The most common indications for thoracotomy include surgery for conditions of the distal aorta, heart, esophagus, and lungs.
Distal thoracic aortic disease may include dissection, rupture, and aneurysmal disease.
Cardiac conditions potentially requiring thoracotomy include congenital heart defects (atrial septal defect), disease of the aortic, mitral, and tricuspid valves, at certain locations of the coronary arteries, pericardial disease, and tumors of the heart and pericardium. However, many of these indications for thoracotomy can also be approached via median sternotomy.
Pulmonary disease is most commonly treated with video-assisted thoracoscopic surgery (VATS), but many pulmonary diseases requiring conventional open surgery are treated via thoracotomy. These include, for example, advanced lung cancer (primary or metastatic) and pleural malignancies.
Esophageal diseases that can be approached via thoracotomy include malignancies in adults and tracheoesophageal fistulas in infants. Right-sided thoracotomy is best suited for conditions involving the mid-esophagus. Left thoracotomy provides good access to the distal esophagus. Transhiatal access may also be considered.
In order to reduce access invasiveness - especially bulk muscle transection - so-called muscle-sparing access routes are propagated. This includes anterolateral thoracotomy, which spares the latissimus dorsi muscle. However, this requires splitting the serratus anterior muscle in the direction of its fibers. For minor and moderate thoracic procedures such as emphysema surgery, reduction pmeumoplasty, routine lung resections, and conditions of the anterior segments of the lungs or mediastinum, the anterolateral thoracotomy provides adequate access. While muscle-sparing approaches have been attributed with reduced analgesic consumption in the early postoperative days, the benefits have yet to be proven.
One drawback in anterolateral thoracotomy is the difficult access to the posterior structures of the mediastinum, which makes it difficult to enlarge the procedure if, for example, the tumor is larger than anticipated preoperatively. Anterolateral access should therefore be reserved for simple resections or benign disease; complex oncologic resections and extensive procedures should be performed via the posterolateral approach because this avoids the difficult problem of having to enlarge the site.