What are the indications for a thoracotomy (surgical incision into the chest cavity)?

From the Guidelines

Thoracotomy is indicated for several critical conditions, including first pneumothorax presentation associated with tension, second ipsilateral pneumothorax, first contralateral pneumothorax, synchronous bilateral spontaneous pneumothorax, persistent air leak, spontaneous haemothorax, and professions at risk, as outlined in the British Thoracic Society guideline for pleural disease 1. The primary indications for thoracotomy can be categorized into several key areas, including:

• Trauma-related conditions, such as massive hemothorax or ongoing hemorrhage
• Non-trauma settings, including lung cancer resection, lung biopsy, and treatment of recurrent or complicated pneumothorax
• Specific conditions, such as spontaneous haemothorax, and professions at risk, such as pilots or divers Some of the specific indications for thoracotomy include:
• First pneumothorax presentation associated with tension and first secondary pneumothorax associated with significant physiological compromise
• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Synchronous bilateral spontaneous pneumothorax
• Persistent air leak or failure of lung re-expansion
• Spontaneous haemothorax
• Professions at risk, even after a single episode of pneumothorax
• Pregnancy It is essential to weigh the potential benefits of thoracotomy against the significant risks, including bleeding, infection, respiratory compromise, and nerve damage, as noted in various studies 1. The decision to perform a thoracotomy should be made on a case-by-case basis, taking into account the individual patient's condition, medical history, and potential risks and benefits, as emphasized in the British Thoracic Society guideline for pleural disease 1. In general, thoracotomy is a valuable procedure for accessing the chest cavity and addressing various thoracic conditions, but it should be performed by experienced surgeons and with careful consideration of the potential risks and benefits, as highlighted in the available evidence 1.

From the Research

Indications for Thoracotomy

The indications for a thoracotomy, a surgical incision into the chest cavity, can be summarized as follows:

• Traumatic injuries, including:
  • Blunt trauma 2
  • Penetrating trauma 3, 4, 5
• Thoracic complications, such as:
  • Hemothorax 4, 2, 5
  • Pneumothorax 3, 4, 5, 6
  • Diaphragmatic injury 3, 5
  • Esophageal injury 3
• Cardiovascular injuries, such as:
  • Great vessel injury 4
• Other indications, including:
  • Lung cancer surgery, such as lobectomy or pneumonectomy 6
  • Access to the thoracic aorta or anterior spine 6

Specific Conditions Requiring Thoracotomy

Certain conditions may require a thoracotomy, including:

• Hemodynamically unstable patients 5
• Patients with cardiovascular or great vessel injury 4
• Patients who cannot tolerate lateral decubitus position or one-lung ventilation 5
• Patients with complications from tube thoracostomy, such as empyema or residual hemothorax 2

Alternative Procedures

In some cases, alternative procedures, such as video-assisted thoracic surgery (VATS) or videothoracoscopy, may be used instead of a thoracotomy, particularly in hemodynamically stable patients with certain types of thoracic trauma 3, 4, 5.