General anesthesia is used. Video-assisted thoracoscopy is a minimally invasive approach to intrathoracic surgical conditions and is being increasingly used. It involves the formation of several (usually 2–3) thoracoscopy ports. This involves creating 0.5–1-cm skin incisions, with dissection through the intercostal spaces and, thus, into the pleural space. The exact location of these thoracoscopy ports is dictated by the intrathoracic problem in question. For pulmonary parenchymal resections (e.g., lung biopsies), two 1-cm ports are made in the 5th intercostal space, the first in the anterior axillary line and the second in the midaxillary line. A further 5-mm port is made in the 4th intercostal space in the posterior axillary line. These port placements can also be used for resection of anterior mediastinal lesions such as germ cell tumors or thymic masses. To approach the posterior mediastinum, the ports must be made in the 3rd, 4th, and 6th intercostal spaces in a vertical line in a position between the midaxillary and anterior axillary lines. Pleural conditions requiring resection or biopsy can be approached simply by two ports in the 6th or 7th intercostal space between the midaxillary and anterior axillary lines. These ports are placed in a lower intercostal space than for pulmonary or mediastinal lesions, such that drains can be placed in a more dependent position to allow more complete drainage of pleural fluid (e.g., to allow for an effective pleurodesis in malignant effusions).

The abovementioned thoracoscopy sites may have to be varied depending on the position of the lesion to be inspected, biopsied, or resected. In particular, lower lobe pulmonary parenchymal lesions often necessitate the use of ports placed in the 6th or 7th intercostal spaces. Pleural adhesions are not uncommon and may prevent successful thoracoscopic surgery. If the pleural space is obliterated, then thoracoscopy will be impossible and the surgeon would need to resort to open thoracotomy. With a partially obliterated pleural space, pleural adhesions can be dissected and allow enough mobilization of the lung to permit the procedure to be carried out thoracoscopically.

See Table 5.2. A significant number of intrathoracic surgical procedures are now performed using the thoracoscopic approach. The main limitation of the thoracoscopic approach involves the fact that, by virtue of the inability to palpate intrathoracic organs, small pulmonary parenchymal lesions not evident on visual inspection of the lung alone may be difficult to locate and thus resect. Serious complications are relatively rare.

The most serious complication of the thoracoscopic approach to intrathoracic pathology is bleeding from the intercostal vessels. This can usually be controlled through the thoracoscopy port but, rarely, will require a minithoracotomy (in the same intercostal space) to control the bleeding. Intercostal neuralgia can occur following thoracoscopy but is significantly less frequent than following thoracotomy. Inadvertent injury to the lung is also possible especially in the presence of dense pleural adhesions, and occasionally pneumothorax or persistent air leak may result. Complications specific to the underlying problem and reason for the thoracoscopy may occur. Basal atelectasis and sometimes secondary lung infection are not uncommon and may affect either lung. Empyema and abscess formation are very rare but are severe if they occur leading to prolonged hospital stay and other sequelae. Multisystem organ failure is extremely serious, the incidence being most related to the underlying lung pathology and other comorbidities.

General anesthesia is used. Thoracotomy involves a full-thickness incision into the pleural space by way of the intercostal space. A thoracotomy can be anterolateral, lateral, posterolateral, or manubriosternal depending on the intrathoracic pathology being attended to. Thoracotomy alone is typically used for exploration, diagnosis, biopsy, decortication, pleurodesis, and the like.

An anterolateral thoracotomy involves an incision between the midclavicular line and the anterior axillary line, usually through the 5th intercostal space.

A true lateral thoracotomy involves an incision situated between the anterior and posterior lines in the 5th or 6th intercostal space incising through serratus anterior and the anterior border of the latissimus dorsi muscles.

A posterolateral thoracotomy involves extension of the lateral thoracotomy skin incision below the tip of the scapular and extending posterosuperiorly between the medial border of the scapular and the vertebral spinous processes. The incision extends through serratus anterior muscle and latissimus dorsi and can also extend to involve the trapezius and paraspinal group of muscles.

An anterior thoracotomy involves dissection through the serratus anterior muscle and the intercostal muscle.

Once the intercostal muscles and parietal pleura have been dissected, then a retractor is placed between the ribs and opened. To facilitate the opening of the intercostal space, a short segment of the posterior rib (either above or below) can be resected, but children usually have very flexible ribs.

A median sternotomy involves a skin incision located between the suprasternal notch and the xiphisternum. A midline division of the manubrium, sternal body, and xiphisternal process is then performed, using a bone saw. This incision allows access to the pericardium and medial aspect of both pleural spaces.

There are few anatomical variants that affect this procedure; however, chest wall deformities such as pectus excavatum and scoliosis may alter the ease of approach and therefore the complications. Acquired anatomical changes due to disease, including trauma or previous surgery, can also affect the ease and results of surgery.

See Table 5.3. The various thoracotomy incisions require significant muscle dissection and result in trauma to the ribs and costovertebral, costotransverse, costochondral, and sternochondral joints. Thus, postoperative pain is a significant issue. Furthermore, dissection of the parietal pleura and the introduction of air and blood into the pleural space result in a pleuritic response, which contributes significantly to the patient’s overall pain. Postoperative analgesia in the thoracotomy patient is significantly improved with the use of thoracic epidural catheters and paravertebral (extrapleural) catheters through which analgesia can be administered.

The major complication directly related to a thoracotomy approach is bleeding, either from the chest wall musculature or the intercostal vessels. Intercostal neuralgia, secondary to intercostal nerve injury and/or scarring, occurs more frequently than in thoracoscopic procedures and can be permanent in some cases.

Costochondritis can occur secondary to trauma at the costochondral joints. This may occur not only in the intercostal space involved but also in costochondral joints several ribs above and below the incisions. Inadvertent injury to the lung is also possible especially in the presence of dense pleural adhesions, and occasionally pneumothorax or persistent air leak may result. Complications specific to the underlying problem and reason for the thoracotomy may occur. Basal atelectasis and sometimes secondary lung infection are not uncommon and may affect either lung. Empyema and abscess formation are very rare but are severe if they occur leading to prolonged hospital stay and other sequelae. Multisystem organ failure is extremely serious, the incidence being most related to the underlying lung pathology and other comorbidities.

General anesthesia is used. A partial lung resection may take the form of a wedge resection, segmental resection, single lobectomy, or bi-lobectomy, greatly facilitated by the use of lung stapling devices. A wedge resection involves a non-anatomical resection of a portion of the lung, most commonly for resection of peripheral lung nodules, where the lesion of interest is resected with a small amount of surrounding lung tissue in the shape of a wedge. A segmental resection (or segmentectomy) involves resection of the anatomical segment including segmental bronchus arteries and veins and segmental lymph nodes. A lobectomy is an anatomical resection of the entire lobe, which includes the lobar pulmonary arterial and venous supply and accompanying lobar lymph nodes. The interlobar fissures (oblique and horizontal on the right and oblique on the left) are commonly incomplete. The fissures can be completed using standard pulmonary stapling devices.

Chest wall deformities such as pectus excavatum and scoliosis may alter the ease of approach and therefore the complications. Acquired anatomical changes due to disease, including trauma or previous surgery, can also affect the ease and results of surgery. Fusion of some of the lung fissures may occur making the dissection more difficult. The most common pulmonary vascular variation involves the pulmonary venous supply. In 10 % of patients the right middle lobe pulmonary vein drains directly into the inferior pulmonary vein rather than the superior pulmonary vein. In 2–5 % of patients, there may be a single pulmonary vein receiving tributaries from all lobes. The lobar pulmonary arterial and venous supply is very variable, thus necessitating careful dissection and identification of individual lobar and segmental vessels prior to ligation and transection. Anatomical variation of the bronchial tree is much less common than that of vascular supply. The intra- and extra-pericardial courses of the pulmonary vessels are quite variable, often necessitating the opening of the pericardium for full assessment. This maneuver often allows the surgeon to fully assess the extent of involvement of the vessels by lesions occurring in a central (hilar, mediastinal) location.

See Table 5.4. The major debility resulting from partial lung resections (wedge resection, segmentectomy, or lobectomy) is empyema (pleural space infection). This occurs more commonly when, after resection, there is a significant residual air space. The other major debility resulting from partial lung resection is post-resection bronchopleural fistula. This occurs more commonly in patients with severe underlying lung disease and can result from a leaking bronchial stump or leakage from a pulmonary parenchymal staple line.

Chylothorax can result from damage to the thoracic duct within the chest and occurs more commonly where there has been extensive mediastinal or esophageal dissection.

Intercostal neuralgia, when it occurs, is usually temporary but may be permanent in some cases. More commonly there is a small area of anterior chest wall numbness or paresthesia in the distribution of the intercostal nerve traumatized at the time of thoracotomy.

The most serious complications are empyema and abscess formation. Many patients will require a surgical drainage procedure; with the consequential debility, this entails including prolonged hospital stay and other sequelae. Inadvertent injury to the lung is also possible especially in the presence of dense pleural adhesions, and occasionally pneumothorax or persistent air leak may result. Complications specific to the underlying problem and reason for the partial lung resection may occur. Basal atelectasis and sometimes secondary lung infection are not uncommon and may affect either lung. Chylothorax and bronchopleural fistula formation are chronic debilitating problems that delay recovery significantly. Multisystem organ failure is extremely serious, the incidence being most related to the underlying lung pathology and other comorbidities, and is associated with mortality.

General anesthesia is used. A pneumonectomy is performed via a posterolateral thoracotomy. This procedure involves complete mobilization and isolation of the right or left pulmonary arteries and the superior and inferior pulmonary veins. It is often safer to divide the pulmonary veins prior to the artery since this may allow for more length and an easier division of the pulmonary artery. The main-stem bronchus is then divided as close to the carina as possible, and the bronchial stump may be buttressed with either a flap of pleura or an intercostal muscle flap. When a pneumonectomy is performed for bronchogenic carcinoma, mediastinal lymph node sampling is a standard part of the procedure.

Chest wall deformities such as pectus excavatum and scoliosis may alter the ease of approach and therefore the complications. Acquired anatomical changes due to disease, including trauma or previous surgery, can also affect the ease and results of surgery. Fusion of some of the lung fissures may occur making the dissection more difficult. The most common pulmonary vascular variation involves the pulmonary venous supply. In 10 % of patients the right middle lobe pulmonary vein drains directly into the inferior pulmonary vein rather than the superior pulmonary vein. In 2–5 % of patients, there may be a single pulmonary vein receiving tributaries from all lobes. The lobar pulmonary arterial and venous supply is very variable, thus necessitating careful dissection and identification of individual lobar and segmental vessels prior to ligation and transection. Anatomical variation of the bronchial tree is much less common than that of vascular supply. The intra- and extra-pericardial courses of the pulmonary vessels are quite variable, often necessitating the opening of the pericardium for full assessment. This maneuver often allows the surgeon to fully assess the extent of involvement of the vessels by lesions occurring in a central (hilar; mediastinal) location.