Complications - Anterolateral thoracotomy

Injury to intercostal nerves and vessels

This complication can be avoided either by dissecting strictly along the superior aspect of the rib or, as demonstrated in the present case, by bringing down the nerve at the inferior aspect of the rib under direct vision, since the intercostal neurovascular bundle courses along the inferior aspect. In case of any bleeding, secure the vessel with a suture ligature or clip since sealing by electrocautery alone is not reliable enough.

Rib fracture

In case of a rib fracture, smooth any sharp projections with a bone rongeur, as they could puncture the lung.

Bleeding when taking down pleural adhesions

→ Seal with electrocautery, hemostatics 

Bleeding from a pulmonary vessel

→ punctiform coagulation or targeted clamping with a hemostat and then suture ligature, otherwise the tear will expand, and the ligature will slip off; alternatively, tangential clamping with an atraumatic Satinsky forceps and closure with atraumatic sutures.

Acute airway obstruction

 → intraoperative bronchoscopy 

Cardiac disorder

due to irritation of the vagus or phrenic nerve

Persistent pulmonary parenchymal leakage

resulting from tears during dissection → close the pleural margins with U-stitches

Respiratory failure

Prevent by regular bronchial toilet and early ambulation of the alert patient.

→ early tracheotomy, lung protective ventilation (tidal volume 6 ml/kg body weight), increased PEEP, in severe cases ECLA.

Secondary bleeding

Usually within the first 24 hours: In case of continuous bloody secretions in the chest tube(s), the indication for rethoracotomy should be determined as soon as possible.

→Clear the hematoma and pack the pleural cavity with towels until the cardiovascular situation has stabilized and venous access has been gained for infusions. Only then search for the source of bleeding.

Atelectasis

by secretions flooding the bronchi, due to bronchial hypersecretion (respiratory sequelae) or absence of expectoration (secretion retention).

→ immediate bronchoscopy, possibly with lavage.

Pulmonary fistula

due to lung parenchyma injury

• Uncomplicated fistulas heal if chest drainage is continued long enough.
• Secondary pleural empyema is possible in rare cases.

Wound infection

Conservative therapy usually suffices.

Subcutaneous emphysema

Its usual causes include: Overlooked or late-onset pneumothorax under inadequate drainage, or subcutaneous position of one of the tube fenestrations. Diagnostic workup would include a chest-CT study and bronchoscopy to rule out a bronchial leak, and then a therapeutic chest tube should be inserted, possibly in targeted fashion.

Early-onset postoperative pneumonia

→ Prophylactic perioperative antibiotics and breathing exercises

Pleural effusion/empyema

Leave chest tube(s) in place longer if secretion volume is high.

In case of pleural suppuration (empyema, pyothorax) clear the pleural cavity surgically of any pus.

Rethoracotomy

Repeat VATS (video assisted thoracoscopy)

 Postthoracotomy pain

→ Protect the intercostal neurovascular bundle from injury!

During the operation, the intercostal nerve may be injured at several different locations:

• When spreading the ribs, by pressure on the intercostal nerve in the intercostal space running along the inferior aspect of the superior rib
• By direct trauma, when dividing/detaching the intercostal muscles
• By the pericostal suture strangulating the nerve running along the inferior aspect of the inferior rib when approximating the ribs during closure of the chest.