The most common indications for thoracotomy include the surgical treatment of conditions of the distal aorta, heart, oesophagus, and lungs.
Distal thoracic aortic disease may include dissection, rupture, or aneurysmal disease.
Cardiac conditions potentially requiring thoracotomy include congenital heart defects (atrial septal defect), disease of the aortic, mitral, and tricuspid valves, at certain locations of the coronary arteries, pericardial disease, and tumours of the heart and pericardium. However, many of these indications for thoracotomy can also be approached via median sternotomy.
Pulmonary disease is most commonly treated with video-assisted thoracoscopic surgery (VATS), but many pulmonary diseases requiring conventional open surgery are treated via thoracotomy. These include, for example, advanced lung malignancies (primary or metastatic) and pleural malignancies.
Oesophageal diseases that can be treated via thoracotomy include, among others, malignancies in adults and tracheo-oesophageal fistulas in infants. Right-sided thoracotomy is best suited for disease processes involving the mid-oesophagus. Left-sided thoracotomy provides good access to the distal oesophagus. A transhiatal approach may also be considered.
In order to reduce the invasiveness of the approach – in particular the transection of large muscle masses – so-called muscle-sparing approaches are advocated. These include the anterolateral thoracotomy, which spares the latissimus dorsi muscle. However, this requires splitting the serratus anterior muscle in the direction of its fibres. For minor and moderate thoracic procedures such as emphysema surgery, resection of giant bullae, standard lung resections, and conditions of the anterior segments of the lungs or the anterior mediastinum, the anterolateral thoracotomy provides adequate access. While muscle-sparing approaches have been attributed with reduced analgesic consumption in the early postoperative days, the benefits have yet to be proven.
A drawback of the anterolateral thoracotomy is the difficult access to the posterior structures of the mediastinum, which makes extension of the procedure difficult if, for example, the tumour extent is greater than anticipated preoperatively. The anterolateral approach should therefore be reserved for simple resections or benign disease; complex oncological resections and extensive procedures should be performed via a posterolateral approach because of these difficult options for extension.