Thoracic Surgery

Thoracic surgery is a speciality that deals with surgical procedures on organs and structures within the chest, including the lungs, pleura, mediastinum, oesophagus, diaphragm, ribs and chest wall. It involves various surgical procedures, from minimally invasive techniques to complex open surgeries. Thoracic surgery is often used to treat conditions such as lung cancer, emphysema, empyema, pneumothorax, bronchiectasis, Esophageal cancer, and various types of chest trauma.

Types of Thoracic Surgery

Some commonly performed procedures include the following:

• Lobectomy:  Lobectomy surgery involves the removal of a lobe of the lung affected by lung cancer or other lung diseases.
• Pneumonectomy: Pneumonectomy is the surgical removal of an entire lung and is typically performed to treat advanced lung cancer or severe lung infections.
• Segmentectomy: This procedure involves the removal of a segment of the lobe of the lung affected by small cell lung cancer or other lung diseases.
• Sleeve lobectomy: This is a procedure in which the involved lobe with part of the main stem bronchus is removed. The remaining lobe(s) is reimplanted on the main stem bronchus.
• Decortication: Decortication is a type of surgical procedure performed to remove a fibrous peel that forms on the surface of the lung, chest wall and diaphragm, restricting the inflation of the lungs.
• Bullectomy: A bullectomy is a surgical procedure to remove bullae—air-filled spaces in the lungs that can compress healthy lung tissue.
• Lung Volume Reduction Surgery (LVRS): It removes diseased, emphysematous lung tissue and reduces the size of an over-inflated lung, allowing for the expansion of the remaining, often more functional, lung. It can be used as a bridge to lung transplants.
• Thymectomy: Thymectomy is the surgical removal of the thymus gland and is commonly performed to treat thymomas (tumours of the thymus) or myasthenia gravis.
• Thoracic Sympathectomy: This procedure involves dividing or removing part of the sympathetic nerve chain in the chest to treat conditions like hyperhidrosis (excessive sweating) or facial blushing.
• Resection of Mediastinal Masses: Many masses in the mediastinum are amenable to surgical resection, like bronchogenic cysts, posterior mediastinal tumours (neurofibroma, schwannoma), thymomas, teratomas, thymic cysts, retrosternal goitre etc.
• Tracheal Resection and Reconstruction: This complex procedure involves removing and reconstructing a portion of the trachea (windpipe) to treat conditions like tracheal stenosis or tracheal tumours.
• Esophagectomy: Esophagectomy is the surgical removal of a portion or the entire oesophagus and is typically performed to treat oesophagal cancer or severe oesophagal conditions.
• Extrapleural pneumonectomy (EPP): It is usually used to treat pleural mesothelioma. It includes the removal of the impacted lung, parts of the diaphragm and the linings of the lung and heart (pleura and pericardium).
• Congenital Lung Lesion Resection: Surgery can be used to remove congenital lung lesions such as congenital cystic adenomatoid malformation (CCAM) or pulmonary sequestration.
• Lobectomy for Pediatric Lung Tumors: In cases of lung tumours in children, a lobectomy may be necessary to remove the affected lobe of the lung. This procedure aims to excise the tumour and surrounding healthy tissue to ensure complete ;[[ tumour removal and prevent further spread.
• Congenital Diaphragmatic Hernia Repair: Congenital diaphragmatic hernia (CDH) is a condition with a hole or defect in the diaphragm, allowing abdominal organs to move into the chest cavity and compress the lungs. Surgical repair is necessary to place the organs back into the abdomen and close the diaphragmatic defect.
• Tracheoesophageal Fistula (TEF) Repair: TEF is a congenital anomaly with an abnormal connection between the trachea and the oesophagus. Surgical repair is necessary to close the fistula and reconstruct the affected areas, allowing proper separation of the airway and the digestive tract.
• Diaphragmatic Plication: It is used to treat diaphragmatic eventrations/paralysis. It can involve the repositioning and/or reshaping the diaphragm to expand lung capacity to improve breathing difficulties caused by these conditions.
• Thoracic Duct Ligation: Thoracoscopic or open ligation of the thoracic duct provides a safe and effective treatment of chylothorax not responding to medical treatment.
• Pericardial Window: It is a procedure done on the sac around the heart for recurrent pericardial effusions. Surgically removing a small part of the sac lets doctors drain excess fluid from the sac around the heart.
• Aesthetic Removal of Floating Ribs: An adjunctive procedure for ideal shaping of the waistline along with liposuction is resection of the 11th and 12th ribs, referred to as floating ribs. It is a form of cosmetic surgery.
• Pectus Excavatum Surgery: The pectus excavatum repair surgery fixes the shape of the bone in the middle of the chest (called the breastbone or sternum) so the lungs and heart are not squeezed by the inward curvature of the chest.
• Pectus Carinatum Surgery: Most patients with pectus carinatum can be corrected with a brace. When bracing is not an option, results can be obtained using the Ravitch method. In this method, a midline incision is made over the sternum, and costal cartilage is resected.
• Chest Wall Resection and Reconstruction: This procedure involves the removal of a portion of the chest wall affected by tumours or infections, followed by reconstruction using various techniques like prosthetic mesh or bone grafts.
• Rib Fracture Fixation: Surgical stabilization of rib fractures is a safe and effective method to treat displaced rib fractures using plates and screws.
• Open Window Thoracostomy: It is used to treat complex pleural empyema incurred from pulmonary resection, cancer and/or infection in patients that cannot be managed by more conservative strategies.
• Lung Transplant: A lung transplant replaces one or both of the damaged or diseased lungs (End Stage Lung Disease) with a donor's healthy lungs.

Approaches for Thoracic Surgery

Thoracic surgeries can be done via different surgical approaches. The three main approaches are:

1. Open Surgery: This has been the traditional thoracic surgery method. In this approach, big incisions are made on the chest to access different organs. The most common types of open thoracic procedures are:

• Thoracotomy: Thoracotomy is a surgical incision made on the side of the chest wall followed by the spreading of ribs to access the organs within the thoracic cavity, such as the lungs, heart, or oesophagus.
• Median Sternotomy: A vertical inline incision is made along the sternum, after which the sternum itself is divided using a sternal saw. The procedure provides access to the heart and lungs for various surgical procedures.
• Hemi Clamshell Incision: The hemi-clamshell approach is a surgical method consisting of a partial median sternotomy and anterolateral thoracotomy.
• Clamshell Incision: Also known as a transverse or crossbow transsternal incision, it is an improved surgical approach for managing bilateral pulmonary or combined pulmonary and mediastinal disease or double lung transplant.

2. Video-Assisted Thoracoscopic Surgery (VATS): VATS is a minimally invasive technique that makes use of a small camera and specialized instruments inserted through tiny incisions in the chest to perform various thoracic procedures.
3. Robotic Assisted Thoracoscopic Surgery (RATS): A minimally invasive surgical technique, it allows enhanced view, accurate and complex movements, and high ergonomics for the surgeon.

When do you need to see a doctor?

You should consider seeing a thoracic surgeon if you are experiencing symptoms such as:

• Chest pain- If you have unexplained or recurrent chest pain that is severe, prolonged, or associated with other concerning symptoms, such as radiating pain to the arm, jaw, or back, it is important to consult a thoracic surgeon. They can assess and diagnose potential causes, such as cardiac or thoracic conditions requiring prompt intervention.
• Chronic cough- If you have a chronic cough that lasts for several weeks, particularly if it is accompanied by coughing up blood (hemoptysis) or worsening over time, it is advisable to consult a thoracic surgeon. These symptoms could be indicative of underlying lung conditions or tumours.
• Difficulty breathing- A thoracic surgeon can evaluate your condition if you experience persistent shortness of breath, difficulty breathing, or wheezing that doesn't improve with conventional treatments. These symptoms may suggest underlying lung diseases or obstructions that require further investigation and specialized care.
• Thoracic trauma: In the case of significant trauma to the chest, such as a motor vehicle accident or a fall from a height, it is essential to seek immediate medical attention, including a consultation with a thoracic surgeon. They specialize in treating injuries to the chest wall, lungs, and other thoracic structures.
• Coughing out blood- Coughing up blood, or hemoptysis, is an alarming symptom that should not be ignored. It involves spitting up blood or bloody mucus from your lower respiratory tract (lungs and throat). It can be a sign of a serious underlying condition like lung cancer, tuberculosis, bronchiectasis or carcinoid tumours, etc. and should be evaluated by a doctor.
• Lung nodules or abnormalities: A thoracic surgeon can evaluate and determine the appropriate course of action if you have been found to have lung nodules or abnormalities on imaging tests such as chest X-ray or CT scan. They can perform further investigations, such as biopsy or surgical removal, to determine the nature of the nodules and provide necessary treatment.

Conditions treated by thoracic surgery

Some conditions that can be treated by thoracic surgery include:

• Lung cancer: Lung cancer is a malignant tumour that originates in the lungs. Thoracic surgery plays a crucial role in lung cancer treatment, with procedures such as lobectomy, pneumonectomy, segmentectomy or wedge resection being performed to remove the tumour.
• Pleural effusion: Pleural effusion refers to the accumulation of excess fluid in the pleural space that surrounds the lungs. Thoracic surgery may be required to drain the fluid and prevent further complications.
• Empyema: Empyema is characterized by the accumulation of pus in the pleural space because of a bacterial infection. Thoracic surgery, including decortication and drainage, is often necessary to remove the infected material and restore normal lung function.
• Pneumothorax: Pneumothorax occurs when air accumulates in the pleural space, causing a lung to collapse. Thoracic surgery may be performed to repair the lung and prevent further air leakage.
• Hyperhidrosis: Hyperhidrosis, or excessive sweating, affects millions of people around the world. While it may not be life-threatening, it can still significantly impact a person's quality of life. Sweaty hands, also known as palmar hyperhidrosis, are one of the most common types of hyperhidrosis. Thoracic Sympathectomy is one of the treatment options.
• Lung Abscess: Lung abscesses refer to a pus-filled cavity in the lung surrounded by inflamed tissue. It usually results from aspirating bacteria that normally live in the mouth or throat into the lungs, leading to an infection. If medical management fails, surgery in the form of resection of the abscess cavity is required.
• Hydatid Cysts of Lung: A hydatid cyst is a cystic space-occupying lesion caused by the larval stage of the parasite Echinococcus. It can occur in any organ but is most commonly seen in the liver and lungs. The standard management of pulmonary hydatid disease is the surgical removal of cysts with or without capitonnage. Large Hydatid cysts may need a Lobectomy.
• Pulmonary Aspergilloma (Fungal Ball): is a mass in the lung caused by a fungal infection. Aspergillosis is an infection that is caused by the fungus Aspergillus. Aspergillomas can form when the fungus grows in a clump in the lung cavity. The cavity may be created by a previous condition like tuberculosis, cystic fibrosis, lung abscess, lung cancer, etc. Treatment involves resection of part of the lung having the cavity (lobectomy).
• Esophageal cancer: Esophageal cancer refers to the malignant growth of cells in the oesophagus. Thoracic surgery, such as esophagectomy or esophagogastrectomy, is commonly performed to remove the cancerous tissue and reconstruct the oesophagus if needed.
• Mediastinal tumours: Mediastinal tumours can develop in the mediastinum, the central region of the chest between the lungs. Thoracic surgery is often necessary to remove these tumours, with procedures such as mediastinoscopy, thoracotomy, or video-assisted thoracoscopic surgery (VATS) being utilized.
• Diaphragmatic hernia: Diaphragmatic hernia refers to a condition with a defect in the diaphragm, allowing abdominal organs to protrude into the chest cavity. Thoracic surgery, specifically diaphragmatic hernia repair, is necessary to restore the normal position of the organs.
• Thymoma: Thymoma is a tumour that develops in the thymus gland located in the mediastinum. Thoracic surgery, such as thymectomy, is performed to remove the tumour and prevent its spread.
• Tracheal stenosis: Tracheal stenosis refers to the narrowing of the trachea, causing breathing difficulties. Thoracic surgery, including tracheal resection or reconstruction, is performed to widen the trachea and improve airflow.
• Chest wall tumours: Chest wall tumours can arise from the bones, muscles, or other tissues in the chest wall. Thoracic surgery may be necessary to remove the tumour and reconstruct the chest wall.
• Bronchiectasis: Bronchiectasis is characterized by the permanent dilation of the bronchial tubes. In some cases, thoracic surgery may be performed to remove the affected lung segments and improve lung function.
• Mediastinal masses: Mediastinal masses can be benign or malignant growths that develop in the mediastinum. Thoracic surgery is often required to remove these masses and determine their nature.
• Esophageal diverticulum: Esophageal diverticulum refers to a pouch or sac that forms in the oesophagal wall. Thoracic surgery, such as diverticulectomy, may be performed to remove the diverticulum and alleviate symptoms
• Broncho-pleural Fistula: A pathologic connection between the main stem, lobar, or segmental bronchus and the pleural space is termed bronchopleural fistula (BPF). It may sometimes need thoracic surgery intervention.
• Myasthenia gravis (MG): People with MG have muscle weakness that worsens throughout the day. This autoimmune disease affects the neuromuscular system. Drooping eyelids are often the first sign. Medications and thoracic surgery (thymectomy) can help relieve the symptoms of this lifelong illness.
• Hemothorax: Blood around the lungs may accumulate due to chest trauma or, after iatrogenic chest injury or sometimes in bleeding disorders. If the blood gets organized or loculated, it needs surgical removal.
• Chylothorax: A rare but serious condition in which lymph formed in the digestive system (chyle) accumulates in the chest cavity around the lungs, often seen after cardiac surgery, oesophagectomy, lymphomas or chest trauma. Thoracic surgery is needed for chylothorax not responding to medical management.
• Rib Fractures: Broken ribs, also known as rib fractures, can be a painful injury. They occur when one or more ribs crack or break due to trauma. In most cases, broken ribs can be managed with non-surgical treatments, such as pain medication, rest, and breathing exercises. In severe cases, surgery may be required.
• Chest Wall Deformities: A chest wall deformity refers to a structural abnormality of the chest ranging from mild to severe. Chest wall deformities may occur when the cartilage that connects the ribs grows unevenly. Two common types of chest wall deformity are:

i. Pectus excavatum- Also known as concave chest or funnel chest, it occurs when the breastbone pushes inwards. Children with this condition appear to have sunken chests.
ii. Pectus carinatum- Also known as raised chest or pigeon chest, it is characterised by the protrusion of the breastbone and ribs. Some children have both sides of the chest stick out, and others may experience that one side of the chest may protrude more than the other side. Thoracic surgery is required to correct these chest wall deformities.

Diagnosis

Before any thoracic surgery, several diagnostic tools and tests are used to evaluate the patient's condition and determine the appropriate surgical approach. Here are some of the key diagnostic tools and tests:

• Chest X-ray: A chest X-ray is a commonly performed imaging test that provides a two-dimensional image of the chest. It helps visualize the lungs, heart, ribs, and other structures within the thoracic cavity. Chest X-rays detect abnormalities such as tumours, infections, or lung diseases.
• Computed Tomography (CT) Scan: CT scan is a detailed imaging technique that uses multiple X-ray images to create cross-sectional images of the chest. It provides a more comprehensive view of the chest, allowing visualization of the organs, blood vessels, and any abnormalities. CT scans are particularly useful in assessing lung tumours, mediastinal masses, or thoracic trauma.
• Magnetic Resonance Imaging (MRI): Magnetic Resonance Imaging (MRI) uses a powerful magnetic field and radio waves to create detailed images of the chest. It provides excellent soft tissue visualization and is particularly useful for assessing mediastinal structures, spinal cord abnormalities, or vascular anomalies.
• Positron Emission Tomography (PET) Scan: PET scan is a nuclear medicine imaging technique that uses a radioactive tracer to detect metabolic activity in tissues. It is commonly used in thoracic surgery to evaluate lung nodules, determine the extent of cancer spread, or assess the response to treatment.
• Pulmonary Function Tests (PFTs): PFTs assess the functioning and capacity of the lungs. These tests measure parameters such as lung volumes, airflow rates, and gas exchange. PFTs help evaluate lung function before surgery and determine the patient's respiratory capacity and eligibility for surgery.
• Bronchoscopy: Bronchoscopy is a procedure that involves the insertion of a thin, flexible tube (bronchoscope) through the nose or mouth into the airways. It allows direct visualization of the trachea, bronchi, and lung tissue. Bronchoscopy can help diagnose lung diseases, assess airway abnormalities, or obtain tissue samples for biopsy.
• Echocardiogram: An echocardiogram is an ultrasound test that uses sound waves to create images of the heart and its structures. It helps assess cardiac function and heart valve abnormalities and detect congenital heart defects before thoracic surgery.
• Spirometry: Spirometry is a lung function test that measures how much air an individual can inhale and exhale and how quickly they can do so. It helps assess lung capacity, airflow limitations, and the presence of respiratory conditions such as chronic obstructive pulmonary disease (COPD) or asthma.
• Fine-needle Aspiration (FNA) Biopsy: FNA biopsy is a minimally invasive procedure that involves inserting a thin needle into a suspicious area to collect cells or tissue samples for examination. In thoracic surgery, FNA biopsy may be used to evaluate lung nodules, mediastinal masses, or lymph nodes, aiding in diagnosing lung cancer or other thoracic diseases.
• Blood tests: Various blood tests can provide valuable information before thoracic surgery. These tests may include complete blood count (CBC), coagulation profile, liver and kidney function tests, tumour markers, and infection screening. Blood tests help assess overall health, identify potential risks, and ensure the patient is suitable for surgery.

What to expect

• Before thoracic surgery, you will undergo a series of tests and evaluations ensuring you are healthy enough for the procedure.
• The surgery itself may be performed under general anaesthesia. It may require an incision in the chest wall and may be performed using minimally invasive techniques like video-assisted thoracoscopic surgery (VATS) or robotic surgery.
• The duration of the procedure and recovery time depends on the type of surgery performed, but you can expect to spend several days in the hospital after the surgery.
• Pain management, physical therapy, and other supportive measures will be provided to aid in recovery.

Frequently Asked Questions (FAQ)

Q1. What is the most common thoracic surgery?

Ans: The most common thoracic surgery is a lobectomy, which involves the removal of a portion of the lung that contains a cancerous or diseased tumour.

Q2. What does a thoracic surgeon do?

Ans: A thoracic surgeon performs surgical procedures on organs and structures within the chest, including the lungs, oesophagus, diaphragm, and chest wall.

Q3. Is a thoracic surgeon a cardiologist?

Ans: No, a thoracic surgeon is not a cardiologist. A thoracic surgeon specializes in surgical procedures on organs and structures within the chest, while a cardiologist specializes in diagnosing and treating conditions affecting the heart and cardiovascular system.

Q4. How serious is thoracic surgery?

Ans: Thoracic surgery can be a serious procedure, as it involves surgical intervention on vital organs and structures within the chest. However, risks and seriousness of the surgery depend on the condition treated, and the patient's overall health and medical history.

Q5. Is thoracic surgery painful?

Ans: Pain and discomfort are common after thoracic surgery, but pain management strategies such as medications, nerve blocks, and other techniques are used to manage pain and promote healing.

Q6. How long does thoracic surgery take?

Ans: The duration of thoracic surgery depends on the type of surgery being performed, but it typically ranges from 2 to 6 hours.

Q7. Is thoracic surgery heart surgery?

Ans: No, thoracic surgery is not heart surgery. While the heart is located in the thoracic cavity, thoracic surgery specifically refers to surgical procedures on organs and structures within the chest other than the heart.

Q8. What is the difference between a thoracic surgeon and a vascular surgeon?

Ans: A thoracic surgeon specializes in surgical procedures on organs and structures within the chest, while a vascular surgeon specializes in surgical procedures on blood vessels throughout the body.

Q9. How much does thoracic surgery cost in India?

Ans: The cost of thoracic surgery in India can depend on factors like the the specific procedure being performed, the hospital or medical facility, and other factors. It is best to consult with a healthcare provider or medical facility for an estimate of the cost.

Q10. Why would you have thoracic surgery?

Ans: Thoracic surgery may be recommended to treat a variety of conditions affecting organs and structures within the chest, such as lung cancer, emphysema, oesophageal cancer, and chest trauma. It may be considered when non-surgical treatments have been unsuccessful or when the condition is severe enough to require surgical intervention.

Review

Reviewed by Dr. Kamran Ali, Principal Consultant- Thoracic Surgery.