Thoracic Surgery | Specialists and Information

“Thorax” is the medical term for the chest. 

The thoracic wall consists of:

• the sternum and ribs
• the thoracic spine and 
• muscles

Anatomy of the chest @ bilderzwerg /AdobeStock

The thorax encloses the thoracic cavity and the upper part of the abdominal cavity. An important procedure in thoracic surgery is thoracotomy, the opening of the thorax.

Video-assisted minimally invasive surgical techniques (keyhole techniques), such as thoracoscopy, are becoming increasingly important in thoracic surgery.

Thoracoscopy requires only small skin incisions. Postoperative complications are therefore significantly lower compared to open surgery.

Typical conditions treated by thoracic surgery include:

• Injuries to the chest (hematoma, pneumothorax, or lymphocele)
• Tumors (chest wall tumors, lung tumors, and lung metastases),
• Inflammation of the lungs and the chest cavity, and
• Thoracic malformations (pectus carinatum and pectus excavatum)

Even before a surgical procedure on the thorax, the conditions the surgeon will encounter during the operation must be known. Only then can the risks of surgery be assessed and a thoracic surgical procedure be planned.

The goal of diagnosis is to determine the size, extent, and location of a disease (e.g., a tumor), as well as whether other organs are involved.

Diagnostics in thoracic surgery begins with a patient interview (medical history) and a physical examination (percussion).

This is often followed by imaging procedures such as a chest X-ray or a chest CT scan. Depending on the findings, additional procedures such as a puncture, thoracoscopy, or thoracotomy may be performed.

• Percussion—Tapping the Chest

In thoracic surgery, physicians define percussion as tapping the body’s surface. Depending on the type of sound produced, the physician can draw conclusions about possible abnormalities in the thorax.

For example, a hollow sound (sonorous percussion sound) indicates healthy lungs. In contrast, an excessive amount of air—as seen in pulmonary emphysema, asthma, and pneumothorax—results in a hypersonorous percussion sound. This sounds louder and more hollow.

If the sound is quieter and shorter (dull percussion sound), this indicates reduced air content or fluid accumulation. This is the case, for example, with ascites, pleural effusion, or pneumonia.

A hollow, drum-like sound (tympanitic percussion sound) indicates the presence of cavities. These can be found in the digestive tract (e.g., in a gas-filled loop of the intestine).

• Chest X-ray (chest overview)

A chest X-ray is a standard examination in thoracic surgery. The denser a tissue is, the brighter it appears on the X-ray image. Bones and organs are particularly well visualized.

A chest X-ray can detect changes in the lungs. However, a chest X-ray is less suitable for examining the mediastinum and the pulmonary hilum.

The pulmonary hilum is the area of the lung where pulmonary vessels, main bronchi, and lymphatic vessels enter the lung.

• Ultrasound in Thoracic Surgery

An ultrasound examination (sonography) is particularly well-suited for fluid-filled or vascularized organs. For this reason, sonography is used in thoracic surgery, especially for examining the pleura.

It can be used to detect pathological changes and tumors in the pleural region. Ultrasound is used to guide biopsies and punctures.

• Thoracic CT

Since chest computed tomography (chest CT) provides a more detailed image of the body’s interior, it complements or replaces X-ray imaging techniques in thoracic surgery.

The computer assembles the X-ray images, taken layer by layer, into three-dimensional images. This allows the physician to gain a spatial understanding of the anatomy.

• MRI in Thoracic Surgery

In the past, the use of magnetic resonance imaging (MRI) in thoracic surgery was problematic due to the many cavities in the chest. Today, there is an MRI technique that uses helium-3 to visualize lung ventilation.

Unlike chest CT and chest X-rays, the patient is not exposed to radiation during an MRI examination. It is particularly effective at visualizing soft tissues and distinguishing areas of inflammation from healthy tissue.

In thoracic surgery, MRI provides important information about the location and extent of tumors. For this reason, it is used not only for preoperative diagnosis but also for monitoring the progression of tumor diseases.

• Thoracoscopy—Endoscopic Examination of the Chest Cavity

Thoracoscopy is a widely used procedure in thoracic surgery. It is an endoscopic procedure that clarifies suspicious findings in the pleural space, on the pleura, and in the outer parts of the lungs.

Minor procedures on the pleura, the lungs, the thoracic spine, or the mediastinum are also possible.

A thin tube (laparoscope) is equipped with a camera, a light source, and often a device for irrigation and suction.

In addition, surgical instruments can be inserted to take biopsies or perform surgery.

Doctors can also administer medication through the laparoscope. A further development of thoracoscopy is video-assisted thoracoscopy (VATS).

• Thoracotomy—The Surgical Opening of the Chest

A classic procedure in thoracic surgery is thoracotomy. Thoracotomy refers to the surgical opening of the chest through an incision in the intercostal space (intercostal incision).

Depending on the location and size of the incision, different types of thoracotomy are distinguished, e.g.,

• posterolateral thoracotomy
• anterolateral thoracotomy
• dorsolateral thoracotomy
• median thoracotomy)

Open heart surgery is almost always performed via a median thoracotomy (sternotomy, a longitudinal incision through the sternum). The patient lies on their back.

Surgeries on the lungs, aorta, and mediastinum are usually performed via a lateral approach. The patient is positioned on their side during the procedure.

In thoracic surgery, a minithoracotomy is a thoracotomy with an incision no longer than 10 cm.

This procedure is frequently used when:

• Parts of the lung need to be removed
• Video-assisted thoracoscopy is not possible, or
• A chest drain is to be inserted

Since significant pain can occur after a thoracotomy, postoperative pain management is of particular importance

• Thoracocentesis—Draining Fluids

Thoracocentesis involves inserting a hollow needle (trocar) through the chest wall into the chest cavity. Doctors then aspirate fluid from the chest.

When doctors remove fluid from the pleural cavity, this procedure is referred to as a pleural puncture.

• Pleural puncture – removal of fluid

A pleural puncture is a specialized procedure in thoracic surgery. For diagnostic or therapeutic reasons, doctors insert a hollow needle into the pleural cavity to remove fluid.

The pleural cavity is located between the costal pleura and the pulmonary pleura. The patient receives local anesthesia.

The procedure is usually performed under ultrasound guidance. The doctor can mark pleural effusions before the puncture and monitor the needle’s safe advancement.

• Thoracic Drainage (Pleural Drainage)

Thoracic drainage is a widely used procedure in thoracic surgery to remove blood, secretions, or air from the chest cavity.

Depending on where doctors drain the fluid from, the procedure is referred to as:

• pleural drainage (drainage from the pleural space),
• mediastinal drainage (drainage from the mediastinal space), or
• Pericardial drainage (drainage from the pericardial sac)

Thoracic drainage is usually performed after chest surgery. The goal is to remove fluid buildup caused by the surgery.

Thoracic drainage is also used following accidents or severe physical trauma.

However, a chest drain may also be appropriate in connection with other chest conditions or diseases of the cardiovascular system.

These include, for example:

• Pneumothorax and hemothorax
• Serothorax
• Chylothorax or
• Pleural empyema

During thoracic drainage, doctors make a small incision (minithoracotomy) and insert a drainage tube (often made of silicone or rubber). They also usually apply gentle suction.

• Chest wall tumors

Tumors of the chest wall may originate in the chest wall itself. However, they may also develop as secondary metastases from other tumors (e.g., due to the spread of lung or breast cancer).

Since these tumors rarely cause distinct symptoms, they are usually discovered incidentally during an imaging examination. Computed tomography (CT) and, as a supplement, magnetic resonance imaging (MRI) are used for diagnosis.

Doctors often surgically remove the tumor in the thoracic surgery department. Additional treatment methods (e.g., radiation therapy, chemotherapy) are used before or after the surgery.

• Chylothorax (Accumulation of Lymph)

When lymph fluid accumulates in the pleural cavity, this is referred to in thoracic surgery as a chylothorax. It is usually the result of an injury to the thoracic duct. If this duct is damaged, lymph leaks into the surrounding tissue; in severe cases, it may also leak into the pericardium (chylopericardium).

Doctors refer to a condition as a chylomediastinum when the lymph remains confined to the mediastinum. If the condition does not resolve after repeated drainage (thoracic drainage) and dietary changes, doctors must surgically treat the chylothorax or the site of the injury.

• Hemothorax (blood accumulation)

In thoracic surgery, the term “hemothorax” is used when blood accumulates in the pleural space.

This form of pleural effusion can occur following an injury (e.g., a broken rib). It can also result from postoperative bleeding following a procedure (e.g., a lung biopsy or pleural puncture).

The accumulation of blood in the chest cavity can impair breathing and lead to shock.

Treatment for a hemothorax initially involves draining the blood via a chest tube. In cases of severe bleeding, doctors must open the chest via a thoracotomy and surgically repair the injured blood vessels.

• Hyperhidrosis (excessive sweating)

In thoracic surgery, hyperhidrosis refers to pathological, excessive sweating. Excessive sweating can be treated to a certain extent with conventional methods such as ointments and deodorants, medications, or Botox injections.

If these methods do not provide relief, thoracic surgery can help by performing an endoscopic block of the sympathetic nervous system in the chest.

Access to the sympathetic nervous system is gained through two small incisions in the armpit area. Certain nerve bundles of the sympathetic nervous system are then electrically blocked.

About 1 to 2% of the population suffers from hyperhidrosis @ dragonstock /AdobeStock

• Pulmonary Emphysema

Pulmonary emphysema is a common condition in thoracic surgery. It is a form of chronic obstructive pulmonary disease (COPD). It is characterized by enlarged and irreversibly damaged alveoli.

As the walls of the alveoli break down due to enzymatic action, large air pockets form in which air becomes trapped. Although the lungs contain air, shortness of breath occurs.

As a result, the body does not receive enough oxygen, and this can potentially lead to organ damage.

Smoking is considered the primary cause of pulmonary emphysema. 

Other risk factors include:

• indoor air pollution,
• open fires,
• inhalation of gases and dust in the workplace,
• a possible genetic predisposition, and
• frequent respiratory infections

The disease is incurable. Therefore, it is very important to prevent further progression. In addition to immediately quitting smoking or avoiding other triggering factors, doctors must reduce the size of the lungs in cases of advanced disease.

In thoracic surgery, they remove overinflated portions of the lungs using video-assisted thoracoscopy and minithoracotomy.

This is intended to improve the function of the remaining lung tissue (bullous resection). In extreme cases, a lung transplant or a single-lung transplant may also be necessary. 

• Pleural Empyema

In thoracic surgery, a pleural empyema (pyothorax) is defined as the accumulation of pus in the chest cavity. This is usually the result of a bacterial infection. 

Treatment initially involves managing the underlying condition (antibiotics) and, if necessary, chest drainage to remove the pus.

In more severe cases, video-assisted endoscopic empyema debridement is performed as part of thoracic surgery. During this procedure, doctors irrigate the chest cavity under video guidance and then suction it out.

If pleural empyema is left untreated, pleural scar tissue (fibrous growths on the pleura) develops. Doctors must surgically remove this tissue via an open thoracotomy. 

• Pleural Effusion

Pleural effusion is a common condition in thoracic surgery. It involves the accumulation of fluid in the chest cavity.  

Depending on the type of fluid, the following distinctions are made:

Serous pleural effusion: Clear, yellowish fluid, often resulting from heart failure, inflammation, or a tumor

Pyothorax: Pus, often resulting from a bacterial infection

Hemothorax: Blood, often resulting from an injury

Chylothorax: Lymph, often resulting from an injury or a lymphatic drainage disorder

• Pneumothorax (air accumulation)

Pneumothorax is a condition in thoracic surgery that usually occurs acutely, in which air enters the pleural space. This severely limits breathing.

If lung function and cardiovascular function are severely impaired, thoracic surgeons refer to this as a tension pneumothorax, which poses an acute threat to life. 

Depending on the cause of the pneumothorax, physicians distinguish between: 

Spontaneous pneumothorax (no identifiable cause) 

Traumatic pneumothorax (direct or indirect injury to the chest or its organs) 

Extensive pneumothorax (doctors typically treat this with chest drainage)

• Pectus carinatum

Pectus carinatum (chicken chest) is diagnosed when the sternum protrudes in a keel-like shape. If the condition causes significant psychological distress for the patient, doctors may consider surgical correction.

Thoracic surgeons either remove parts of the ribs and the sternum or implant a metal bar that presses down on the keel. 

• Funnel chest

Pectus excavatum describes abnormal cartilage connections between the sternum and the ribs. These cause the front of the chest to sink inward. Psychological and physical impairments may indicate the need for surgical correction in thoracic surgery. 

Pectus excavatum is a malformation of the anterior chest wall that is often genetically caused @ smile35 /AdobeStock

Recently, minimally invasive procedures have been increasingly used, such as: 

• The minimally invasive pectus excavatum correction according to Nuss (MIRPE) and 
• Sternocondroplasty (Erlanger method)

In the Nuss procedure, metal bars inserted behind the sternum realign the deformed costal cartilages. The sternum is pushed outward. 

In the Erlanger correction method, doctors detach the ribs at their attachment to the sternum. They then insert one or two lightweight metal bars, which are surgically removed after one year.

A relatively new procedure in thoracic surgery is the suction bell, which slowly lifts the chest.