From the Guidelines
Thoracotomy is indicated in patients with lung cancer who have chest wall invasion, as it provides the best chance of complete resection and improved survival rates, with overall survival figures of 30-40% for complete en bloc resection 1. The indications for thoracotomy can be broadly categorized into emergency and elective situations. Emergency indications include penetrating chest trauma, cardiac tamponade, massive air leak, esophageal perforation, and traumatic diaphragmatic rupture. Elective indications include:
- Lung cancer resection, particularly in cases with chest wall invasion 1
- Lung transplantation
- Esophageal surgery
- Cardiac procedures when sternotomy is contraindicated
- Thoracic aortic aneurysm repair
- Management of recurrent or complicated pleural effusions or empyema
- Removal of mediastinal masses
- Sympathectomy for hyperhidrosis
- Correction of chest wall deformities The procedure provides direct visualization and access to thoracic structures when less invasive approaches like video-assisted thoracoscopic surgery (VATS) are inadequate or contraindicated 1. The specific approach (posterolateral, anterolateral, or axillary) depends on the pathology location and surgical goals. In the context of lung cancer with chest wall invasion, an en bloc chest wall resection should be considered to achieve complete resection, as failing to do so is a predictor of poor long-term prognosis 1.
From the Research
Indications for Thoracotomy
The indications for a thoracotomy, a surgical incision into the thorax, can be summarized as follows:
- Emergency situations such as evacuation of pericardial tamponade, direct control of intrathoracic haemorrhage, control of massive air-embolism, open cardiac massage, and cross-clamping of the descending aorta 2
- Hemorrhage, cardiac tamponade, injury to a great vessel, and rupture of the diaphragm 3
- Continued or recurrent bleeding, widening of the mediastinum, hemoptysis, and recurrent hemothorax 3
- Retained infected pleural collections (RIPC) refractory to conventional therapies 4
- Penetrating and blunt chest trauma, with lung parenchyma injuries being the most common intraoperative findings 5
Specific Indications
Some specific indications for thoracotomy include:
- Penetrating chest injuries, such as stab wounds and gunshot wounds 5
- Blunt thoracic injuries, with a higher mortality rate compared to penetrating injuries 5
- Damage control in chest trauma patients, with the goal of quickly performing the thoracotomy and limiting the procedure to only what is necessary 5
Predictors of Mortality
The following factors have been identified as independent predictors of in-hospital mortality after thoracotomy:
- Injury Severity Score (ISS) of >40 5
- Acute Physiology and Chronic Evaluation II (APACHE II) score of >30 5
- Prolonged duration of thoracotomy 5
- Low body temperature on admission to the emergency department 5
- Abnormal arterial blood lactate, bicarbonate, and pH at the end of thoracotomy 5
- Use of vasopressors during the first 24 hours of ICU stay 5