Thoracotomy

A thoracotomy is a surgical operation in which a surgeon makes an opening through the chest wall to reach the organs inside the chest cavity.

During the procedure the surgeon cuts between two ribs and sometimes spreads them apart so that the lungs, heart, major blood vessels, or the oesophagus (the food pipe connecting the mouth to the stomach) can be directly seen and treated. The exact location of the cut depends on which organ needs attention. Thoracotomy is considered a major operation because it opens the chest, and it is usually performed under general anaesthesia (medicine that puts you into a deep, controlled sleep).

Thoracotomy is used when a condition inside the chest must be treated in a way that cannot be done through a small camera port alone. A cardiothoracic surgeon will recommend it after reviewing scans and other test results.

• Lung cancer — to remove a tumour or part of the lung (lobectomy) or an entire lung (pneumonectomy)
• Pleural empyema (a collection of infected fluid between the lung and chest wall) that does not clear with drainage alone
• Haemothorax (blood pooling in the chest cavity) caused by injury or surgery
• Oesophageal cancer or a severe narrowing of the oesophagus requiring reconstruction
• Aortic aneurysm (a dangerous bulge in the body's main artery) in the chest that needs repair
• Heart conditions — such as certain valve repairs or surgery on the heart muscle — when less invasive approaches are not suitable
• Removal of a mediastinal mass (a growth in the central area of the chest between the lungs)
• Severe chest trauma that causes life-threatening bleeding or organ damage
• Recurrent or large pneumothorax (collapsed lung) not resolved by other methods

Thoracotomy is not always the right choice. Doctors usually consider less invasive alternatives first, and some patients may not be suitable for this operation.

• Patients whose overall health is too poor to safely tolerate general anaesthesia or major surgery
• Advanced disease that has spread widely and where surgery would not improve outcomes
• Severe impairment of lung function, making recovery after opening the chest very high risk
• Blood clotting disorders that cannot be corrected before the operation

Thoracotomy is a major operation and carries real risks; your surgical team will discuss these with you in detail before you sign a consent form.

• Pain at the incision site and along the ribs — this is very common and is actively managed with pain relief
• Post-thoracotomy pain syndrome — persistent chest wall pain that can last weeks to months after healing
• Chest infection or pneumonia (infection of the lungs), especially in smokers or those with reduced lung function
• Air leak — air escaping from the lung into the chest cavity, which may require a chest drain to be left in longer
• Bleeding that may need a return to the operating theatre
• Atrial fibrillation (an irregular heartbeat) — a relatively common complication after chest surgery
• Wound infection at the skin incision
• Deep vein thrombosis (a blood clot forming in the leg veins) or pulmonary embolism (a clot that travels to the lungs)
• Injury to nearby structures such as the diaphragm (the breathing muscle below the lungs), oesophagus, or major blood vessels
• Respiratory failure requiring support from a breathing machine in intensive care
• Risks related to general anaesthesia, including allergic reactions and, very rarely, awareness during surgery

Preparation for a thoracotomy usually begins days or even weeks before the operation. Following your team's instructions carefully helps reduce the chance of complications.

Your care team will typically ask you to:

• Stop eating solid food and drinking anything (including water) for a number of hours before the operation — the exact fasting period will be given to you in writing
• Stop smoking as early as possible before surgery, ideally several weeks ahead, because smoking significantly increases the risk of chest infection and poor wound healing
• Avoid alcohol for at least the days leading up to admission
• Pause or adjust certain medicines — blood thinners, anti-inflammatory drugs, and some supplements are usually stopped beforehand; your team will give a specific list
• Continue other essential medicines, such as those for blood pressure or diabetes, unless told otherwise — always follow your doctor's guidance

Before the operation day, you will usually undergo several tests to make sure it is safe to proceed:

• Blood tests to check your general health, kidney and liver function, and blood clotting
• Chest X-ray or CT scan (computed tomography, a detailed cross-sectional scan) to map the area to be operated on
• Pulmonary function tests (breathing tests that measure how well your lungs work)
• Electrocardiogram — ECG (a recording of the heart's electrical activity)
• Echocardiogram — an ultrasound scan of the heart, if heart function needs to be assessed
• Anaesthesia consultation to review your medical history and plan safe sedation

On the day of the operation, the following steps typically occur — though the exact sequence may vary between hospitals:

• 1. You change into a hospital gown and your identity and consent are confirmed by the nursing team.
• 2. A cannula (a small plastic tube) is placed into a vein in your arm to allow fluids and medicines to be given.
• 3. You are taken to the operating theatre and helped onto the operating table.
• 4. The anaesthetist places monitoring equipment — including ECG stickers, a blood pressure cuff, and a clip on your finger to measure oxygen — and gives you general anaesthesia.
• 5. A special breathing tube called a double-lumen tube is passed into your airway so that each lung can be ventilated (inflated) separately; this allows the surgeon to work on one lung while the other keeps you breathing.
• 6. You are positioned on your side (or sometimes on your back), depending on which part of the chest is being accessed.
• 7. The surgeon makes an incision between two ribs — usually at the side or back of the chest — and gently separates the ribs to create a clear view of the chest cavity.
• 8. The planned procedure is carried out: removing tissue, repairing a structure, or stopping bleeding.
• 9. One or more chest drains (flexible tubes) are placed inside the chest cavity to drain air or fluid during recovery.
• 10. The ribs are brought back together and secured, and the muscles, tissue layers, and skin are closed in stages.
• 11. You are transferred to a recovery area where nurses monitor you closely as the anaesthesia wears off.

Recovery from a thoracotomy takes time, and the pace varies from person to person depending on the reason for surgery, overall health, and any complications. Most patients spend several days in hospital after the operation, often with time in a high-dependency or intensive care unit (ICU) first, before moving to a regular ward.

• Chest drains: One or more tubes coming out of the side of your chest will drain fluid and air. They are removed by the nursing team once output settles — this usually happens within a few days but may take longer.
• Pain management: Pain after thoracotomy can be significant. The team typically uses a combination of approaches, which may include an epidural (medicine delivered near the spine) or a nerve block, as well as oral pain medicines. Good pain control is important because it allows you to breathe deeply and cough, which prevents chest infections.
• Breathing exercises: A physiotherapist (a specialist in movement and rehabilitation) will visit you early after surgery to teach deep breathing techniques and controlled coughing. These exercises are a core part of recovery.
• Activity restrictions: Heavy lifting, strenuous exercise, and driving are usually restricted for several weeks. Your surgical team will give a timeframe based on what was done.
• Wound care: The incision site should be kept clean and dry. You will be given specific instructions on dressing changes and signs of infection to watch for, such as increasing redness, warmth, swelling, or discharge.
• Follow-up appointments: You will usually be seen in outpatient clinic within a few weeks of discharge so the surgeon can check the wound, review any pathology results (laboratory findings from removed tissue), and plan next steps such as oncology (cancer treatment) or rehabilitation.
• Lifestyle: Smoking must be avoided completely during recovery, as it delays healing and increases infection risk. A gradual return to normal activities is guided by how you feel and your doctor's advice.
• Warning signs: Seek medical attention promptly if you develop increasing breathlessness, a fever, severe chest pain, or notice the wound opening or producing unusual discharge.