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PubMedDate not supplied

Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer.

Major surgery is immunosuppressive, and this could have an impact on postoperative tumor immunosurveillance and, therefore, long-term survival in cancer patients. Video-assisted thoracic surgery (VATS) lung resection is a new alternative surgical approach to thoracotomy for patients with early lung cancer. This is a pilot study to examine the postoperative changes in leukocytes, lymphocyte subsets, B cells, T cells, and natural killer (NK) cells in non-small-cell lung cancer (NSCLC) patients undergoing lung resection with VATS versus thoracotomy approaches. Twenty-one consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 3-month period. Blood samples were collected preoperatively and at postoperative days (POD) 1, 3, and 7 for flow cytometry determination of total leucocytes, B cells, NK cells, lymphocytes, total T cells, and T4 and T8 cell numbers. There were no demographic differences between the two groups. Compared with the preoperative values, significantly increased total white cell numbers were detected at POD 1, 3, and 7 in all patients. At POD 1, although T8 cells and NK cells were reduced in both groups, total T cell, T4 cell, and lymphocyte numbers were significantly reduced only in the thoracotomy group. At POD 7, NK cell numbers were significantly lower in the thoracotomy group than that in the VATS group. No significant intra- or intergroup differences were seen with B cells. No significant differences in survival or disease-free survival were found between the two groups. Thus, VATS major lung resection for NSCLC is associated with less, as well as quicker recovery from, postoperative immunosuppression compared with the thoracotomy approach. The clinical relevance of better preserved cellular immunity in the early postoperative period warrants confirmation from large randomized trials.

Adenocarcinoma↗
PubMed1993

Emergency department thoracotomy in children: rationale for selective application.

Although emergency department (ED) thoracotomy is performed only in selected adult trauma victims, it continues to be widely used in children. To evaluate if use of this liberal policy is justified in children, the charts of 23 pediatric trauma victims who underwent ED thoracotomy at our institution in the past 5 years were reviewed. Mechanism of injury was blunt trauma in 65% and penetrating injury in 35%. Optimal field care was provided, with the majority (74%) of these patients having had intubation and vascular access achieved in the field and transported within 10 minutes to the trauma center. Thoracotomy and open cardiac massage were performed within 5 minutes of arrival in the ED. Despite this aggressive management, only one child (4.4%) survived to discharge, although transient restoration of spontaneous circulation (RSC) was achieved in four (17.4%) children. There were no survivors in the blunt trauma group. All patients with penetrating trauma who had no vital signs in the field died. The cost of ED thoracotomy was $2,740 +/- $214; however, the total hospitalization charges per patient averaged $14,848 +/- $1,724. Forty-six percent of total charges were reimbursed, and financial loss to the hospital per patient was $6,448 +/- $1,441. This study demonstrates that children who arrive at the ED following blunt or penetrating trauma with no cardiac rhythm are unsalvageable and should not undergo ED thoracotomy. The burden of unreimbursed care for this procedure is not trivial. Indications for ED thoracotomy in pediatric trauma victims should therefore be the same as those currently used for adult trauma victims.

Adolescent↗
PubMed1998

Pulmonary tractotomy as an abbreviated thoracotomy technique.

BACKGROUND: Operative abbreviated thoracotomy techniques in thoracic trauma include emergency center thoracotomy, ligation of major arterial branches, packing the thoracic cavity for diffuse bleeding, towel clip or Bogota bag closure of the chest, and pulmonary tractotomy. Pulmonary tractotomy with selective vascular ligation was originally described for deep through-and-through lung injuries that did not involve hilar vessels or airways. Pulmonary tractotomy has evolved into use as an abbreviated thoracotomy technique in patients with severe thoracic or multivisceral trauma. As with any operative technique in high-risk patients, specific procedure-related complications may occur and are analyzed herein. The objective of this manuscript is to review the indications, techniques, and results for pulmonary tractotomy in trauma patients requiring abbreviated thoracotomy. METHODS: Medical records were retrospectively reviewed for 30 of 32 consecutive tractotomy patients treated at Ben Taub General Hospital, during a 3-year period. By using a model for logistic regression analysis, the characteristics of each patient and their clinical course were tested for impact on mortality. RESULTS: Seventy percent of patients had at least one intraoperative parameter indicative of acidosis (pH < 7.2), coagulopathy (prothrombin time > 13.8 or partial thromboplastin time > 38.0 seconds), or hypothermia (core temperature < 34 degrees C), and 50% of patients manifested two of these three parameters. The mortality rate among the 30 patients was 17%. Three of the five patients who died were noted to be acidotic, coagulopathic, and hypothermic. Twelve of 25 patients who survived more than 1 day had at least one thoracic complication. There were no late deaths. There was one failed tractotomy and one missed injury. A second thoracotomy was not required for control of a lung injury in any patient. Logistic regression analysis showed that intraoperative blood loss was the only predictive factor for mortality. CONCLUSION: Pulmonary tractotomy is a simple and effective technique in injured patients who require an abbreviated thoracotomy and has an acceptable mortality and complication rate. This follow-up report notes that as definitive therapy, tractotomy continues to allow for direct control of bleeding and air leak and obviates the need for formal resection.

Adolescent↗
PubMed2002

Upper extremity functional assessment after anterior spinal fusion via thoracotomy for adolescent idiopathic scoliosis: prospective study of twenty-five patients.

STUDY DESIGN: A prospective review of upper extremity function in 25 patients after anterior thoracotomy for instrumentation and fusion of thoracic adolescent idiopathic scoliosis was conducted. OBJECTIVE: To assess the effects of anterior spinal fusion with open thoracotomy on upper extremity function. SUMMARY OF BACKGROUND DATA: The treatment of idiopathic scoliosis through anterior thoracotomy and spinal fusion using instrumentation is a new method for correcting and stabilizing patients with major thoracic and thoracolumbar curves. No studies have assessed the functional outcome for the upper extremities after anterior open thoracotomy that involves splitting through the latissimus dorsi and serratus anterior muscles. METHODS: For this study, 25 adolescent patients with idiopathic scoliosis treated surgically were examined over a 3-year period. The average patient age was 15 years and 3 months, with a range of 11 years and 11 months to 20 years and 9 months. Preoperative activities of daily living, active range of motion, and strength were recorded by an independent occupational therapist (L.P.) for both upper extremities. Postoperative measurements were assessed at 1, 3, 6, 12, and 24 months. All the patients underwent a right thoracotomy with ribs used for autograft. The left upper extremity served as the control limb. No patients had associated anomalies or previous upper extremity surgery. All the patients underwent an upper extremity postoperative stretching and strengthening protocol. RESULTS: At 1 month, 35% of the patients had some difficulty with activities of daily living, primarily in tying their shoes and cutting meat with a knife during meals (P = 0.03). However, by 3 months, all the patients could equivocally and independently perform activities of daily living: dressing, bathing, grooming, attending to hygiene, and feeding (P = 1). Full active range of motion in their upper extremities and shoulder was achieved in all the patients by 1 month (P = 1). All 25 patients had regained normal, bilaterally symmetric strength by 3 months (P = 0.25). No postoperative complications occurred. CONCLUSIONS: Patients undergoing anterior spinal fusion with instrumentation after open thoracotomy can expect to regain full function of the ipsilateral upper extremity in terms of strength, active range of motion, and activities of daily living within 3 months. Compliance with a structured postoperative flexibility and strengthening protocol is recommended to optimize functional outcomes. A novel rehabilitation protocol for the upper extremities is presented.

Activities of Daily Living↗
PubMed1994

Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery.

The prevalence and severity of chronic pain after video-assisted thoracic surgery for pulmonary resection remains to be defined. Three hundred forty-three of 391 consecutive patients 3 to 31 months after pulmonary resection by lateral thoracotomy (n = 165) or video-assisted thoracic surgery (n = 178) responded to a questionnaire aimed at comparing the relative occurrence of chronic postoperative pain after video-assisted thoracic surgery and lateral thoracotomy approaches for pulmonary resection. Patients less than 1 year after operation (video-assisted thoracic surgery = 142; thoracotomy = 97) and more than 1 year after operation (video-assisted thoracic surgery = 36; thoracotomy = 68) were analyzed as individual cohorts. Chronic pain was assessed by questioning patients about the presence and the intensity of discomfort on the side of the operation (using a visual analog scale) and their need for analgesic medication and the presence of ongoing limitations in shoulder function. Patients who underwent video-assisted thoracic surgery (less than 1 year from operation) had less pain and subjective shoulder dysfunction although their pain medication requirements were similar to those of thoracotomy patients less than 1 year from operation. After 1 year, there was no significant difference in these "pain related" morbidity parameters between the two surgical approach groups (video-assisted thoracic surgery or thoracotomy).

Chronic Disease↗
PubMedDate not supplied

Ventricular assist device implantation using a right thoracotomy.

Most patients needing implantation of a ventricular assist device (VAD) require repeated sternotomy; some after cardiac surgery, and others later for heart transplantation. The purpose of this study was to establish the right thoracotomy technique as an alternative for VAD implantation to reduce repeated sternotomy-related morbidity and mortality. We performed a right thoracotomy in animals, preclinical cadaver fitting tests, and a clinical case. A total of 20 various animals underwent right thoracotomy for implantation of bi-VAD (BVAD, n = 17) and left VAD (LVAD, n = 3). The right chest cavity was entered through the fourth intercostal space with partial resection of the fifth rib. There was no procedure-related morbidity or mortality, except for one calf with right anterior leg paralysis. Preclinical fitting tests were performed on 7 human cadavers to observe the anatomical feasibility of BVAD cannulation from the right side of the heart. In humans, the ascending aorta, interatrial groove, right atrium, and main pulmonary artery were identified as optimal cannula insertion sites for BVAD implantation. A patient with cardiogenic shock underwent a right thoracotomy for implantation of an external LVAD. Cardiac function recovered after 3 weeks, and the device was successfully explanted through a repeat right thoracotomy. In conclusion, a right thoracotomy can be an alternative method to the standard median sternotomy for patients who need repeated sternotomy because of previous cardiac surgery, transplantation at a later date, or those with mediastinal infections.

Aged↗
PubMed1996

Routine video-assisted thoracoscopy prior to thoracotomy.

We investigated the role of routine video-assisted thoracoscopy (VAT) prior to thoracotomy. From June 1993 to May 1995, we routinely performed VAT prior to all our elective thoracotomies in adults. Patients who planned to have video-assisted thoracic surgery (VATS), those who underwent emergency thoracotomy, and patients younger than 10 years old were excluded from this study. There were 63 patients (47 men and 16 women; age range, 16 to 84 years), of whom 39 (62%) had malignant disease and 24 (38%) had benign disease. In four cases, VAT could not be performed because of either pleural symphysis or inability to adequately collapse the upper lung. In six cases, thoracoscopic findings influenced subsequent management. Pleural metastases were found in two cases that led to abandonment of thoracotomy; in four cases, identification of chest wall involvement by a malignant or benign process led to proper planning of subsequent thoracotomy. There was no added morbidity from this procedure which took, on average, 6.2 min to complete (range, 3 to 17 min). There was no added cost for consumables. We concluded that: (1) routine VAT is a safe procedure; (2) it adds little to the overall cost or operating time; (3) it can provide useful information that could alter subsequent operative strategy. We recommend routine VAT prior to thoracotomy in patients with known or suspected intrathoracic malignancy and those suspected of having chest wall involvement on CT scans.

Adolescent↗
PubMed1999

[Thoracoscopy versus thoracotomy in spinal surgery: comparison of 2 paired series].

PURPOSE OF THE STUDY: This study was carried out to compare the intraoperative and postoperative results of conventional surgery of the thoracic spine by thoracotomy with those of the thoracoscopic technique to determine the advantages of this new approach. MATERIAL AND METHODS: A series of twenty-nine patients operated by thoracoscopy for a spinal disorder was matched regarding the etiology of spine disease and type of surgical procedure with twenty-four patients operated by thoracotomy. This matching procedure yielded two similar groups of twenty patients. The criteria used for evaluation were the duration of the procedure, blood loss, intraoperative complications, the duration of stay in postoperative intensive care, the duration and yield of pleural drainage, the time until return to the upright position, duration of use of WHO grade-three analgesics (morphine derivatives), the postoperative complications, and the length of hospitalization. RESULTS: There was a significant difference in three parameters: the duration of the procedure (thoracotomy, 172 min; thoracoscopy, 246 min; p < 0.006), intraoperative bleeding (thoracotomy, 837 mL; thoracoscopy, 447 mL; p < 0.0009), and duration of use of WHO grade-three analgesics (thoracotomy, 4.5 days; thoracoscopy, 2.3 days; p = 0.011). There was no difference in the intra- or postoperative complication rates of the two methods. DISCUSSION: The better view provided by thoracoscopy and its preservation of the wall structures probably explain why there was less bleeding and postoperative pain with this technique. The insufficiency of the current thoracoscopic instrumentation and the learning curve account for the longer duration of these interventions. CONCLUSION: These data confirm the usefulness of thoracoscopy which is less traumatizing, less hemorrhagic, and causes no more complications than thoracotomy. The longer operative duration is currently a minor drawback, and should shorten with experience and the development of specific instrumentation.

Adolescent↗
PubMed2001

[Limited thoracotomy as surgical therapy for lung cancer: lobectomy and lymph node dissection by means of 12 cm skin incision].

In the domain of respiratory surgery minimally invasive approaches are currently being used and video-assisted thoracic surgery (VATS) is one of these methods. However VATS has some problems in its use for malignant lung diseases for example, with VATS adequate lymph node dissection and continuation of lobectomy in cases with severe adhesion are both difficult. In consideration of these points, limited thoracotomy has been practiced for treatment of lung cancer in our hospital. This study made comparisons between this new method (group A) and the conventional standard thoracotomy (group B). For the limited thoracotomy group (A) the skin incision and amount of bleeding were smaller than for the standard thoracotomy group (B) and the operation time was shorten. All limited thoracotomy group patients could lift up and move the hand of the affected side without pain immediately after the operation. The limited thoracotomy is an excellent approach as a curative operation for lung cancer, for preservation of post-operative pulmonary function, for movement capacity of the hand of the affected side and from the cosmetic viewpoint.

Adult↗
PubMed2001

The preferred approach for mitral valve surgery after CABG: right thoracotomy, hypothermia and avoidance of LIMA-LAD graft.

BACKGROUND AND AIM OF THE STUDY: An alternative to avoid redo sternotomy in patients with patent left internal mammary artery-left anterior descending coronary artery (LIMA-LAD) grafts undergoing mitral valve surgery is right thoracotomy with moderate-deep hypothermia (approximately 20 degrees C) and fibrillatory arrest without aortic cross-clamping. Few reports exist which directly compare re-sternotomy and right thoracotomy. METHODS: Between July 1992 and February 2000, 47 patients (39 males, eight females; median age 66 years; range: 41-83 years; 41 in NYHA class III or IV) with patent LIMA-LAD grafts underwent mitral valve surgery. Thirty-seven patients were approached through a right thoracotomy with moderate-deep hypothermia (median 20 degrees C) and fibrillatory arrest (right thoracotomy group), and 10 were approached through a re-sternotomy, with aortic cross-clamping and cardioplegic arrest. The median ejection fraction was 42% (range: 20-71%). Univariate analysis was used to determine predictors of outcome, as well as to evaluate differences in characteristics between groups. RESULTS: Operative mortality (OM) and perioperative myocardial infarction for the entire cohort was 11% and 10%, respectively, and there were no inter-group differences. No preoperative characteristics were associated with OM. Two LIMA-LAD graft injuries occurred in the re-sternotomy group compared with none in the right thoracotomy group (20% versus 0%, p = 0.04). Transfusion requirements were also greater in the redo sternotomy group (median 7 versus 2 packed red blood cell units, p = 0.04). CONCLUSION: Right thoracotomy with moderate-deep hypothermia and fibrillatory arrest is the preferred approach for reoperative mitral valve surgery after coronary artery bypass grafting in the presence of patent LIMA-LAD grafts. These data suggest that this approach is associated with decreased incidence of LIMA-LAD graft injury, as well as reduced transfusion requirements.

Adult↗
PubMed1994

Efficacy of urgent thoracotomy for trauma in patients attended by a helicopter emergency medical service.

Over a 12-month period the Helicopter Emergency Medical Service underwent 1084 missions attending casualties in the London area. Sixteen patients required an emergency thoracotomy for resuscitation, nine of which were performed at the scene and seven in the emergency department. The median injury severity score of these patients was 29.9 (SIR 11.8) of which 11 had suffered blunt injuries. Medical attention at scene was administered 16.2 min (SIR 4.0) following the London ambulance service receiving the emergency call. Significantly longer time was spent attending patients who had a scene thoracotomy (35.1 min SIR 16.4) compared with those in whom the thoracotomy was performed in the casualty department. No patient in this series survived resuscitative thoracotomy. It is suggested that scene thoracotomy be abandoned and emphasis placed upon the rapid transport of patients to an emergency facility. This enables other resuscitative measures in addition to thoracotomy to be applied effectively and concentrated over a brief period by a multidisciplinary team.

Adolescent↗
PubMedDate not supplied

Double-blind randomized evaluation of intercostal nerve blocks as an adjuvant to subarachnoid administered morphine for post-thoracotomy analgesia.

BACKGROUND AND OBJECTIVES: Thoracotomy is associated with pain and compromised pulmonary function. Intercostal nerve blocks (INB) and subarachnoid morphine (SM) act on different portions of the pain pathway. Each is effective for post-thoracotomy pain relief. The combination of these two modalities in relieving post-thoracotomy pain and improving postoperative pulmonary function has not been investigated. METHODS: In a double-blind study, 20 patients undergoing lateral thoracotomy for lung resection were randomized to receive 0.5 mg SM preoperatively and INB with bupivacaine (INB+) prior to wound closure or 0.5 mg SM with INB using saline (INB-). Visual analog scale pain scores at rest, with cough, and with movement of the ipsilateral arm, forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC) were measured at 4, 24, 48, and 72 hours after the operation. Opioid use was measured during the initial 24 hours after the operation. RESULTS: At 4 hours, the INB+ group demonstrated better FEV1 (56.6% vs. 40.4% of baseline, P < .05) and FVC values (54.6% vs. 39.6% of baseline, P < .05) and less resting and cough pain (P < .05). However, FEV1 continued to decline in the INB+ group at 24 hours to lower than the INB- group although pain scores were similar beyond 4 hours. Opioid usage during the first 24 hours was similar (INB-, 16.7 mg vs. INB+, 13.2 mg, P = .7). CONCLUSIONS: Although postoperative INB provided modest improvements in pain and pulmonary function when used as an adjuvant to 0.5 mg SM for post-thoracotomy analgesia, the benefits were transient. The authors do not recommend adding INB for patients undergoing lateral thoracotomy who receive 0.5 mg SM.

Aged↗
PubMed1996

Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome.

To assess the efficacy of emergency thoracotomy performed for thoracic trauma in the accident and emergency department, a retrospective analysis of patients who underwent this procedure and were brought to hospital by the Helicopter Emergency Medical Service was carried out. Between 1991 and 1994, 16 patients had emergency thoracotomy performed in the accident department. Twelve patients had sustained blunt trauma and four patients had sustained penetrating injuries. Three patients first assessed at the scene and 11 patients on arrival at the emergency department had Glasgow Coma Scores < 3. Eight thoracotomies were performed by the cardiothoracic team and eight by the trauma team. There was one survivor in this group; he had been stabbed at multiple sites and emergency thoracotomy was required to control bleeding from an intercostal vessel. Our results demonstrate experience of one of the first phase Level One trauma centres in the United Kingdom. From our small series, we believe that selection criteria for emergency thoracotomy in trauma patients need to be revised. From this series and a review of the literature, patients with penetrating injuries, vital signs at the scene and those with a high index of suspicion for tamponade seem to benefit most from thoracotomy in the emergency setting.

Adolescent↗
PubMed1997

[Effect of thoracoscopic procedure versus standard posterolateral/muscle-sparing thoracotomy on pulmonary lung function].

To understand the effects of thoracoscopic approach to thoracotomy on lung function, we investigated the changes in lung function after thoracoscopic operation (n = 7) and compared them to those after standard posterolateral (n = 5) or muscle-sparing thoracotomy (n = 6). In 18 patients with benign lung tumor in which surgical treatment resected in partial resection of the lung tissue, we measured TLC, VC, RV, FEV1.0, FEV1.0%, Peak Flow and DLco preoperatively and at 2, 4 weeks postoperatively. In the standard posterolateral or muscle-sparing thoracotomy groups, FVC, TLC, FEV1.0 and Peak Flow decreased to about 80% of preoperative value at 2 weeks. At 4 weeks after operation, these values showed to increase some what, but did not reach to the preoperative value. Whereas, the thoracoscopic procedure group, did not show the decrease in lung function through the time course. There was not significant different between standard posterolateral and muscle-sparing thoracotomy. We conclude that thoracoscopic approach is an useful technique to thoracotomy because of its minimizing after thoracotomy effect of lung function loss.

Adult↗
PubMedDate not supplied

[The incidence of emergency thoracotomy in thoracic trauma. 7000 cases of thoracic trauma (T.T.) treated in the period of 1978-1995].

With intensive care, pleural drainage and judicious physiotherapy most thoracic injuries can be treated adequately. We reviewed the experience with urgent thoracotomy, to compare the relative indications and injury pattern after blunt versus penetrating trauma. Among 7000 patients with thoracic trauma (T.T.), excluding 319 resuscitative thoracotomy, 83 required urgent thoracotomy. A thoracotomy was necessary in 14% of the patients with blunt thoracic trauma, and 33% with penetrating trauma. Thoracotomy for penetrating trauma was performed earlier and had better results than thoracotomy for blunt trauma. Seventy-five percent of penetrating trauma were operated in the first hour after admission against 29% of blunt trauma. Postoperative mortality for penetrating trauma was three times lower than for blunt trauma (18% versus 56%). Surgical procedure depends on the type and extend of the thoracic and general injuries and on the patients general condition.

Emergencies↗
PubMed1984

Pain amelioration after thoracotomy: a prospective, randomized study.

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 +/- 9.2% (standard deviation; p less than 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 +/- 7.5% (p less than 0.05) than in the control group (38.4 +/- 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.

Adult↗
PubMedDate not supplied

Muscle-splitting posterolateral thoracotomy: a novel technique.

PURPOSE: In an effort to decrease the morbidity of a standard posterolateral thoracotomy, numerous muscle-sparing approaches have been developed. However, these incisions have been limited by the need for excessive muscle retraction with resultant neuropraxia, difficulty with exposure, and postoperative wound seroma. We report our results of a novel muscle-splitting thoracotomy incision, which affords excellent exposure without significant morbidity. METHODS: We conducted a retrospective chart review of 37 consecutive patients who underwent "muscle-splitting" thoracotomy from June 1997 to June 1998. The technique, which involves a bidirectional spread of the latissimus dorsi and serratus anterior muscles, was performed by the same attending surgeon in all patients. RESULTS: There were 22 male and 15 female patients, aged 26 to 81 (mean, 58), with a body mass index ranging from 18 to 40 kg/m(2) (mean, 25 kg/m(2)). Procedures included lobectomy/segmentectomy (19), wedge resection (5), pneumonectomy (2), Belsey IV fundoplication (5), Ivor-Lewis esophagogastrectomy (1), T8/T9 thoracic exposure (1), and miscellaneous thoracic cases (4). Operative time ranged from 90 minutes to 420 minutes (mean, 176), which was comparable with similar procedures through a standard incision. No patients required conversion to a muscle-cutting thoracotomy. CONCLUSIONS: Our technique of muscle-splitting posterolateral thoracotomy appears to provide excellent operative exposure and to avoid problems seen with current muscle-sparing incisions. A prospective, randomized trial to compare this technique with a standard thoracotomy incision would be useful in determining its viability as an alternative thoracic approach.

Journal Article↗
PubMed1983

Rationale for selective application of Emergency Department thoracotomy in trauma.

The indiscriminate application of thoracotomy in the resuscitation of trauma has recently been challenged. Since 1 May 1974 400 consecutive trauma patients have undergone resuscitative thoracotomy in our Emergency Departments (ED). The mechanism of injury was blunt in 195 (49%) patients, gunshot wound in 147 (37%), and stab wound in 58 (14%) Upon arrival in the ED, 352 (88%) patients had no obtainable blood pressure (BP), 334 (84%), fixed pupils, and 315 (798%) failed to exhibit agonal respirations or other waning signs of life. One hundred six (27%) patients reached the operating room and 28 (7%) survived to be admitted to the intensive care unit. Sixteen were eventually discharged from the hospital, but four of these survivors had sustained irreversible cerebral damage. Overall, 12 of 400 (3%) patients survived ED thoracotomy with intact neurologic function. Four factors appeared predictive of poor prognosis. There were no survivors with intact neurologic function among: 150 patients sustaining blunt trauma and arriving in the ED without signs of life (BP, pupil reactivity, respiratory effort); or 87 patients with penetrating torso injuries who had no signs of life at the scene. Following thoracotomy, in the absence of cardiac tamponade, there were no intact survivors of 124 patients without cardiac activity or of aortic occlusion. We believe the above factors should militate against initiating resuscitative thoracotomy in the ED or in deciding to continue heroic measures following thoracotomy.

Adolescent↗