Thoracotomy is a surgical incision into the chest. It is performed by a surgeon to gain access to the thoracic organs most commonly the heart, the lungs, the esophagus, or the thoracic aorta.

Thoracotomy is a major surgical maneuver -- the first step in thoracic surgery, which involves major procedures such as coronary artery bypass surgery and pneumonectomy for lung cancer -- and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation.

There are many different approaches to thoracotomy. The most common modalities of thoracotomy follow.

Median thoracotomy provides wide access to the mediastinum and is the incision of choice for most open-heart surgery.

Anterolateral thoracotomy is performed upon the anterior chest wall, typicall between the 4th and 6th intercostal spaces; left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic cardiac arrest. Anterolateral thoracotomy, like most surgical incisions, requires the use of tissue retractors -- in this case, a "rib spreader" such as the Finochietto retractor.

Bilateral anterolateral thoracotomy combined with tranverse sternotomy results in the "clamshell" incision, the largest incision commonly used in thoracic surgery.

Posterolateral thoracotomy -- similar to anterolateral thoracotomy, only practiced on the posterior aspect of the chest wall -- is also a common approach for operations on the lungs or mediastinum.

Upon completion of the surgical procedure, the chest is closed. A chest tube -- with one end inside the violated pleural cavity and the other submerged under saline solution inside a sealed container, forming an airtight drainage system -- is necessary to remove air from the pleural cavity, preventing the development of pneumothorax.

In addition to pneumothorax, complications from thoracotomy include infection, bleeding and respiratory failure. Postoperative pain is common and intense, generally requiring opioids, and interfering with the recovery of respiratory function.

Video-assisted thoracic surgery (VATS) is currently being explored as an alternative to thoracotomy in selected cases, much like laparoscopic surgery. Unlike laparoscopic surgery, its current indications are relatively limited. Robotic surgery also holds promise.