Anterolateral Thoracotomy: A Detailed Walkthrough of the Surgical Process

Anterolateral thoracotomy is an essential surgical approach for gaining access to the thoracic cavity and intrathoracic organs. This technique involves a precise incision through the chest wall, allowing exposure of the lung, heart, great vessels, and other mediastinal structures. It is performed for various reasons, such as removing tumors, repairing injuries, or correcting defects in the lungs, heart, or esophagus. This guide primarily covers the step-by-step process for an Anterolateral Thoracotomy surgery to help you avoid medical errors and steer clear of legal troubles.

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Surgery

What is an Anterolateral Thoracotomy?

An anterolateral thoracotomy is a surgical procedure where an incision is made in the chest wall on the side of the thorax to access the chest cavity and organs within. The incision is made between the ribs into the intercostal space. This approach allows access to the lung, heart, great vessels, esophagus, and vertebral bodies for procedures such as tumor removal, lobectomy, coronary artery bypass grafting, and more. Before surgery, the patient receives general anesthesia, and one lung is deflated.

Anterolateral Thoracotomy Step-By-Step Surgery Procedure

Once you’ve set up the surgery room, you can proceed with the steps below:

Step 1: Skin incision

To begin the Anterolateral Thoracotomy surgery procedure, make a careful incision on the patient’s skin using the following steps:

1. Locate the starting point for the incision, which is about 4 fingers below the nipple in the midclavicular line. From there, continue the incision along the submammary crease.
2. Special attention is given when making the incision in women to avoid potential cosmetic issues along the breast area.
3. The incision is then extended diagonally towards the posterior axillary line, which is approximately 2 fingers above the tip of the scapula (shoulder blade).
4. Depending on the specific case, the incision may be extended further, reaching as far as the sternum.
5. For a posterolateral thoracotomy, continue the incision around the tip of the scapula, extending it to about 4 fingers lateral to the spinous processes (the bony projections along the spine).
6. Carefully divides the subcutaneous fatty tissue down to the muscles using electrocautery. Electrocautery helps to minimize bleeding during the procedure.

By completing this step, you will gain access to the thoracic cavity, which allows you to proceed with the rest of the Anterolateral Thoracotomy surgery with a clear view of the internal structures. And in case you cannot make a thorough incision with the steps above, you can watch Anterolateral Thoracotomy surgery videos online on an e-learning platform like Webop.

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Step 2: Transecting the serratus anterior

Here’s how you can perform this step:

1. Identify the serratus anterior muscle, which lies along the lateral (side) aspect of the chest wall.
2. Using precise techniques, carefully transected (cut) the serratus anterior muscle down to the level of the ribs. It’s essential to spare the latissimus dorsi muscle, which is another muscle located in the back, to maintain its function and structural stability.
3. To minimize blood loss during this part of the procedure, use electrocautery to divide the muscles of the chest wall.

By successfully transecting the serratus anterior muscle while sparing the latissimus dorsi muscle and using electrocautery to control bleeding, you can ensure a safer and more efficient progression through the surgery procedure.

This step provides better access to the thoracic cavity and prepares for further exploration and treatment of the underlying condition.

Step 3: Opening the intercostal space

In the Anterolateral Thoracotomy surgery procedure, the next critical step is to open the intercostal space, creating access to the pleural space. This is achieved by taking down the intercostal muscles, along with the intercostal nerve, from the inferior aspect of the superior rib using electrocautery.

Here’s how to perform this step:

1. The surgeon locates the intercostal space, which is the space between two adjacent ribs.
2. To open the pleural space, the intercostal muscles, which lie between the ribs, are carefully taken down from the inferior aspect (underside) of the superior rib. The intercostal nerve, which runs along this space, is also managed during this process.
3. Electrocautery is employed to facilitate dissection and minimize bleeding during the procedure.

Step 4: Inserting the rib retractor

The rib retractor is inserted next in the Anterolateral Thoracotomy surgery process. In case you don’t know, the rib retractor is a specialized piece of equipment used to hold the incision open and separate the ribs, allowing you to work within the chest cavity with clear vision and appropriate room.

Here’s how you can go about this step:

1. After opening the intercostal area, delicately insert the rib retractor into the incision.
2. The rib retractor is made of adjustable blades or arms that you can use to gently spread the ribs apart while maintaining the chest cavity accessible.
3. You can have better access to the organs and tissues within the thoracic cavity by employing the rib retractor, which allows you to execute the necessary treatments with precision.
4. The rib retractor is carefully positioned and adjusted to avoid injury to the surrounding tissues and nerves while maintaining a stable and clear field of view.

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Step 5: Closing the thoracotomy: chest tubes

The last phases of the Anterolateral Thoracotomy surgery technique involve you sealing the thoracotomy incision and placing chest tubes to aid in the healing process.

Closing the Incision

Bring the cut’s edges together gently to ensure a speedy recovery and minimal scarring. Use stitches or staples to close the layers of muscles and tissues that were exposed when they reached the chest. This rebuilds the chest’s strength and stability.

Using Chest Tubes

Insert flexible, soft tubes into the chest through tiny incisions once the wound has been stitched up. These tubes assist in draining any extra fluid or air that may have accumulated after the procedure.

Connect the tubes to a drainage system to collect the liquid or air. By removing extra fluid and air, the chest tubes help the lungs expand properly and prevent difficulties after surgery. The chest tubes should stay in place until the draining stops and the lungs recover.

Step 6: Suturing the ribs

After closing the chest and inserting chest tubes, the next step is stabilizing the ribs. Carefully bring the separated ribs back together using stitches. This helps the chest become stable and strong again.

Stabilizing the ribs is important for preventing any chest wall problems and ensuring a smooth recovery. You may use wires or other devices to secure the ribs if needed. Take special care to do this step well for the patient’s best outcome.

Step 7: Suturing the serratus anterior

After securing the ribs, the next step is to stitch the side muscles back together. Carefully find the muscles on the side that were separated during the surgery.

Use strong stitches to bring these muscles back together. Closing the muscles helps them heal properly and makes the chest wall stable and strong again.

Properly stitching the side muscles is crucial for a successful surgery and a smoother recovery. The surgeon takes special care to do this step well so that the patient can breathe comfortably after the Anterolateral Thoracotomy surgery.

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Step 8: Closing the subcutaneous tissue and skin

For the final step of the surgery, stitch the tissue beneath the skin (subcutaneous tissue) with absorbable sutures or stitches. It helps the wound heal well and makes it more stable.

After that, close the skin with stitches or staples, ensuring the wound is securely sealed. You may use skin adhesive or glue to help close smaller incisions.

Conclusion

Anterolateral Thoracotomy surgery is quite a complicated procedure used to treat various chest illnesses. Overall, both the patient and the surgeon play a big role in making sure the procedure goes successfully.

Keep in mind that you will also need to help patients deal with any discomfort that might arise and keep an eye on the wound until it heals. And if you are new to surgery, you can explore different surgery videos to help you keep the knife steady and gain more confidence with what you do.

References

Force, S., & Patterson, G. A. (2003). Anterolateral thoracotomy. Operative Techniques in Thoracic and Cardiovascular Surgery, 8(2), 104-109. https://doi.org/10.1016/S1522-2942(03)70026-9

Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J., & Good, A. (2005). Emergency thoracotomy: “how to do it”. Emergency Medicine Journal, 22(1), 22-24. https://doi.org/10.1136/emj.2003.010843