Posterolateral thoracotomy for tumor excision

Pushpa1*, Bharathi2

1Operation Theater In charge, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

2Operation Theater Secretary, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

*Correspondence

Abstract

Lateral thoracotomies include many different variants with a common pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. We will describe first the standard posterolateral thoracotomy, which has been the classic reference, and then the muscle-sparing posterolateral thoracotomy. Surgical techniques, indications, pitfalls, and tips are described. Discussion and an overview of literature are developed.

Key words: Lateral thoracotomies; Posterolateral thoracotomy; Pneumonectomy

Introduction

A posterolateral thoracotomy is the traditional “gold standard” surgical incision for accessing the thoracic cavity, particularly for major lung resections like pneumonectomy or lobectomy. Performed with the patient in a lateral decubitus position, this approach involves a curved incision from the back, around the scapula to the axilla, allowing extensive access to the lungs, esophagus, and mediastinum. It offers excellent exposure but is associated with more pain and potential respiratory muscle impact compared to muscle-sparing or VATS techniques

Case presentation

18 years female was presented with history of back pain for 2 months and now complaints of angina, dyspnea, palpitation, giddiness. She initially went to GH and came here for further management.  She was diagnosed with left upper lobe lesion, osteochondroma from left 4th rib, pulmonary hematoma, malignant peripheral nerve sheath tumor.

On examination

Patient conscious, oriented and Afebrile

Temp97.6 F
PR98 beats /min
RR20 breaths /min
BP100/60mmHg
SpO297 % decreases while on RA
CVSS1S2+
RSBAE+
P/ASoft
CNSB/L PERL+
Height48cms
Weight40kgs

Pre OP medications

Tab. Hifenac P 100/650

Pre OP investigations

Hb11.7g/dL
RBC Count4.10ml/109
WBC Count7960 cells/mm3
Urea15mg/dl
Creatinine0.4mg/dl
Na137mmol/L
K4.4mmol/L
SerologyNegative
CAGNot done

ECG Pre – OP

ECG post-OP

X-Ray

Before                                                     After

USG

CT scan – Thorax Plain

Impression

  • Osteochondroma away from left 4th
  • Pulmonary Hematoma.
  • Malignant peripheral nerve sheath tumor.

Operation Notes

Diagnosis: Posterior Mediastinal Tumor – Malignant melanoma

Surgery

Posterolateral Thoracotomy for Tumor Excision

Procedure

  • Under DLETGA Posterolateral thoracotomy 6 x 4cm cystic tumor found attached to the lateral wall of chest, feeding vessels from intercostal artery clipped.
  • Hemostasis ensured – Chest drain 32 Fr
  • Routine thoracotomy closure
  • Wound closed in layers

Procedure Image

Benefits of Posterolateral Thoracotomy

A posterolateral (PL) thoracotomy is a traditional, open surgical approach to the chest, characterized by an incision along the back and side. It is often considered the “gold standard” for complex thoracic procedures because it provides the surgeon with unparalleled, direct access to the lungs, esophagus, and mediastinum.

Superior exposure: It provides the best, most direct visualization of the entire thoracic cavity, allowing for safe management of complex, large, or centrally located tumors that might be adjacent to critical structures.

Ideal for extensive resections: It is the preferred method for major operations like a pneumonectomy (removal of the entire lung) or complex lung cancer surgeries, where wide access is necessary for safe resection.

Versatility in trauma: It allows for rapid, wide, and direct access to control severe internal bleeding in emergency trauma situations.

Accessibility for non-cancerous conditions: It is highly effective for treating complicated pleural diseases (like empyema) or performing pulmonary resections when minimally invasive approaches (like VATS) are not technically feasible.

Capacity for extension: If needed during surgery, a PL thoracotomy can be extended to provide even greater access, which is crucial for managing complications or unexpected findings.

Post operative period

0 – POD

  • Patient received from HCOT with AMBU bag ventilation then connected with mechanical ventilator.
  • Mode – SIMV(VC+PS)
  • Fio2 -80%, PEEP- 5cmof H2O, TV-350ml
  • Patient vitals were stable.
  • He was managed with necessary support
  • Adrenaline 1ml/hr
  • NTG 0.1ml/hr
  • Anawin 5ml/hr
  • NS 100ml/hr on flow
  • Total ICD drain – 50ml
  • Every 4hr patient was given back care and ET suctioning
  • Extubation is done and connected with 8-liter O2 via facemask.
  • Nebulization given.
  • Oral care is given.

1st POD

  • Patient vitals are stable.
  • He was managed with necessary support
  • Adrenaline 1ml/hr
  • Anawin 5ml/hr
  • NS 100ml/hr on flow
  • Early morning patient was given mouth care ,combing and dressing done.
  • Total ICD drain -20ml
  • Patient on Room air and stop O2 supply.
  • Arterial line and ICD removed.
  • Liquid diet given.

2nd POD

  • Patient vitals are stable
  • He was managed with Inj. Dexetomidate 2ml
  • CVC removed.
  • Chest Physio Given.
  • Nebulization Given
  • Patient shift to ward with stable status and no complaints.
S NoName of Investigation0 - POD1st - POD
1Hb (g/dL)10.29.6
2PCV (%)2926
3Urea (mg/dl)-16
4Creatinine (mg/dl)-0.5
5Na (mmol/L)135134
6K (mmol/L)2.83.1
7Ph7.377.40
8PO2 49385
9PCo23333
10HCO320.621.9
11Glucose (mg/dL)221129

Advice on discharge

Diet: 1500 Kcal low-fat diet.

Activities: Avoid lifting weights for 3 months.  To continue chest physiotherapy.

Medications

DrugDoseDuration
Tab. Supradyn-OD
Tab. Dolo650mgTDS x 1 week
Cap. Pan d40mgOD (before food)
Syp. Mucolite10mlTDS

Nursing Diagnosis

Ineffective Airway Clearance 

Related to: Increased tracheobronchial secretions, pain, anesthesia, and diminished lung volume capacity.

Interventions: Encourage deep breathing and coughing, splint the incision while coughing, perform endotracheal suctioning, and administer humidifier/nebulizer therapy.

Acute Pain

Related to: Surgical incision, chest tube insertion, and trauma to nerve tissue (neuropathic pain).

Interventions: Assess pain at rest and movement, administer analgesics as prescribed, evaluate pain scores, and maintain epidural or patient-controlled analgesia (PCA).

Impaired Gas Exchange / Ineffective Breathing Pattern 

Related to: Decreased lung capacity, surgical trauma, pleural space manipulation, or presence of chest tubes.

Interventions: Monitor oxygen saturation and respiratory rate, monitor chest drainage system (air leaks/patency), and place in a semi-Fowler’s position.

Impaired Physical Mobility 

Related to: Thoracic incision, pain, and presence of chest drains.

Interventions: Encourage range of motion exercises for the shoulder and arm on the affected side to prevent frozen shoulder and encourage early ambulation.

Risk for Infection 

Related to: Surgical incision, chest tube, and invasive procedures.

Interventions: Monitor wound site for redness, heat, and drainage; maintain sterility of chest tube dressing.

Anxiety

Related to: Surgical outcome, pain, and unfamiliar technology (chest drainage systems).

Interventions: Provide emotional support, explain all procedures, and teach about the purpose of the chest drainage system.

Risk for Imbalanced Fluid Volume 

Related to: Surgical blood loss or fluid overload following pneumonectomy.

Interventions: Monitor hourly intake and output, monitor for signs of pulmonary edema.

Deficient Knowledge 

Related to: post-operative care, exercises, and restrictions at home.

Interventions: Instruct deep breathing exercises, arm/shoulder exercises, smoking cessation, and signs of infection to report to the provider.

Nursing management

Preoperative care

Education: Instruct on incentive spirometer use, deep breathing exercises, and splinted coughing.

Preparation: Ensure pulmonary function tests are done, promote smoking cessation, and perform mouth care to reduce infection risk.

Postoperative care

Respiratory management

Monitor SPO2 (>94%) and respiratory rate/depth.

  • Auscultate breath sounds (diminished sounds may indicate atelectasis or pneumothorax).
  • Encourage incentive spirometry hourly to prevent pneumonia.
  • Administer oxygen as ordered.

Pain management

  • Assess pain intensity (0-10 scale) at rest and with movement.
  • Administer analgesics (often epidural or PCA) to facilitate deep breathing.

Chest tube maintenance

  • Ensure the drainage system is below the chest level, tubing is patent (no kinks), and suction is correctly set.

Positioning & mobility

  • Elevate the head of the bed (semi-Fowler’s) to aid breathing.
  • Turn the patient and encourage early ambulation.

Wound care

  • Inspect incision site for signs of infection (redness, drainage, dehiscence).
  • Maintain sterile dressing on the chest tube site.

Monitoring complications

  • Watch tachycardia and hypotension (tension pneumothorax or hemorrhage).
  • Monitor for subcutaneous emphysema (crepitus) around the incision.

Discharge education

  • Instruct on wound care, pain management, and smoking cessation.
  • Advice to avoid heavy lifting and report fever (>101.5°F), increased shortness of breath, or foul-smelling drainage.

Reference

  1. Frederick JR, Woo YJ. Thoracoabdominal aortic aneurysm. Ann Cardiothorac Surg. 2012 Sep;1(3):277-85. [PMC free article] [PubMed]
  2. Cao H, Zhou Q, Fan F, Xue Y, Pan J, Wang D. Right anterolateral thoracotomy: an attractive alternative to repeat sternotomy for high-risk patients undergoing reoperative mitral and tricuspid valve surgery. J Cardiothorac Surg. 2017 Sep 21;12(1):85. [PMC free article] [PubMed]
  3. Romano MA, Haft JW, Pagani FD, Bolling SF. Beating heart surgery via right thoracotomy for reoperative mitral valve surgery: a safe and effective operative alternative. J Thorac Cardiovasc Surg. 2012 Aug;144(2):334-9. [PubMed]
  4. Park CB, Suri RM, Burkhart HM, Greason KL, Dearani JA, Schaff HV, Sundt TM. Identifying patients at particular risk of injury during repeat sternotomy: analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg. 2010 Nov;140(5):1028-35. [PubMed]
  5. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA., Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. [PubMed]
  6. Edmiston CE, Bruden B, Rucinski MC, Henen C, Graham MB, Lewis BL. Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. 2013 May;41(5 Suppl):S49-55. [PubMed]
  7. Holman WL, Goldberg SP, Early LJ, McGiffin DC, Kirklin JK, Cho DH, Pacifico AD. Right thoracotomy for mitral reoperation: analysis of technique and outcome. Ann Thorac Surg. 2000 Dec;70(6):1970-3. [PubMed]
  8. Ginsberg RJ. Alternative (muscle-sparing) incisions in thoracic surgery. Ann Thorac Surg. 1993 Sep;56(3):752-4. [PubMed]
  9. Sakakura N, Mizuno T, Arimura T, Kuroda H, Sakao Y. Design variations in vertical muscle-sparing thoracotomy. J Thorac Dis. 2018 Aug;10(8):5115-5119. [PMC free article] [PubMed]
  10. Reid JC, Jamieson A, Bond J, Versi BM, Nagar A, Ng BH, Moreland JD. A pilot study of the incidence of post-thoracotomy pulmonary complications and the effectiveness of pre-thoracotomy physiotherapy patient education. Physiother Can. 2010 Winter;62(1):66-74. [PMC free article] [PubMed]

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment