Thoracic surgery (chest surgery, thoracic surgery) includes surgical procedures
The medical discipline of thoracic surgery also deals with the prevention and diagnosis of thoracic diseases and postoperative treatment.
Thorax is the medical term for chest.
The thoracic wall consists of:
Anatomy of the thorax @ bilderzwerg /AdobeStockThe thorax encloses the chest cavity and the upper part of the abdominal cavity. An important procedure in thoracic surgery is the 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 only requires small skin incisions. The postoperative complications are therefore significantly lower compared to an open procedure.
Typical diseases treated by thoracic surgery are
The conditions that the doctor will encounter during the operation must be known before a thoracic operation. This is the only way to assess the surgical risks and plan a surgical procedure in thoracic surgery.
The aim of diagnostics is to determine the size, extent and location of a disease (e.g. tumor). It also determines 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, further procedures such as puncture, thoracoscopy or thoracotomy are used.
In thoracic surgery, percussion is the tapping of the body surface. Depending on the type of sound, the doctor can draw conclusions about any disorders in the thorax.
For example, a hollow sound (sonorous tapping sound) indicates a healthy lung. In contrast, excessive air content, such as emphysema, asthma and pneumothorax, results in a hypersonic knocking sound. This sounds louder and more hollow.
If the sound is quieter and shorter (muffled head sound), this is an indication of a reduced air content or an accumulation of fluid. This is the case with ascites, pleural effusion or pneumonia, for example.
A hollow, tympanic sound (tympanic knocking sound) indicates cavities. These can be found in the digestive tract (e.g. in the case of a gas-filled intestinal loop).
An X-ray of the thorax (chest X-ray) is a standard examination in thoracic surgery. The denser the tissue, the brighter it appears on the X-ray image. Bones and organs can be visualized particularly well.
An X-ray examination of the thorax allows changes in the lungs to be detected. A chest X-ray, on the other hand, is less suitable for examining the mediastinum and pulmonary hilus.
The pulmonary hilus is the point in the lungs where the pulmonary vessels, main bronchi and lymph vessels enter the lungs.
An ultrasound examination (sonography) is particularly suitable for fluid-filled or perfused organs. This is why sonography is used in thoracic surgery, particularly for the examination of the pleura.
It can be used to detect pathological changes and tumors in the pleural area. Ultrasound is used to monitor biopsies and punctures.
As thoracic computed tomography (thoracic CT) provides a more precise image of the inside of the body, it supplements or replaces X-ray examination procedures in thoracic surgery.
The computer assembles the layered X-ray images into three-dimensional images. This gives the doctor a spatial impression.
In the past, the use of magnetic resonance imaging (MRI) in thoracic surgery was problematic due to the large number of cavities. Today, there is an MRI procedure that allows the ventilation of the lungs to be depicted using helium-3.
In contrast to chest CT and chest X-ray, the patient is not exposed to radiation during an MRI examination. Soft tissue can be visualized particularly well and areas of inflammation can be differentiated from healthy tissue.
In thoracic surgery, MRI provides important information about the location and extent of tumors. This is why, in addition to preoperative diagnostics, it is also used in the follow-up of tumor diseases.
Thoracoscopy is a widely used procedure in thoracic surgery. It is an endoscopic procedure that clarifies suspicious findings in the pleural cavity, the pleura and the outer parts of the lungs.
Small interventions on the pleura, the lungs, the thoracic spine or the mediastinum are also possible.
A thin tube (laparoscope) is fitted with a camera, a light source and often a device for irrigation and suction.
Surgical instruments can also be inserted in order to take biopsies or perform an operation.
Doctors can also administer medication via the laparoscope. A further development of thoracoscopy is video-assisted thoracoscopy (VATS).
A classic procedure in thoracic surgery is the thoracotomy. Thoracotomy refers to the surgical opening of the thorax through an incision in the space between the ribs (intercostal incision).
Depending on the position and size of the incision, there are different types of thoracotomy, e.g.
Open heart surgery is almost always performed via a median thoracotomy (sternotomy, longitudinal separation of the sternum). The patient lies in the supine position.
Operations on the lungs, aorta and mediastinum are usually performed through a lateral approach. The patient is in the lateral position.
In thoracic surgery, a minithoracotomy is a thoracotomy with anincision of a maximum length of 10 cm.
This procedure is often used when
As considerable pain can occur after a thoracotomy, postoperative analgesia is of particular importance
Thoracocentesis is the insertion of a hollow needle (trocar) through the chest wall into the chest cavity. Doctors then aspirate fluids from the thorax.
If doctors remove fluid from the pleural cavity, this is referred to as a pleural puncture.
Pleural puncture is a special 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 pleura and the pleura of the lungs. The patient is given a local anesthetic.
The procedure is usually performed under ultrasound guidance. The doctor can mark pleural effusions before the puncture and observe the safe advancement of the needle.
Thoracic drainage is a widely used procedure in thoracic surgery to drain blood, secretions or air from the thorax.
Depending on where doctors drain fluid from, it is referred to as
Thoracic drainage is usually performed after chest surgery. The aim is to drain fluid accumulations caused by an operation.
A chest drain is also used after accidents or major violence.
However, chest drainage can also be useful in connection with other thoracic diseases or diseases of the cardiovascular system.
These include, for example
In thoracic drainage, doctors insert a drainage tube (often made of silicone or rubber) after a small incision (minithoracotomy). They usually also apply a gentle suction.
Tumors of the thoracic wall can originate in the chest wall. However, they can also or secondarily develop as metastases of other tumors (e.g. through the ingrowth of a lung or breast cancer).
As these tumors rarely cause clear symptoms, they are usually discovered by chance during an imaging examination. Computer tomography and an additional MRI examination are used in the diagnosis.
Doctors often remove the tumor surgically during thoracic surgery . Further treatment methods (e.g. radiotherapy, chemotherapy) are used before or after the operation.
If lymphatic fluid accumulates in the pleural cavity, this is referred to as a chylothorax in thoracic surgery . It is usually the result of an injury to the thoracic duct. If this duct is injured, lymph leaks into the adjacent tissue or, in the case of severe injuries, into the pericardium (chylopericardium).
Doctors speak of a chylomediastinum when the lymph remains confined to the mediastinum. If there is no healing after repeated drainage (thoracic drainage) and a change in diet, doctors must surgically treat the chylothorax or the site of injury.
In thoracic surgery, the term hemothorax is used when blood collects in the pleural cavity.
This form of pleural effusion can occur after an injury (e.g. after a rib fracture). It can also be the result of post-operative bleeding (e.g. lung biopsy or pleural puncture).
The accumulation of blood in the chest can impair breathing and lead to shock.
Treatment of a hemothorax is initially carried out by draining the blood using a chest tube. In the event of severe bleeding, doctors must open the chest by thoracotomy and surgically treat the injured vessels.
In thoracic surgery, hyperhidrosis is defined as abnormal, excessive sweating. Excessive sweating can be treated to a certain extent with traditional methods such as ointments and deodorants, medication or Botox injections.
If these methods do not provide relief, thoracic surgeons can help by endoscopically blocking the sympathetic nervous system in the chest.
The sympathetic nervous system is accessed via two small incisions in the armpit area. Certain nerve bundles of the sympathetic nervous system are then electrically blocked.
Around 1 to 2 % of the population suffer from hyperhidrosis @ dragonstock /AdobeStock
Pulmonary emphysema is a common clinical picture in thoracic surgery. It is a form of chronic obstructive pulmonary disease (COPD). It is characterized by dilated and irreversibly destroyed alveoli.
As the dividing walls of the alveoli dissolve enzymatically, large bubbles form in which the air we breathe becomes trapped. Although the lungs contain air, shortness of breath occurs.
As a result, the body does not receive enough oxygen and damage to the organs can occur under certain circumstances.
Smoking is the main cause of emphysema .
Other risk factors are
The disease cannot be cured. It is therefore very important to prevent further progression. In addition to stopping smoking immediately or avoiding other triggering stimuli, doctors must reduce the size of the lungs if the disease is advanced.
In thoracic surgery, they use video-assisted thoracoscopy and minithoracotomy to remove over-inflated parts of the lung.
This is intended toimprove the remaining lung function (bullar resection). In extreme cases, a transplant of the lung or a lung lobe may also be necessary.
In thoracic surgery, pleural empyema (pyothorax) is the accumulation of pus in the chest cavity. This is usually the result of a bacterial inflammation.
Treatment initially consists of treating the underlying disease (antibiotics) and, if necessary, chest drainage to drain off the pus.
In more severe cases, video-assisted endoscopic empyema evacuation is performed as part of thoracic surgery, in which doctors irrigate the thorax under video control and then aspirate it.
If pleural empyema is not treated, a pleural rind develops (connective tissue growths on the pleura). Doctors must surgically remove these via an open thoracotomy.
Pleural effusion is a common clinical picture in thoracic surgery. It involves the accumulation of fluid in the chest cavity.
Depending on the type of fluid, the following distinctions can be made:
Serothorax: Clear, yellowish secretion, often the result of cardiac insufficiency, inflammation or a tumor
Pyothorax: Pus, often the result of a bacterial inflammation
Hemothorax: Blood, often the result of an injury
Chylothorax: lymph, often the result of an injury or a lymph drainage disorder
Pneumothorax is a mostly acute clinical picture in thoracic surgery in which air enters the pleural cavity. As a result, breathing is only possible to a limited extent.
If the lungs and cardiovascular function are drastically restricted, thoracic surgeons speak of a tension pneumothorax, in which there is an acute danger to life.
Depending on the cause of the pneumothorax, doctors differentiate between
Spontaneous pneumothorax (no recognizable cause)
Traumatic pneumothorax (direct or indirect injury to the chest or its organs)
Extensive pneumothorax (usually treated by doctors using a chest tube)
A keel chest (chicken breast, pectus carinatum) is when the breastbone is bulging out in a keel shape. Doctors consider surgical correction if the affected person is under severe psychological stress.
Thoracic surgeons either remove parts of the ribs and sternum or implant a metal bar that pushes the keel down.
A funnel chest (pectus excavatum) describes altered cartilage connections between the sternum and ribs. This leads to the front of the thorax sinking in. Psychological and physical impairments may be an indication for surgical correction in thoracic surgery.
The funnel chest (pectus excavatum) is often a genetic malformation of the anterior chest wall @ smile35 /AdobeStock
Recently, minimally invasive procedures have been increasingly used, such as
In the Nuss method, metal brackets inserted behind the sternum bend the deformed rib cartilage. The sternum pushes outwards.
In the Erlangen correction method, doctors detach the ribs at the base of the sternum. They then insert one or two light metal brackets, which are surgically removed after a year.
A relatively new procedure in thoracic surgery is the suction cup, which slowly lifts the ribcage.
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