All patients undergoing thoracotomy should have postoperative drainage of the pleural space. The chest tube used must be of adequate size, and anything less than a 32 French catheter will obstruct with blood clots. It is often advantageous to have two chest tubes in the postoperative chest—one lying over the diaphragm muscle in the posterior gutter along the spine and the other directed anteriorly. The posterolateral chest tube is brought out through stab wounds in the skin as low as possible in a posterolateral position (Figure 12). The chest tubes are to be placed prior to the closure of the thoracotomy and should ideally be anterior to the midaxillary line for patient comfort and ease of drainage. Single, untied skin nonabsorbable sutures may be placed through the stab wound before the tube is inserted to aid in closing when the chest tubes are withdrawn. In placing the chest tube, the surgeon first grasps the lower cut edges of the latissimus dorsi and the serratus anterior, and the assistant retracts them superiorly. The surgeon forms a tunnel through the chest wall with Kelly forceps, grasps the chest tube, and draws it out through the wall. The catheter serves two main purposes: to remove air escaping from lung parenchymal injury. The chest tubes are usually attached with underwater seal with or without sutures for as long as there is drainage from the pleural space or persistence of an air leak (Figure 13). Should excessive air leakage be present, another chest tube is placed in the second or third interspace anteriorly at the level of the midclavicular line (Figure 13). A smaller Silastic catheter will suffice and will be the last chest tube to be removed. The catheters allow expansion of the lung with approximation of pleural surfaces and thus prevent postoperative atelectasis and fluid accumulation with infection. The catheters are usually attached to an underwater-seal device with or without negative suction (Figure 14).