Thoracic Surgery

Basic surgical intervention in the thoracic cavity has the primary goal of alleviating any malady that mechanically affects the function of the heart and lungs, which can be secondary to underlying pathologies or, most commonly, trauma. Interventions such as tube thoracostomy and thoracentesis are performed to evacuate fluid, blood, or air that is occupying the thoracic cavity in order to restore thoracic negative pressure. When direct intervention to the heart and mediastinum is required, an emergency thoracotomy is performed. Once the immediate mechanical problems are addressed, more advanced reparative surgery involving heart, lungs, or mediastinal structures can then be performed as necessary.

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Surgical Anatomy

It is important to review the anatomy of the chest wall in order to more easily avoid the important vascular and nervous components as well as to locate the appropriate entry points during surgical interventions.

Surface anatomy landmarks

  • Clavicle
  • Sternal angle (Lewis angle)
  • Midclavicular line
  • Anterior, middle, and posterior axillary lines
  • Lower border of the pectoralis major muscle/inframammary fold (5th intercostal space)
Surface anatomy landmarks of the thorax

Surface anatomy landmarks of the thorax to keep in mind for chest tube placement

Image by Lecturio.

Layers of the chest wall

  • Skin
  • Subcutaneous tissue
  • Intercostal muscles:
    • External intercostal muscle
    • Internal intercostal muscle
    • Innermost intercostal muscle
  • Parietal pleura
Muscles of the thoracic wall

Muscles of the thoracic wall, showcasing the external and internal intercostal muscles

Image by BioDigital, edited by Lecturio

Neurovasculature of the chest wall

  • Blood supply:
    • Intercostal arteries: branches of the aorta and internal mammary artery that anastomose
    • Internal mammary artery
  • Venous drainage:
    • Intercostal veins
    • Internal thoracic vein
  • Innervation:
    • Intercostal nerves
    • Long thoracic nerve
  • Intercostal neurovascular bundle:
    • Located in close vicinity to the inferior costal groove
    • The structures in the bundle are located from superior to inferior as follows, and can be recalled by the mnemonic VAN:
      • V: Intercostal vein
      • A: Intercostal artery
      • N: Intercostal nerve
Intercostal neurovascular bundle

The intercostal neurovascular bundle, right below the costal groove, is made up of an intercostal vein, artery, and nerve.

Image by Lecturio.

Chest Tube Placement (Tube Thoracostomy)


Chest tube placement, or tube thoracostomy, is an invasive procedure that consists of inserting a large-bore tube into the pleural cavity to provide continuous drainage of pleural fluid and/or air.


  • Pneumothorax
  • Pleural effusion
  • Hemothorax
  • Hemopneumothorax
  • Thoracic empyema
  • Chylothorax


There are no contraindications for the placement of a chest tube. However, insertion must be done with caution in the following cases:

  • Underlying coagulopathy or low platelet count
  • Antiplatelet therapy and anticoagulants


  1. Chest X-ray has to be carefully reviewed to determine the best approach and location.
  2. Patient can be placed in the supine or in the lateral decubitus position.
  3. The arm is placed over or behind the head.
  4. The site of insertion is usually at the anterior axillary line in the 4th or 5th intercostal space, but can be adjusted:
    • Can be placed more posteriorly for pleural effusion
    • A more precise localization with radiologic guidance may be required for complex loculated air or fluid collections.
  5. A 2-cm incision is made in the skin.
  6. A Kelly clamp is used to make a tunnel through the incision and intercostal muscles into the pleural cavity.
  7. A finger is used to make sure the lung is away from the incision site.
  8. The chest tube is inserted starting from its perforated end in a superior–posterior–medial direction. This step can be aided with a Kelly clamp.
  9. The tube is connected to a drainage system (Pleur-Evac) and secured to the skin with a purse-string suture.
  10. A chest X-ray is obtained to ensure adequate placement.
Steps of the hemostat technique for chest tube placement

Steps of the hemostat technique for chest tube placement

Image by Lecturio.


  • Injury to the lung parenchyma: can present as a persistent air leak
  • Perforation of the diaphragm and/or abdominal viscera:
    • If the insertion site is too low
    • Can result in liver (on the right) or spleen (on the left) injury with intra-abdominal hemorrhage
  • Perforation of the heart:
    • From left tube thoracostomy
    • Will get rapid blood return in tube
  • Injury to the intercostal vessels:
    • Can happen if the chest tube is inserted close to the lower costal margin, where intercostal vessels lie
    • Can present as intrathoracic and/or insertion site bleeding
  • Reexpansion pulmonary edema:
    • Rare
    • Can happen if a large pleural effusion (> 1.5 L) is evacuated too quickly
    • Presents as acute onset of respiratory distress/cough/frothy sputum



Thoracentesis is an invasive procedure that consists of inserting a catheter into the pleural space to evacuate pleural fluid for diagnostic and/or therapeutic reasons.


Thoracentesis may be required in any condition that presents with pleural effusions that compromise breathing, such as:

  • Congestive heart failure
  • Parapneumonic effusion
  • Empyema
  • Atelectasis
  • Malignancy
  • Pulmonary embolism
  • Hepatic hydrothorax
  • Hypoalbuminemia
  • Pancreatitis
  • Uremia


There are no absolute contraindications to thoracentesis. However, caution is advised with the following:

  • Coagulopathy
  • Use of antiplatelet agents and anticoagulants
  • Recent surgery on the ipsilateral thoracic cavity
  • Metastatic cancer

Factors predictive of difficult thoracentesis:

  • Use of positive-pressure ventilation (i.e., mechanical, continuous positive airway pressure (CPAP))
  • Chest wall cellulitis
  • Loculated pleural effusion


Preoperative preparation:

  • Perform a full physical examination with special emphasis on chest percussion.
  • Preprocedure images need to be carefully reviewed:
    • Chest X-ray
    • Chest CT scan
  • Withhold anticoagulants before the procedure.
  • Continuous monitoring:
    • HR
    • BP
    • Oxygen saturation


  1. The patient should be sitting, leaning forward, and resting the elbows on a table. In patients who are not able to sit up, the head of the bed is elevated 30 degrees.
  2. Ultrasonography can be performed to guide the procedure.
  3. When ultrasonography is not available, one of the following sites is located and marked:
    • 3rd–5th intercostal space in the midaxillary line
    • 5th–7th intercostal space in the posterior scapular line
    • Dullness to percussion indicates a site of greater fluid accumulation, ideal for puncture.
  4. A 22-gauge needle is used to enter the pleural space while applying negative pressure.
    • Entrance is confirmed by the aspiration of free-flowing fluid.
    • Bubbles in the syringe may indicate lung puncture.
  5. A thoracentesis needle catheter is prepared, including a 3-way stopcock, syringe, and tube leading to a collection bag.
  6. The thoracentesis needle catheter is inserted into the superior margin of the lower rib while maintaining negative pressure.
  7. An initial 30–60 mL of fluid is collected for laboratory analysis (e.g., Gram stain, culture, chemistry, cell count).
  8. The remaining fluid is drained into the collecting bag until 1 of the following occurs:
    • Fluid stops draining spontaneously.
    • The patient starts coughing or reports chest discomfort.
    • A total of 1–1.5 L of fluid is drained.
  9. When drainage is complete, the patient is instructed to hold their breath and then exhale while the catheter is withdrawn.
  10. Sterile gauze and dressing are placed on the wound.
  11. Postprocedure chest X-ray is obtained to rule out pneumothorax.
Thoracentesis on a left hemithorax

Thoracentesis on a left hemithorax

Image: “Thoracentesis” by National Heart, Lung and Blood Institute. License: Public Domain


  • Reexpansion pulmonary edema
  • Pneumothorax
  • Hemothorax
  • Hematoma at the injection site
  • Intra-abdominal puncture, with liver or spleen injury
  • Soft tissue infection
  • Pleural infection and empyema

Pleural fluid analysis

  • Transudative effusions (caused by changes in hydrostatic or oncotic pressure or pleural permeability):
    • Congestive heart failure
    • Liver cirrhosis
    • Severe hypoalbuminemia
    • Nephrotic syndrome
  • Exudative effusions (altered formation and absorption of pleural fluid):
    • Malignancy
    • Infection (e.g., empyema due to bacterial pneumonia)
    • Trauma
    • Pulmonary infarction
    • Pulmonary embolism
  • Light’s criteria (for diagnosis of exudative effusions):
    • Pleural fluid/serum protein ratio > 0.5
    • Pleural fluid/serum LDH ratio > 0.6
    • Pleural fluid LDH > 23 the normal upper limit for serum 
  • Other findings associated with exudative effusions:
    • Color/appearance: purulent, bloody, milky, black, presence of particles
    • LDH > 1000 IU/L
    • Glucose < 3.4 mmol/L
    • pH < 7.3
    • Amylase > 110 U/L
    • WBCs > 50,000
    • Triglycerides > 1.24 mmol/L (chylothorax)

Emergency Thoracotomy


Emergency, or resuscitative, thoracotomy is an invasive procedure that consists of making a large incision in the left hemithorax to attain access to the heart and other mediastinal structures, including the thoracic aorta, to control bleeding and quickly repair life-threatening injuries.

Therapeutic goals

  • Resuscitation of agonic patients with penetrating cardiothoracic injuries
  • Evacuation of cardiac tamponade (especially in penetrating trauma)
  • Direct cardiac massage
  • Direct repair of cardiac injuries
  • Control of massive intrathoracic hemorrhage
  • Clamping of the descending thoracic aorta for maintenance of perfusion to the heart and brain
  • Prevention of air embolism


  • Cardiac arrest following penetrating or blunt chest trauma with signs of life
  • Cardiac tamponade with profound shock in a patient who is unresponsive to volume expansion and unlikely to survive until proper surgery can be performed
  • Blunt or penetrating trauma to the chest or abdomen with profound shock in a patient who is unresponsive to volume expansion and unlikely to survive until proper surgery can be performed
  • Massive chest or abdominal bleeding with profound shock (> 1500 mL of blood obtained via chest tube)


  • Traumatic cardiac arrest with no signs of life in the prehospital setting (e.g., asystole, prolonged lack of pulse)
  • Patient who is immediately responsive to volume expansion or decompression of tension pneumothorax
  • Penetrating or blunt thoracic injury with > 15 minutes of CPR and no signs of life


Preoperative preparation:

  • Perform bedside FAST, if available:
    • Cardiac tamponade
    • Hemothorax
    • Intra-abdominal hemorrhage
  • The patient should be intubated and ventilated.
  • The site of the incision is washed with a skin-sterilizing solution and covered with sterile drapes.
  • Continuous monitoring:
    • HR
    • BP
    • Oxygen saturation
    • ECG


The usual approach in an emergency is through left thoracotomy. Thoracotomy is a last-resort potentially lifesaving procedure that needs to be performed quickly.

  1. The 4th or 5th intercostal space is identified (reference point: the nipple in men, the inframammary fold in women).
  2. An incision is made going from the lateral border of the left sternocostal junction to the posterior axillary line (anterolateral thoracotomy), exposing the intercostal muscles.
    • The incision should follow the curvature of the ribs.
    • The inferior border of the superior rib should be avoided to prevent damaging the intercostal neurovascular bundle.
  3. The intercostal muscles are transected from the sternum to the posterior axillary line, to gain access to the pleural space. 
  4. The ribs are spread with the fingers in order to insert and be separated further by the rib spreader (Finochietto retractor).
  5. The left lung is displaced superiorly, and the pericardium is inspected for tamponade or lacerations.
  6. To relieve tamponade:
    • The pericardium is grasped using forceps and opened from the apex toward the base (pericardiotomy).
    • Clotted blood is manually removed and liquid blood is suctioned.
  7. To perform direct cardiac massage:
    • With the wrists together, the physician gently compresses the heart in a clapping motion from the apex toward the base.
    • If ventricular fibrillation is felt, defibrillation with internal paddles is performed.
  8. To control myocardial laceration: with surgical staples, mattress sutures, or a Foley catheter (a balloon is inflated within the cardiac cavity with normal saline)
  9. To clamp the aorta in cases of nonresponse to fluid resuscitation:
    1. The pleura and fascia are dissected to expose the aorta.
    2. A nasogastric tube is inserted to identify the esophagus.
    3. A vascular clamp, aortic compression device, or the physician’s hand is used to clamp/put pressure on the aorta against the spine.
  10. The rest of the cavity is checked for uncontrolled sources of bleeding and other life-threatening injuries.
  11. If the injury is located on the right hemithorax, the thoracotomy is expanded by transecting the sternum (clamshell thoracotomy).
  12. If resuscitation is successful, the patient is immediately transferred to the OR.
Types of thoracotomy

Types of thoracotomy incisions

Image by Lecturio.

Postoperative care:

  • It is still under debate whether one should close the chest completely or perform a temporary closure.
  • Transfer to the OR for definitive management.
  • After definitive management, transfer to the ICU for continued resuscitation.


  • The most important determinant of survival is the location and magnitude of the injuries.
  • Reported survival of up to 70% following emergency thoracotomy in penetrating trauma
  • The survival rate is much poorer for blunt trauma.
  • Survival is related to the length of CPR, with > 15 minutes equated with poor survival.
  • Direct cardiac massage may result in better cardiac output and cerebral perfusion.
  • A 5th of survivors suffer significant neurologic injury.

Clinical Relevance

Indicates for tube thoracostomy:

  • Pneumothorax: accumulation of air within the pleural space between the parietal and visceral pleura, which can be open (with communication to the outside) or under tension (without an opening in the chest wall and ongoing air leak from the injured lung parenchyma)
  • Pleural effusion: accumulation of fluid within the pleural space, which can be a transudate or an exudate according to Light’s criteria, depending on the result of the cytochemical analysis
  • Hemothorax: accumulation of blood within the pleural space due to profuse bleeding, usually seen in the context of trauma to the chest
  • Hemopneumothorax: accumulation of both blood and air within the pleural cavity, also frequently seen in the context of trauma to the chest: The clinician must be careful at the time of decompression, since the pressurized air may propel blood through the incision.
  • Thoracic empyema: accumulation of purulent material (pus) within the pleural cavity, seen in the context of infections of the lower respiratory tract (i.e., pneumonia)
  • Chylothorax: accumulation of chyle within the pleural cavity after injury to the thoracic duct

Indication for thoracentesis:

  • Pleural effusions: the accumulation of fluid within the pleural space, which, according to cytochemical analysis (Light’s criteria), can be classified as a transudate or exudate

Indication for emergency thoracotomy:

  • Cardiac tamponade: restriction in cardiac filling due to the excessive accumulation of fluid within the pericardial cavity that leads to decreased cardiac output and serious systemic consequences (hypotension and shock)
  • Massive hemothorax: drainage of > 1500 mL of blood via tube thoracostomy or bleeding of > 200 mL per hour for at least 2 hours: Hemothorax itself is the accumulation of blood within the pleural space.
  • Massive hemorrhage with witnessed or impending cardiac arrest: The descending aorta can be clamped to control the hemorrhage and temporarily restore the circulation to the brain and heart. Survival in this situation is rare, and there is significant morbidity related to spinal cord and kidney ischemia.


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