This incision is ideal for a wide variety of elective as well as emergency procedures. Through the left side, the left lung, the heart, descending aorta, lower esophagus, vagus nerves, and diaphragmatic hiatus are well exposed, whereas both vena cavas, the right lung, the superior exposure of the hepatic veins, and the upper esophagus are approached through the right chest.
The height of the incision on the chest wall varies with the nature of the procedure to obtain optimum exposure of either the apex, the middle, or the basal portions of the chest cavity. One or more ribs may be divided posteriorly and occasionally removed, depending on the mobility of the chest wall and the exposure required. For optimum exposure of the upper portion of the chest cavity, such as in closure of a patent ductus or resection of a coarctation, the chest is entered at the level of the fifth rib. This may be divided posteriorly, along with the fourth rib, if necessary. For procedures on the diaphragm and lower esophagus, the thoracic cavity should be entered at the level of the sixth or seventh rib. If still wider exposure is desired, one or two ribs above and below may be transected at the neck.
Except in acute emergencies, the patient must be prepared for optimal pulmonary function by cleaning the tracheobronchial tree with postural drainage, expectorants, and antibiotics, which may be given both systemically and by inhalation. Preventative spirometry is preferably started preoperatively to improve compliance postoperatively. Patients should be advised not to smoke for several weeks before an elective operation. Pulmonary function studies a room air blood gas should be performed on all patients being considered for thoracotomy. A further evaluation can be obtained by noting the patient's tolerance to climbing stairs. For practical purposes, any patient able to walk up three flights of stairs will tolerate a thoracotomy. When a patient has borderline pulmonary function, aggressive preoperative pulmonary rehabilitation may be appropriate. Because technical difficulties may arise necessitating more extensive resection than planned, the surgeon must be thoroughly familiar with the patient's respiratory reserve.
Prior to undergoing a thoracotomy, all patients should undergo fibro-optic bronchoscopy at the beginning of the case via a single-lumen endotrachial ...