MS: Thoracotomy

Thoracotomy is an incision into the pleural space of the chest It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, the esophagus or thoracic aorta, or for access to the anterior spine such as is necessary for access to tumors in the spine.

Thoracotomy is a major surgical maneuver—it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer—and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation.

Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia.

Approaches to Thoracotomy

There are many different approaches to thoracotomy. The most common modalities of thoracotomy follow.

Median sternotomy provides wide access to the mediastinum and is the incision of choice for most open-heart surgery and access to the anterior mediastinum.

Posterolateral thoracotomy is an incision through an intercostal space on the back, and is often widened with rib spreaders. It is a very common approach for operations on the lung or posterior mediastinum, including the esophagus. When performed over the fifth intercostal space, it allows optimal access to the pulmonary hilum (pulmonary artery and pulmonary vein) and therefore is considered the approach of choice for pulmonary resection (pneumonectomy and lobectomy).

Anterolateral thoracotomy is performed upon the anterior chest wall; left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic cardiac arrest. Anterolateral thoracotomy, like most surgical incisions, requires the use of tissue retractors—in this case, a "rib spreader" such as the Tuffier retractor.

Bilateral anterolateral thoracotomy combined with transverse sternotomy results in the "clamshell" incision, the largest incision commonly used in thoracic surgery.

Upon completion of the surgical procedure, the chest is closed. One or more chest tubes—with one end inside the opened pleural cavity and the other submerged under saline solution inside a sealed container, forming an airtight drainage system—are necessary to remove air and fluid from the pleural cavity, preventing the development of pneumothorax or hemothorax.

Complications

• Hemorrhage
• Infection
• Tension pneumothorax
• Bronchopleural fistula
• Empyema   

Nursing Assessment

Health perception and management

■ Fear about serious nature of illness and impending major surgery

■ Family history of heart disease or lung conditions such as asthma

■ High‑risk respiratory health patterns, such as stress, smoking, or exposure to respiratory toxins

Nutrition and metabolism

■ Loss of appetite

■ Weight loss

Activity and exercise

■ Shortness of breath or labored breathing on exertion

■ Tiredness and less tolerance for exercise than usual

■ Difficulty in breathing at rest and during exercise

■ Weakness and fatigue

Self-perception and self-concept

■ Fear of disfigurement and scarring

Roles and relationships

■ Fear of inability to return to work after surgical procedure

Nursing Physical Examination

1. Cyanosis
2. Pallor
3. Abrasions or open wounds
4. Dyspnea
5. Shortness of breath
6. Tachypnea
7. Use of accessory muscles
8. Gurgles, wheezes, crackles
9. Possible open sucking wound, flail chest, paradoxical asymmetrical chest movements, or orthopnea
10. Arrhythmias
11. Chest pain
12. Hypotension
13. Tachycardia

Diagnostic Studies

Because of the various conditions for which thoracotomy may be performed, this section instead presents monitoring tests.

• Arterial blood gas (ABG) levels reveal oxygenation, ventilation, and acid‑base status.
• Chest X‑ray may reveal abnormalities of the chest structures and heart and lung tissues.
• Fluoroscopy may reveal mobility abnormalities of the intrathoracic structures.
• Magnetic resonance imaging may reveal abnormalities of the thoracic structures and organs.
• Computed tomography scan may reveal abnormalities of the lung, such as tumors, calcium deposits, or cavities.
• Biopsy may aid in definitive diagnosis of lung problems.
• Ventilation‑perfusion pulmonary scan may reveal areas of nonventilation and nonperfusion.
• Pulmonary function tests reveal static and dynamic lung volumes and capacities.
• Bronchoscopy may reveal abnormalities of the pulmonary tree.
• Sonography of the lung may reveal collections of fluid and may be used postoperatively to locate the best site for thoracentesis.
• Thoracentesis may reveal abnormal fluid or tissue specimens.
• Bronchography may reveal abnormal airway structures or a tumor.

Nursing Care Plan

Nursing Diagnosis	Nursing Priorities
Deficient knowledge (treatment regimen) related to lack of exposure to information about thoracotomy	■    Prepare the patient and his family preoperatively for surgery and postoperative care.
Impaired gas exchange related to hypoventilation	■    Optimize ventilation and oxygenation.
Ineffective breathing pattern related to pneumothorax, hemothorax, or mediastinal shift secondary to malfunction or removal of chest drainage system	■    Maintain patency of chest drainage system. ■    Observe for complications after chest tube removal.
Risk for infection related to surgical incision and endotracheal intubation	■    Prevent infection.

Sources: www.fchs.com and www.wikipedia.com