What are the indications for thoracotomy in adults and pediatric patients?

Indications for Thoracotomy

Thoracotomy is indicated for specific life-threatening conditions in both trauma and non-trauma settings, with VATS preferred over open thoracotomy in most non-emergent situations due to reduced morbidity, but open thoracotomy remains essential for resuscitative emergencies, massive hemorrhage, and complex organized empyema requiring decortication.

Trauma Indications

Resuscitative Emergency Thoracotomy

• Cardiac arrest or impending cardiac arrest within 15 minutes of onset from penetrating or blunt trauma requires immediate thoracotomy, performed via left anterolateral incision or clamshell approach 1
• The procedure must include concurrent blood transfusion, fluid resuscitation, open pleura and pericardium, aortic clamping, and intrathoracic CPR 1
• Survival rates are approximately 9-12% for penetrating trauma but only 1-2% for blunt trauma, making patient selection critical 2
• Penetrating chest trauma with signs of life at the scene but lost during transport justifies attempting the procedure 3

Damage Control Thoracotomy

• Initial chest tube drainage >1000 mL or ongoing drainage >200 mL/hour for >3 hours despite anti-shock treatment mandates immediate surgical intervention 1, 4
• Pericardial tamponade with Beck's triad (hypotension, muffled heart sounds, jugular venous distension) requires thoracotomy for relief 1, 3
• Severe pulmonary laceration when closed thoracic drainage fails to relieve dyspnea or causes continuous hemorrhage 1
• Major airway injuries (severe tracheal/bronchial injuries) when tracheotomy and closed drainage cannot alleviate dyspnea 1
• Upper mediastinal entrance wounds, admission blood pressure <90 mmHg, initial thoracostomy blood loss >800 cc, or radiographic retained hemothorax are additional indicators 5

Surgical Approach in Trauma

• Anterolateral left thoracotomy through the 4th-5th intercostal space is the initial approach for most damage control situations, providing access to pericardium, descending aorta, and left hilum 1, 3
• Clamshell extension when bilateral exposure is needed or visualization is inadequate 1
• Median sternotomy for isolated cardiac and great vessel injuries 1

Pneumothorax Indications (Adults)

Accepted Indications for Surgical Referral

• First pneumothorax with tension or first secondary pneumothorax with significant physiological compromise 6
• Second ipsilateral pneumothorax or first contralateral pneumothorax 6
• Synchronous bilateral spontaneous pneumothorax 6
• Persistent air leak despite 5-7 days of chest tube drainage or failure of lung re-expansion 6
• Spontaneous hemothorax 6
• High-risk professions (pilots, divers) even after a single episode 6
• Pregnancy 6

Surgical Approach Selection for Pneumothorax

• VATS should be considered over thoracotomy for general pneumothorax management due to reduced length of stay, postoperative pain, and complications 6
• However, thoracotomy access should be used when the lowest recurrence risk is required for specific high-risk occupations, as recurrence rates are slightly higher with VATS 6

Pleural Infection Indications

Adults

• Failed optimal medical therapy in pleural infection requires surgical intervention, though precise criteria remain unclear 6
• VATS access should be considered over thoracotomy for pleural infection due to less immediate postoperative pain, shorter hospital stay, and fewer complications, while maintaining similar mortality and repeat intervention rates 6
• The surgical technique must facilitate optimal clearance of infected material and achieve lung re-expansion where appropriate 6
• Decortication via formal thoracotomy should be individualized for patients with trapped lung, considering patient fitness and empyema stage, though it carries longer postoperative stay and higher mortality but reduces breathlessness 6

Pediatric Patients

• Organized empyema with thick fibrous peel causing restricted lung expansion and chronic sepsis with fever in symptomatic children requires formal thoracotomy and decortication 6
• Asymptomatic children with organized empyema do not necessarily require surgery 6
• Open formal thoracotomy should be reserved for late presenting empyema and chronic empyema in children 6
• VATS has its most appropriate role in early surgery as failure rates are higher in advanced organized empyema, which then necessitates later open thoracotomy 6
• Contraindications for VATS debridement include inability to develop a pleural window, presence of thick pyogenic material, and/or fibrotic pleural rinds 6

Critical Pitfalls to Avoid

• Do not delay emergency thoracotomy seeking "proper" equipment in resource-limited settings, as every minute dramatically reduces survival 3
• Recognize that patients with open thoracostomy remain at significant risk for tension pneumothorax, especially under positive pressure ventilation, which can cause death within minutes if unrecognized 4
• Do not perform surgery on asymptomatic children with persistent radiological abnormalities from empyema 6
• Avoid complex repairs in emergency settings; focus on simple suturing, packing, and clamping for damage control 3
• Patient choice should inform pneumothorax surgery decisions, weighing reduced recurrence risk against chronic pain and paresthesia 6