tube for single-lung ventilation is typically required
Careful hemodynamic monitoring and pain control strategies are paramount.
Preoperative Medications:
Prophylactic antibiotics (e.g., cefazolin or clindamycin), deep vein thrombosis (DVT) prophylaxis (e.g., heparin or sequential compression devices), and bronchodilators if indicated.
Procedure Steps
Patient Positioning:
The patient is typically positioned in the lateral decubitus position, with the affected side up, ensuring adequate exposure of the hemithorax.
Incision Placement:
An incision is made over the selected intercostal space, usually the 4th or 5th, extending from parasternal to the mid-scapular line
The incision can be anterior, lateral, or slightly posterior depending on the target anatomy.
Intercostal Muscle Dissection:
The intercostal muscles are carefully divided along the length of the incision, preserving the intercostal nerve and vessels where possible, or ligating them if necessary.
Rib Spreading:
A rib spreader or Tuffier's rib approximator is used to spread the ribs apart, creating a surgical window into the pleural cavity.
Pleural Entry:
The parietal pleura is incised, often in a stepwise manner, to avoid injury to underlying lung parenchyma
This allows for inspection of the pleural space and its contents.
Thoracic Cavity Exploration:
Once the pleural cavity is entered, exploration is performed to identify and access the target structures
Hemostasis is meticulously maintained throughout the procedure
The surgeon may perform pulmonary resection, lymph node dissection, pleural procedures, or repair of great vessels as indicated.
Closure:
After the primary surgical intervention is complete, chest tubes are usually placed for drainage of air and fluid
The intercostal muscles are approximated, and the skin is closed in layers, often with absorbable sutures
Chest tubes are secured and connected to an underwater seal drainage system.
Postoperative Care
Pain Management:
Aggressive pain control is critical
This may involve patient-controlled analgesia (PCA) with opioids, epidural analgesia, or intercostal nerve blocks
Adequate pain relief facilitates deep breathing and ambulation, reducing the risk of atelectasis and pneumonia.
Respiratory Support:
Monitoring of oxygen saturation and respiratory rate
Encouragement of incentive spirometry and early mobilization
Chest physiotherapy may be required
Close monitoring for signs of respiratory distress or prolonged air leak.
Chest Tube Management:
Regular monitoring of chest tube output (air leak, fluid), system patency, and patient comfort
Chest tubes are typically removed once air leak has resolved and drainage is minimal.
Ambulation And Physiotherapy:
Early mobilization to prevent DVT, pneumonia, and muscle deconditioning
A structured physiotherapy program is essential for regaining strength and pulmonary function.
Wound Care:
Routine wound care to prevent infection
Monitoring for signs of wound dehiscence or infection.
Complications
Early Complications:
Bleeding (intraoperative or postoperative hemothorax)
Persistent air leak
Pneumonia
Atelectasis
Chylothorax
Injury to adjacent structures (nerves, vessels, diaphragm, heart)
Respiratory failure
Post-thoracotomy pain syndrome (early manifestation).
Late Complications:
Chronic post-thoracotomy pain syndrome
Incisional hernia
Intercostal neuralgia
Adhesions and entrapment of lung
Recurrence of disease.
Prevention Strategies:
Meticulous surgical technique with careful dissection and hemostasis
Appropriate chest tube placement and management
Aggressive pain control and respiratory physiotherapy
Prophylactic antibiotics and DVT prophylaxis
Careful patient selection and preoperative optimization.
Key Points
Exam Focus:
Understand the indications for anterolateral thoracotomy versus other approaches (e.g., VATS, median sternotomy)
Key anatomical landmarks and critical structures at risk
Management of common postoperative complications like air leak and pain.
Clinical Pearls:
When performing an anterolateral thoracotomy for anterior mediastinal masses, the incision might be extended more anteriorly
In cases of cardiac tamponade requiring emergency thoracotomy, the incision can be extended across the sternum if necessary
Consider intercostal nerve block for improved postoperative pain control and earlier ambulation.
Common Mistakes:
Inadequate hemostasis during dissection
Incomplete pleural space exploration
Improper chest tube placement or management leading to complications
Underestimation of postoperative pain and inadequate analgesia
Delayed recognition and management of persistent air leak or hemothorax.