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Thoracotomy is a surgical procedure to give a surgeon access to the chest cavity.
There are two methods of entry.
The first method gives superior access to specific structures in one side of the chest (depending on which ribs the incision is made), whilst the median thoracotomy allows a more general inspection of both sides.
Thoracotomy is rarely carried out in first opinion practice, and is more common in a referral setting. The aim is to gain physical access to a particular anatomical structure (such as a lung tumor or the heart) in order to remove it or correct a problem.
The entirety of the chest is clipped and aseptically prepared for surgery. For an intercostal thoracotomy the patient lies on their side. The surgeon plans where to make the incision using preoperative imaging, and then counts the number of ribs to find the correct space. A long skin incision is made between two ribs, from the spine down to the sternum. The sheet of muscle overlying the ribs is incised, and then further muscles are cut to gain access to the chest cavity. The ribs are held apart using retractors, so as to allow good visualization. A chest drain is placed and then the ribs closed and bound together with strong suture material.
For a median thoracotomy the patient lies on their back. A skin incision is made and then an oscillating saw is used to cut through the cartilage of the sternum. Again, a chest drain is placed prior to closure, and the sternum held together with wire sutures.
The skin incision is closed and the patient woken.
In itself, thoracotomy is a successful procedure that provides good surgical access to the chest. The ultimate outcome depends on selecting the most appropriate entry route. For example, it is difficult to perform a complete exam of all thoracic structures via an intercostal thoracotomy, however the latter can gives superior access to specific structures should removal be required.
When indicated, thoracotomy is a valuable tool to enable removal of diseased structures or collect samples for analysis. The alternative would be to manage conditions medically, which may be possible in the short term but in the longer term is likely to lead to morbidity due to progression of the initial problem.
Skillful use of pain relief can greatly improve patient comfort and speed recovery. Tips such as using local anesthetic around the thoracotomy site and dripping local into the chest prior to closure also make a big difference to patient comfort.
The patient must be closely monitored in the hours following the procedure. Complications include leakage of air into the chest, hemorrhage, circulatory collapse, and hypothermia. All of these can usually be addressed when spotted early.
After thoracotomy, the dog must not exert itself for several weeks, in order to allow adequate tissue healing. The skin sutures are removed after 10 to 14 days.
There may be significant costs involved in the workup prior to thoracotomy. This could include specialist consultations fees of $200 and $1,500 for an MRI scan. The actual thoracotomy is likely to cost upwards of $3,000, with additional costs for complex surgery once within the chest. Also the expense of postoperative nursing cannot be ignored, at around $600 per night.
Thoracotomy is a major surgical procedure, but should not be discounted as an option because of this. With good postoperative nursing, most patients do very well and morbidity rates are low. The advantage of thoracotomy is that it enables removal of the root cause of a problem, so when surgery is successful there may be a good chance of a 'cure'.
Thoracotomy may be performed to stabilize a patient after a blunt trauma, such as a traffic accident. It is always advisable for owners to keep their dog on a leash near to roads and to have them trained to a solid recall.
Dogs that require surgical correction of congenital heart disease should not be bred from.
Other conditions such a primary lung tumors, do not have an identifiable inciting cause and so prevention is not appropriate in this context.
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